6.1 Diagnostic Drawing Series (DDS) & Scoring Methodology

Foundations of the Diagnostic Drawing Series (DDS)

The Diagnostic Drawing Series (DDS) is one of the most rigorously researched and widely utilized standardized art therapy assessment instruments in clinical mental health. Developed in 1982 by Barry M. Cohen and Barbara Mills, the DDS was designed to establish an empirically grounded, cross-culturally reliable drawing assessment capable of distinguishing formal graphic manifestations of psychiatric disorders classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Prior to the inception of the DDS, projective drawing assessments in art therapy and psychology predominantly relied on psychoanalytic "sign-approach" interpretations—attributing fixed, symbolic meanings to isolated graphic details (e.g., interpreting a missing hand strictly as castration anxiety). Cohen and Mills departed radically from this subjective tradition by anchoring the DDS in the assessment of formal structural elements (such as color usage, line pressure, spatial distribution, integration, and abstraction) rather than thematic or symbolic content. By standardizing both the administration protocol and the scoring manual, the DDS established high inter-rater reliability and provided art therapy with a scientifically validated diagnostic tool.

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Standardized Administration Protocol and Materials

Standardization is absolute in the administration of the DDS. Any deviation in materials, paper dimensions, verbal directives, or time limits invalidates the normative baseline and compromises the clinical utility of the assessment.

Mandatory Materials

• Art Media: Exactly one 12-color set of Alphacolor square pastels (semi-hard chalk pastels). The specific palette contains: primary red, yellow, blue, orange, green, violet, magenta, turquoise, black, white, brown, and peach (flesh).
• Drawing Paper: Exactly three sheets of 18" x 24" white drawing paper (standard 60–70 lb weight). Each sheet is presented individually in horizontal (landscape) orientation directly in front of the client, although the client is permitted to rotate the sheet vertically if they choose.
• Work Surface: A smooth, flat drawing table that easily accommodates the 18" x 24" sheet, situated in a quiet, well-illuminated room free from distracting visual stimuli.
• Excluded Materials: No pencils, erasers, tortillons (blending stumps), rulers, or fixative sprays are permitted during administration. Fixative may be applied only after the entire assessment and inquiry are concluded.

Administration Procedures and Timing

• Time Limit: Exactly 15 minutes per drawing. If a client completes a drawing before the 15 minutes expire, the therapist notes the elapsed time and proceeds to the next drawing. If the client is still drawing at the 15-minute mark, the clinician gently intervenes: "Your 15 minutes are up for this drawing; please finish the stroke you are working on so we can move to the next sheet."
• Clinician Role: The art therapist acts as a non-intrusive, objective observer. The clinician must not offer suggestions, thematic ideas, praise, or interpretive commentary. The clinician unobtrusively records behavioral observations: starting color, sequence of elements, body posture, motor tempo, affective expressions, verbalizations, and total drawing time.

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The Standardized Three-Drawing Sequence

The DDS consists of three sequential drawings, each presenting a distinct cognitive, affective, and structural demand designed to systematically probe ego functioning, defense mechanisms, and emotional regulation.

Drawing 1: Free Drawing (Unstructured) ───► Baseline Ego Functioning & Defenses
Drawing 2: Tree Drawing (Structured)   ───► Core Ego Strength & Self-Concept
Drawing 3: Feeling Drawing (Affective)  ───► Emotional Integration & Translation

1. Drawing 1: The Free Drawing

• Verbal Directive: "Make any picture you wish using the chalks."
• Clinical Purpose: Assesses unstructured problem-solving, baseline comfort with ambiguity, and spontaneous defense deployment. Because no thematic prompt is provided, the client must navigate the anxiety of an open-ended directive on a large 18" x 24" surface. Drawing 1 establishes the individual's idiosyncratic baseline for space usage, line pressure, color preference, and compositional organization.

2. Drawing 2: The Tree Drawing

• Verbal Directive: "Draw a tree."
• Clinical Purpose: Introduces a universal, structured stimulus deeply rooted in projective tradition (Karl Koch's Baum Test and John Buck's House-Tree-Person). The tree serves as an unconscious metaphor for the somatic self-concept, developmental history, and structural ego stability. The tree directive allows the clinician to assess structural coherence (trunk and baseline), environmental interaction (branches and foliage), and physical grounding (roots).

3. Drawing 3: The Feeling Drawing

• Verbal Directive: "Using lines, shapes, and colors, draw how you feel."
• Clinical Purpose: Challenges the client to translate internal affective and somatic states into visual form using abstract formal elements. This directive evaluates emotional awareness, affective tolerance, and integration. It tests whether the client can access and articulate primary emotional experiences without experiencing decompensation, fragmentation, cognitive constriction, or concrete defensive flight.

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The Cohen DDS Rating Guide: 23 Formal Scoring Criteria

Scored using the Cohen DDS Rating Guide (Cohen, 1986; revised 1994), the assessment evaluates 23 objective structural and formal dimensions. Rather than asking what a symbol means, the rater measures how the image was constructed.

Summary of Core Scoring Dimensions

[!IMPORTANT] The DDS Rating Guide is designed for objective, empirical scoring. Art therapists must demonstrate inter-rater reliability by achieving agreement across raters on the 23 formal elements. Clinical diagnoses must never be made on the basis of a single graphic element, but rather on verified multi-scale profiles across all three drawings.

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Empirically Validated Diagnostic Graphic Profiles

Extensive clinical research across psychiatric inpatient, outpatient, and normative populations has established statistically validated graphic profiles for major DSM diagnostic categories:

1. Major Depressive Disorder (MDD)

• Space Usage: Marked spatial constriction; typically covers less than 33% of the 18" x 24" page, often occupying a small corner or isolated central patch surrounded by vast empty white space.
• Color Count: Extremely low color variety; typically 1 or 2 colors, frequently restricted to black, dark brown, or blue.
• Line Quality: Faint, hesitant, light, or broken linework reflecting psychomotor retardation and low vital energy.
• Drawing 2 (Tree): Predominantly bare, dead, or deciduous winter trees devoid of leaves, fruit, or foliage; trunks are thin, frail, or hollow; roots are typically absent.
• Drawing 3 (Feeling): Constricted, empty, or blank response; minimal markings; monochromatic scribbles; or verbal protestations of "feeling nothing" or "emptiness."

2. Bipolar Disorder: Manic Episode

• Space Usage: Expansive hyper-coverage; exceeds 66% and frequently covers nearly 100% of the paper, with strokes running off the margins onto the table.
• Color Count: Elevated color usage; 8 to 12 colors applied across the sheet in rapid succession.
• Line Quality: Heavy, pressured, vigorous, and forceful pastel application; lines may snap chalk sticks due to excessive physical force.
• Drawing 2 (Tree): Flourishing, exaggerated, hyper-fruiting or flowering trees; unintegrated decorative elements; grandiose scale dominating the paper.
• Drawing 3 (Feeling): Explosive, unintegrated, chaotic bursts of color, radiating lines, and swirling forms reflecting flight of ideas and affective lability.

3. Schizophrenia and Psychotic Disorders

• Integration and Coherence: Severe structural fragmentation, bizarre spatial dislocations, and lack of compositional unity.
• Color Fit: Highly inappropriate, bizarre color assignment (e.g., bright purple tree trunk with black leaves, neon yellow skin, discordant clashing hues).
• Abstraction: Incongruous, high abstraction in Drawings 1 and 2 where representational imagery is normative; difficulty adhering to the concrete "Draw a tree" directive.
• Peculiar Signs: Inappropriate written words, neologisms, mathematical symbols, mechanical parts embedded into biological figures, or transparent "X-ray" drawings displaying internal organs.

4. Dissociative Identity Disorder (DID) & Complex Dissociative Disorders

• Inter-Drawing Discrepancies: The hallmark DDS indicator for DID is the presence of striking graphic and stylistic discontinuities between the three drawings (e.g., Drawing 1 appears as an advanced adult technical drawing, Drawing 2 resembles a 5-year-old child's crayon scribble, and Drawing 3 presents an adolescent abstract configuration).
• Signatures and Identities: Drawings may contain distinct names, initials, or alters' signatures in different handwriting styles.
• Encapsulation and Switching: Multiple compartmentalized boxes, split images down the vertical center line, or distinct figures representing segregated personality states.

Comparative Diagnostic Profiles on the DDS

The following clinical matrix summarizes the empirically established formal characteristics of major diagnostic groups evaluated under the Cohen DDS Rating Guide:

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Clinical Inquiry and Psychometric Boundaries

Following the completion of Drawing 3, the clinician administers a structured, non-leading inquiry:

1. Title Generation: The client is asked to provide a title for each of the three drawings, recorded verbatim in their own words.
2. Clarification of Marks: The therapist asks open-ended questions to clarify ambiguous marks, figures, or shapes without suggesting content (e.g., "Can you tell me about this shape over here?").
3. Affective Inquiry: The client is invited to describe their emotional experience while creating Drawing 3 (e.g., "What feelings are being expressed in this picture?").

Psychometric Strengths and Limitations

• Inter-Rater Reliability: Peer-reviewed studies demonstrate high inter-rater agreement (frequently yielding Cohen's kappa values exceeding .75 to .85) for the objective rating of physical formal elements such as space, color count, and groundline.
• Diagnostic Boundaries: Board-certified art therapists must recognize that the DDS is an adjunctive screening instrument, not an autonomous diagnostic test. A DDS drawing profile generates clinical hypotheses regarding affective states, cognitive organization, and defense structures that must be integrated with clinical history, mental status examination, and biopsychosocial assessment.