Patients with multiple personality and dissociative disorders have learned to create an alternate identity system, originally designed to protect them from experiencing the pain of inescapable, unrelieved trauma and abuse. The resulting amnesia and identity confusion cause significant dysfunction in daily living. Issues of trust and control are paramount, and occupational therapists are challenged with the task of engaging these patients in meaningful activity. Although these patients often avoid structured groups, they have generally been responsive to expressive art opportunities as an initial activity. This paper outlines an expressive framework by which occupational therapists can therapeutically manage the artwork behaviors of the patient with dissociative or multiple personality disorder. The material presented is based on clinical observation of more than a dozen patients with multiple personality disorder in various stages of recovery and of many persons with dissociative trauma who may have multiple personality disorder. These observations took place within an acute care, inpatient occupational therapy setting. Guidelines for the creation of a positive working alliance and therapeutic climate for self-expression are outlined, and a progressive model for the viewing of patients’ art products is described.