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The Arts in Psychotherapy 60 (2018) 82–90

Contents lists available at ScienceDirect

The Arts in Psychotherapy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a r t s p s y c h o

esearch Article

sing photovoice with children of addicted parents to integrate henomenological and social reality

enny Malka a, Ephrat Huss b,∗, Lilach Bendarker c, Orel Musai c

School of Social Work, Sapir College, Hof Ashkelon, Israel Arts in Social Work Masters Specialization, Charlotte B. and Jack J. Spitzer Dept. of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel Charlotte B. and Jack J. Spitzer Dept. of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel

r t i c l e i n f o

rticle history: eceived 24 April 2017 eceived in revised form 19 July 2017 ccepted 13 November 2017 vailable online 21 November 2017

a b s t r a c t

On a micro level, addiction of a parent has a long-term psychological impact on children’s social, develop- mental, cognitive and emotional levels. On a macro level, the energy required to bear the social shame of the parent’s addiction and the need to keep the secret are also very difficult. Photovoice makes it possible to express both the inner experience through symbols and metaphors, and the social reality, through

eywords: hotovoice hildren of alcoholics roup art-therapy ase-study

photographing surroundings at the same time. Within a group context this creates a shared-reality on multiple levels. This case study explores the central themes of a group of children of addicted parents using photovoice. The central themes were photovoice effectiveness in integrating internal developmen- tal milestones and the external social reality of addiction. The intervention protocol and its rationale, as well as implications of the central themes will be outlined.

© 2017 Published by Elsevier Ltd.

ntroduction and literature survey

Addiction of a parent has a long-term psychological impact on hildren’s social, developmental, cognitive and emotional levels. hese children are defined as a high-risk group because addiction ften makes parents ineffective and unable to provide the nurtur- ng and safe environment that children need (Rothman, Edwards, eeren, & Hingson, 2008). These children are often exposed to psy- hological and physical neglect and have been shown to suffer from igh levels of anxiety, depression and other psychological prob-

ems (Hill, Tessner & McDermott, 2011; Hussong, Bauer, & Chassin, 008; Molina, Donovan & Belendiuk, 2010). The energy required o bear the shame of the parent’s addiction and the ensuing family mpoverishment, along with the need to take on parental roles at ome, greatly challenge developmental processes of individuation hat are central to adolescent development.

These children also devote much energy into keeping the addic- ion secret, which creates isolation, and they must deal with nstable parental models, often causing problematic behaviors

nd a high risk for later use of addictive substances themselves Rothman, Edwards, Heeren, & Hingson, 2008). At the same time, ome children develop positive behaviors such as responsibility

∗ Corresponding author. E-mail address: [email protected] (E. Huss).

ttps://doi.org/10.1016/j.aip.2017.11.001 197-4556/© 2017 Published by Elsevier Ltd.

and high achievement aspirations to counteract these problems. However, others become survivors and develop an “adaptive-self” based on the lack of authenticity (Bröning et al., 2012; Gabriel-Fried & Teichman, 2007; Teichman, Rahav, & Peleg-Oren, 2004).

Early intervention has been shown to be effective in promoting children’s coping methods and in making defenses more flexible, enabling containment of the secret and shame in a way that does not exhaust their energy and that enables them to experience the developmental milestones of youth (Peleg-Oren, 2002a, 2002b).

Group therapy for children of alcoholics, and art

A group setting helps counteract isolation and teaches effective coping methods. At the same time, groups help these children con- nect to the element of latency in a moderated peer group, while also providing a shared reality group, and the advantages of hope, effective interactions, and alternative parental models in the group leaders (Bar-On, Levine-Rozalis, & Yodelevitz, 2000; Gabriel-Fried & Teichman, 2007; Thompson and Trice-Black, 2012). Group work creates a chance to be exposed to more appropriate roles and is a safe place where the child can share emotions and thoughts and use peers to work through shame, loneliness, low self-esteem, guilt and anger, while providing support for others in the group. Gain-

ing knowledge about addictions, learning effective interactions, emotional language, and conflict resolution, and finding alterna- tive methods to cope with stress that do not include addictive substances are all very important preventive strategies for these

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ouths (Chazan, 2001; Peleg-Oren, 2002a, 2002b). The children can ddress dangers, such as drunk driving, can learn how to interact ith the addicted parent and can practice making good decisions.

However, it is often hard for these children to reap the bene- ts of group work because of secrecy and shame. Previous articles ave shown that these children suffer from shame and keep their arent’s addiction secret. The combination of shame and secrecy

ead to social isolation (Christozov & Toteva, 1989; Peleg-Oren & eichman, 2006; Rubio-Stipec et al., 1991). Shame and fear are pri- ary emotions, while secrecy becomes a defense mechanism that

an spiral inwards to emotional numbness and dissociation (Kroll, 004). Group work is thus the setting in which the children and arents can deal with the shame and secrecy through focusing on

shared reality (Peleg-Oren, 2002b) Thus, it seems that indirect and expressive methods, such as

orking in the arts, would be helpful in the group setting (Peleg- ren, 2002b). Art is a natural educational and therapeutic language

n childhood that enables enhancement of emotional and cogni- ive development, and sharing emotional experiences in a more oncrete and embodied way than the use of language to describe motional states, as demanded in adult verbal psychotherapy Author, 2012, 2015; Kramer, 2000; Malchiodi, 2008).

Indeed, from a dynamic standpoint, art therapy with such chil- ren has been noted as enabling differential states of feeling by isualizing them and containing them within the art products so as o learn more adaptive ways of expressing these feelings (Kramer, 000). From a humanistic and psychosocial point of view, the arts elp to overcome the impoverishment of self, due to lack of family urturing, and aid in regulating feelings in effective ways. The arts lso help to develop a symbolic language for defining the self, out- ide of the addiction (Allen, 2000; Moon, 2002; Rogers, 1993). From

CBT perspective, the arts can overcome denial by helping to visu- lize specific elements of the parent’s addiction, becoming a type of onfrontation with reality. Talking about a drawing has been found o be a trigger for a richer and more detailed narrative among chil- ren of addicted parents (Lev-Wiesel, 2007), The painful and often raumatic experiences of these children must be constructed into nabling narratives in order to overcome the secret and make sense f the experience. In terms of positive psychology, the arts provide

space where a sense of mastery and control over art materials an be experienced, rather than the sense of being controlled and eactive to the chaotic family climate. From a systemic viewpoint, he arts can become a safe place to make mistakes and to play, nabling the experience of childhood for children who have had to ecome parental (Malchiodi, 2008). In the group context, a group f children with similar problems is especially relevant for those ho must keep a secret, and the arts make it possible to gradually

eveal their secrets. The arts also enable indirect expression of the secret by using

ymbols and metaphors, thus maintaining a sense of safety for the hildren that allows for sharing but also for keeping the secret Allen, 2000; Author 2012). For children who do not have the chance o play or to experience a childlike role due to home problems, n arts group enables regression, and develops the psychosocial, motional, and educational advantages of shared play that includes xpressing the safe, maintaining boundaries, sharing, and more Malchiodi, 2008; Winnicott, 1991). The arts become a medium of ymbolic reality within the group space that allows for the prac- ice of social communication mediated through the arts and via the roup leaders in the here and now. (Wolfgang, 2006).

hotovoice

Photovoice was developed by Wang & Burris (1994, 1997) as a ethodology for utilizing critical pedagogy and feminism in social

nteractions. It aims to enable marginalized groups to identity day

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to day issues for them and to capture them through photography. The photograph is then discussed in a shared-reality group context to create a critical community narrative, that can be shared with power holders and others in the same situation (Wang & Burris, 1994, 1997).

Photovoice is a holistic approach that uses photography to empower individuals and groups. This approach provides visual expression and thus agency to individuals, groups and communities by utilizing their active “gaze” to define issues and engage in addi- tional discussion in order to share and further define the issues, so that the hegemony or dominant voices are not the ones that define things (Lust, 2013; Woodlrych, 2004).

Since 2007 there has been a sharp increase in the use of pho- tovoice among different populations (Lal, Jarus, & Suto, 2012). Specifically, photovoice has been used extensively with marginal- ized and voiceless groups as a type of social empowerment tool that provides voice and visibility for lived experience in these groups as described above. This perspective of giving voice has been used for both intervention and research as a space to coproduce knowledge with these silenced groups (e.g., Shea et al., 2011; Wang, 1999; Woodgate & Kreklewetz, 2012).

Photovoice is also effective with populations who are less verbal due to age, disability, differences in culture, and traumatic experi- ences that are shameful to express directly, such as abuse (Drew, Duncan, & Sawyer, 2010). The camera enables enough physical and symbolic distance from the experiences to approach them and to share them with others (Levin et al., 2007).

Photovoice usually involves distributing cameras to participants in the group, teaching basic skills, and providing structured sub- jects for photographs. These are then discussed and shared in the group space as a reflective and communicative tool that helps to access and expand verbal narratives that can still stay indirect and remain focused on the image rather than on the direct painful expe- rience (Hergenrather et al., 2009; Lust, 2013; Thompson et al., 2008; Lassetter, Mandleco, & Roper, 2007).

Photovoice also enables children to be witnesses and phe- nomenological describers of their own difficult social experiences in an indirect way that does not endanger them psychologically or socially. This is also relevant when working with teenagers who do not want to directly expose their social life to adults. It enhances the relative power of youths in relation to adults because the youths control visibility and symbolic construction of their own reality. Thus, the camera becomes a bridge to the children’s experiences that is a more embodied and appropriate way of addressing them than through direct questions based on adult knowledge (Drew et al., 2010; Lal et al., 2012).

The use of a camera is also psychosocially enhancing, as it develops new skills, enables “having fun”, and enhances a sense of efficacy and agency, which children often do not have (Moletsane et al., 2007; Strack, Magill, & McDonagh, 2004).

The use of photovoice in the field of addictions tends to focus on programs and policies aimed at preventing drug use and less on children’s lived experiences. This project aims to use photovoice at the interface between giving voice and enabling agency and ther- apeutic interventions (Helm et al., 2015; Goodhart et al., 2006; Wilson et al., 2008). This use of photovoice is less often described in the literature in relation to children who are dealing with parental addictions. We identify a need for innovative methods to intervene and research this population, burdened with secrets and shame, that relates both to the micro and macro levels of experiences, and thus enables both releasing the external secret and building internal self-esteem (Malchiodi, 2008; Peleg-Oren, 2002b; Sharma,

2010, pp.3-5).

Photovoice was chosen for this group because learning to use a camera connects to the media infused peer culture of young ado- lescents: It helps to overcome a lack of confidence in doing art and

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nables learning a new developmentally appropriate skill that is ard to fail at. This can help raise self-esteem. More specifically, in elation to dealing with the secret of parents’ addiction, it facili- ates bringing the home into the group space in a gradual manner. n other words, it connects to the real surroundings or familial nd social realities of the children, helping them to broach these ealities within the group space.

For these children, photovoice can help empower their own oices in terms of how they experience their family situation. As tated, it also enables control over the amount of ‘reality’ shared, ow the children experience their ‘background’ and how it con- tructs them. An innovation of photovoice in this model is that it s utilized as a therapeutic, psychosocial, and empowerment tool ll at once. This approach encourages empowerment and expands reedom of choice of fringe groups and is consistent with the fun- amental values of a social perspective in art therapy.

Specifically, the aim of this paper is to explore central themes ithin group and individual processes of a group for children of

ddicted parents, using photovoice as the therapeutic intervention. e wish to understand what processes have occurred, and how the

se of photovoice has enabled these processes. Making use of this nformation, we provide a protocol and a therapeutic model for sing photovoice with children of addicted parents

ethods

The present research project is qualitative, using art as a phe- omenological methodology (Holstein & Gubrium, 2011). Arts ased methods are especially relevant for dealing with diffi- ult emotions and issues of cultural taboo, because symbols and etaphors enable distance, partial sharing, and control over expo-

ure of these contents. The qualitative format is that of a case study, defining the

roup and the intervention as the parameters of the case. The case resents the problem, the method for dealing with it, and the results f this intervention (Gagnier et al., 2014; Stake, 2000; Yin, 2014). his case study is about a group of children of addicted parents in a ocal inner-city center for treatment of alcohol and drug addiction. he center provides personal and group interventions for children nd wives of the addicted members. It provides psychosocial inter- entions for the children in ongoing group formats that last for bout three months each group. The group under inquiry in this aper chose to use photovoice as its central intervention.

It is based on the use of photovoice with this group for 15 struc- ured sessions that were held over a period of four months. The ationale for the use of photovoice is outlined in the above intro- uction and literature review, which suggests that photovoice may e an effective tool to indirectly address the secret of an addicted arent. Information collection included observation of the group, ranscripts of meetings and artwork, and the self-report of group eaders and the group supervisor over the period of activity, as well s the report of an external expert in the arts. As mentioned, the roup consisted of fifteen sessions and a final exhibition.

ield of research

The group included seven children between the ages of eleven nd fourteen, three girls and four boys, who were receiving reatment at the local welfare center and assistance from the

unicipality. The center serves about 400 people in the area, ncluding children of alcohol, drug and gambling-addicted families.

esearch methods- the group protocol

First, the group leaders, who knew the children on an individual evel, developed a set of concerns expressed by the children and

otherapy 60 (2018) 82–90

then created a structured group intervention using photography based on these challenges. The group had two supervisors, an art therapy expert and an expert on addicted populations. The group leaders were social workers who had worked with the families and children in another program. This team together created a protocol that was used flexibly and was adjusted to issues and processes that arose within the group. Based on group theory, the aims of the group intervention were to create a corrective positive relationship within the group space and thus to enable developmental growth, as well as creating a shared reality group to address the secret and pain of the parents’ addiction.

The children were bussed to and from their homes with a stu- dent to make sure they arrived despite their chaotic home life and to show the children how important the group was. They received food and free time on arrival, followed by a warm up activity, then sharing the photovoice assignments described in the proto- col below, and finally, there was a summary of the meeting and a description of what had happened emotionally.

Meetings 1–3 were devoted to training in the use of the camera. Meetings 4–5 dealt with expressing “who I am” and “what is

around me” with the camera. Meetings 6–7 dealt with my family and the family surroundings.

Meetings 8–11

dealt with the subject of addiction in an abstract way. Meetings 12–14 dealt with separation and ending, and with

preparations for the exhibition. Meeting 15 was a group exhibition of photos with the atten-

dance of the parents. The following is a summary of the photography assignments:

1) introduction and learning to use the camera; 2) who am I and what is around me; 3) my family:

alcohol and addiction; 4) ending and separating; 5) group exhi- bition and invitation to parents to view the exhibition

Group meeting protocol

1. Arriving: a mini-buss was sent to fetch the children due to difficulties of the parents to get organized.

2. Warm up: food and drink and games, as transition into the meeting

3.Presenting photographs from homework from last meeting, and then presenting the central photography mission for the next meeting. The sharing of photos was mediated by the questions in the SHOWeD model of Wang (1999, p. 188): What do we see here?; How does this relation to our lives?; Why does this situation exist?

What can we do with it? 4. Discussion based on overt and covert contents in the pho-

tographs (that is, what as photographed but also, what symbols and compositional elements were used to photograph the elements).

5. Working through of feelings that arose during the meeting and closure

Final data sources

included a summary of transcribed group meetings from record- ings, a summary of preliminary and final interviews with the children, photographs taken by the children and their explana- tions, and discussion about them, and a summary of supervision meetings.

Method of analyses

The analytical method of the visual material was based on a few stages that included gathering the images, coding the contents and

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ompositional elements of the images as a single entity, and coding he developing and emerging contents of each child’s images as a arrative whole. This enables to create narrative themes for each hild, and general themes for the group as a whole (Bell, 2001; Bock, sermann & Knieper, 2011).

The photographs were also analyzed as a process that encom- asses their creation, and the reactions that they elicit: To elaborate, hey were analyzed first, in the context that they were taken, sec- nd, according to the reaction to them by the photographer and he group in the sessions, and third, according to the reactions of he family to the final exhibition. They were also analyzed by the roup of leaders, using their different expertise areas to identify nconscious processes and elements and to point to central themes.

The above two group leaders and supervisors (creating a multi- isciplinary analyses of art therapist, social worker and group orker) analyzed the group process and photographs as a team. e divided each session into themes, but also read each section

arratively as a developing process. We mapped each child’s indi- idual development, as well as mapping the group process as a hole.

alidity and trustworthiness

Use of multiple data sources including group work, transcribed eetings, acquaintance by the group leaders with the children’s

amilies and the photographs themselves, helped to consolidate the ata. The peer analyses by a group of researchers and practitioners ith different areas of expertise also created validity.

thics

Because one of the aims of the group was to share the secrets f their parents’ alcohol addiction, ethical issues were complicated. he welfare youth center obtained the parents’ signed consent for he research. The welfare ethics committee also signed their own onsent as did the university departmental committee. This is the rotocol for ethical clearance in Israel. However, because of the sen- itivity of using photographs, we have added a section on privacy ssues:

rivacy issues All identifying characteristics of the children were omitted from

he texts and photographs. It is important to state that the area f research was the use of photovoice in a group context, rather han delving into each child’s personal situation and history, so he information is not necessarily personal. Additionally, the aim as to create more effective use of photovoice for groups; thus,

he findings have a direct impact on the wellbeing of the children. he photographs used symbolic elements and any specific loca- ions were omitted from the study. At the same time photovoice by efinition raises complex questions of identification of real places nd people. These are acceptable within the framework of a group hotography exhibition. (This issue is elaborated in the discussion ection of the paper).

In fact, as recommended in the literature, this study sought to ssentially combine three important ethical principles for research nvolving children and adolescents that are relevant in Israel and n the US: a. maximizing immediate benefits or benefits for future articipants, in this case, a combination of therapeutic interven- ions that helped adapt the process to the needs of the children; b.

inimizing risk of exposure due to the research by ensuring con- dentiality and ensuring that personal information would not be

xposed c. ensuring social justice, using photovoice research and ntervention as a tool for listening to the voices of the children of lcoholics and creating an opportunity to adjust to their needs for uture interventions.

otherapy 60 (2018) 82–90 85

Findings

We illustrated each of the following themes with a few examples and sub-themes:

Personal processes of individuation through photography The children first learned to use the camera. This focus on an

external skill could be seen as adapting to the challenges of master- ing reality. The agreement of the group for privacy and respect was also defined. The group learned composition, meaning, symbols, and use of props.

In the first three meetings after learning how to use the cam- era, the participants were assigned to photograph elements that created a collage of personal identity. Overall, as shown in the first section of the vignettes, this enabled a space for exploring self- development, transition from adulthood to childhood, processes of separation (from sisters and mothers) and examining the empty depleted self.

As stated in the literature review, the energy required to bear the shame of the parents’ addiction, together with the dysfunction of parental roles at home pose great challenges for developmental processes of individuation that are central to adolescent develop- ment. The following vignettes show how photovoice enabled the youth in the group to address this subject: Each example repre- sents a theme in development and how the camera enabled the group member to address this theme.

a. Separating from symbiotic home relationships through the distance of photographing these relationships:

Osher is thirteen and has low self-esteem, with a father who is still drinking. He has a symbiotic and infantilized relationship with his mother who does his homework, ties his shoelaces and cleans his room for him. Osher avoided taking pictures at the begin- ning, stating that he did not have anything to photograph. He expressed passivity about finding interesting pictures. Towards the sixth meeting he took ten pictures of his mother from behind, in the kitchen. His mother did not know that he had taken these pic- tures, and he was very happy about them. This was understood as an effort at individuation from his mother, as he pictured her from the back, and without her knowledge. In the group exhibi- tion, the mother was very upset that she hadn’t known she was being photographed, expressing her difficulty with his individua- tion

We see that the camera enabled Osher to observe his mother, and thus to define himself as a separate being. His ability to subjec- tively define what he saw, enabled him to have his own vision and to individuate.

b. Keeping a private space instead of lying (a behavior learnt from the addicted parent)

Dor used to lie a lot in his interactions with the children. His pho- tographs enabled him to have an additional private space. Rather than lying, he stated that he didn’t want to show his pictures.

Instead of using lies as his addicted father did, to create a sepa- rate space, the camera could show his ‘truth’ or reality. This was more proactive behavior and a shift from the learned behavior of lying used by his alcohol dependent father. The photographs enabled him to show things indirectly and symbolically, but they were still the ‘truth’ in the eye of the photographer.

c. Capturing an empty space, or inner emptiness that, by becoming art, becomes something rather than nothing.

Emma is a small underdeveloped eleven-year-old who lives with her older sister and mother who is still drinking. Her father is actively addicted to drugs and is in prison. She has no identity out- side of her older sister, follows her everywhere and likes what she

86 M. Malka et al. / The Arts in Psychotherapy 60 (2018) 82–90

Photo 1. Emma’s room: using multipl

Photo 2. Emma’s personal belongings.

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use of alcohol. However, he photographed a wine bottle on the floor by the fridge next to a crack in the wall. He explained that the crack

Photo 3. Swings in a playground in Emma’s neighborhood.

likes. Emma had difficulty thinking of ideas for herself to photo- graph and photographed whatever her older sister did, such as her sister’s images of favorite pop groups. This dependence on her sis- ter was captured in the photo of the two walls that are the same (Photo 1). By choosing to photograph this, Emma was beginning to confront her lack of identity, as in the following themes:

d. Creating images as a positive way to fill in empty spaces or ack of content, rather than using addictive substances as learnt t home

Towards the end of the group, Emma photographed an empty all in her bedroom and explained that above her bed there used

o be a poster of a pop group her sister liked, but she took it down nd now the wall was empty. She is thinking about what to put on he wall.

e. Using symbolic images to capture developmental transi- ions and processes.

Later on, Emma also photographed her makeup box (Photo 2), and the swings in her playground (Photo 3) as symbols of her transition from childhood to teenage-hood.

Gradually, she filled the empty space in the image with an explo- ation of her own identity and her own transitions from childhood

ication to expand private space.

to adulthood. The discussion of the two images in the group space enabled her to find words for her developmental processes.

In sum, in the above three examples we see how photography can be an external projection of an inner individuating space that in becoming ‘something’. The creativity of photography makes it possible to start to fill up the impoverished self. Thus, photography becomes something to fill an empty space but also something that can capture emptiness as an entity. It enables filling the space with positive elements rather than with addictions.

Using the discussion of the image in the group space as a distanced way to find words for emotional processes

The discussion of the image within the group space enabled the participants to find words for their inner emotional world, but also to address the secret of the parent’s addiction indirectly.

The second set of assignments dealt with the addiction that rep- resented the shared reality of the group. The group leaders actively verbalized the legitimacy of the emotions that the children felt about the addiction. In addition, information about addiction was shared by the group leaders as part of their shared reality orienta- tion.

The participants were asked to photograph elements that expressed different emotions concerning the addiction. The emo- tions of love, shame, guilt, courage and fear of violence were photographed

a. Control over the ability to show a photograph to some but not others and to erase pictures, as ways of self-regulating disclosure of the secret of addiction at home.

Within the group, the use of the camera, the choice of images, and how they were shared, became a metaphor for “how I share shameful parts of my identity”.

Tina, in answer to the request to photograph something to do with addiction, photographed her father’s beer bottles and showed the group leader, but then in the group space, she erased the photo- graph. One of the girls stated, “It’s good that you erased it because it’s an ugly picture”, and she said, “Well, I’m glad you saw it first, before it was erased”

Tina used the control of showing or erasing a picture to mediate where she felt safe to show the ‘secret’ of the addiction. She showed the group leader, and then erased it when the group signaled that it was too painful a picture.

By the control of disclosure which remained with her, she could create a more flexible position towards the secret.

b. Using symbols and metonyms in photographs to indirectly depict parent’s addiction

Dor photographed drunks in the area and broken beer bottles on the rocks in a park (Photo 4). He did not photograph his own parents’

was in the picture because alcohol cracks the home open and brings people down.

M. Malka et al. / The Arts in Psychotherapy 60 (2018) 82–90 87

Photo 4. Broken beer bottle on a rock in the park.

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Photo 5. bottle headless.

c. Using photographs to show reactions to the addiction hrough symbols

In this example, Dor used the symbolic and metaphorical license f the photograph to create a symbolic and distanced depiction of is parents’ alcohol use without directly photographing them. He lso used the symbolic elements of the image to depict how he felt bout the addiction in a generalized way.

d. Creating a dual narrative in which what is shown is denied erbally, or using photographs showing what children are not et ready to ‘tell’

The two sisters in the group (Emma and Nataly) photographed a picture of alcohol bottles with a cut off top (Photo 5): One of the sisters said that they were photographed in their home and stated that their mother drinks.

e. Expressing defenses, such as denial within the group space round the meaning of the pictures.

The other sister denied this and said they were photographed in the local store

F. Disclosing the secret through the image

Alex stated that his father also drinks; he pretends that he has over- time work but comes back drunk. He also stated that his mother would be angry that he shared the information that his father drinks within the group space

In this example we see that photography enabled participants to how one reality, but define it verbally in different ways. The reac- ion to the photograph enabled one sister to express her shame nd the other to express her denial in the group space, around he negotiation of the meaning of the image. The photograph is

broad enough symbolic space to contain multiple interpreta- ions or explanations, and this enables the participants to gradually pproach the truth, from verbal denial to disclosure.

Photo 6. Blur to sharpen.

By explaining her refusal to photograph her ‘garbage’ neigh- borhood (and home), Nataly was still accessing her strong painful emotions around her home. She could bear to access them because she also showed her positive photos with her girlfriends.

g. Compositional elements of photographs as projective ele- ments that help to access inner experience of parent’s addiction.

Moran created a blurred picture so as to hide his father smok- ing (Photo 6). When it was pointed out that the photograph was blurred, he said that smoking makes one feel and behave in a blurred way.

Creating a projected distanced symbol of the vulnerable self through photography

a. Expression of painful feelings through a picture

Dor created a picture of his grandmother’s dog. He explained that his parents found it abandoned and adopted it. They gave it to his grandmother to look after, just as he moved into his grandmother’s house when his parents split up due to unresolved addiction prob- lems

Within the group space, the abandoned dog was discussed, although this was clearly also Dor’s experience of being a ‘wounded dog’, looked after by his grandmother.

Dor’s identification with the dog enabled him to indirectly work through his pain at being abandoned by his parents.

b. Using the process of photographing to express defenses.

Nataly explained that she didn’t photograph anything because they only have garbage in their area and there is nothing to photograph. She stated that “everything at home is ugly”. She did not photograph anything from home but she showed group pictures with girlfriends

that she likes and with whom she socializes

Together, the group created posters and slogans showing the dangers of drinking, based on their own images of broken bottles.

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Photography helped reduce denial of parents’ addiction: As tated in the literature review, a central theme for children of ddicted parents is the shame over their parents’ addiction and the eed to deny it from themselves and from others. This makes medi- tion of separation and individuation through peer interaction, and uilding a fulfilling social reality outside of the home very difficult or them, increasing their isolation.

eparation and final group project The final project consisted of making a personal album of pic-

ures for each of the children. The children decided which pictures ould and wouldn’t enter the group album and which would and ouldn’t be shown at the exhibition. The pages of the album were ecorated with additional art materials. The children were afraid o create an ‘ugly’ album, and although the art materials created a evel of aggression, it was limited by the focus on the product. For xample, Emma decided to devote a page to the alcohol problem n her book but many refused to add alcohol to their albums. They rew things outside of the album. The ability to decide helped to ive them a sense of control over their lives.

roup exhibition

Finally, there was a group exhibition of the pictures and of the lbums to which the parents were invited. This enabled the children n one level to undergo a normative experience of showing parents ow they mastered a new skill.

At the same time, on a psychological level, it enabled them to ecome ’ visible ’ to the parents, and to indirectly introduce the ddiction into the room. Within the exhibition, family dynamics nd addiction were acted out:

or example

One mother didn’t arrive. The child was very upset. When he mother understood that there was an exhibition after being honed, she arrived, thus giving space to her child.

The mother said: “Ah, that’s my bottle of alcohol”, and she stated hat she would prefer to be having a drink now than being at the xhibition

The exhibition became an indirect way to turn the subject of rinking into a talked about element in the room.

iscussion

This paper aimed to explore how photovoice can help to achieve he aims of a support group for children of addicted parents: Two entral themes or psychological effects emerged from the data: irst, we saw how photovoice was effective in enabling develop- ental growth. Second, we found that photovoice was effective in

xpressing secret and negative feelings about parents’ addiction in non-threatening way. The second theme is connected to the first ecause it freed up energy to deal with development rather than ealing with the negative and secret feelings about the parents’ ddiction.

In relation to the first theme, we observed that the use of pho- ography enabled a space for developmental milestones such as ndividuation and the creation of a positive self-image and iden- ity. In this case-study, photovoice became a concrete tool and a ew skill that was developmentally appropriate. The acquisition f a new and normative skill helped to enhance self-esteem. On

systemic level, the distancing of the camera made it possible to

bserve rather than to participate in symbiotic relationships with ddictive parents, and this in turn enhanced the developmentally ppropriate separation of latency. We saw this in the example of sher who photographed his mother from behind, so that she could

otherapy 60 (2018) 82–90

not look at him. To elaborate, the private space of the camera per- mitted the creation a zone of self-experience that was private and controlled by the photographer. The second stage, sharing images, enabled the sharing of one’s experiences and having them con- firmed. This in it self was a basic developmental milestone that addicted parents often cannot provide because of their own denial of feelings. The externalizing of inner experience through an exter- nal metaphor was shown to be a safe space to meet the self and the inner-emptiness that became full by giving it shape and form. This defined the use of an art activity as a positive way to fill in empty spaces or lack of content (rather than using addictive substances as learned at home). This is shown above when Emma photographed the empty wall above her bed, rather than her sister’s pop posters. The camera became a space to capture developmental transitions and processes through symbolic images, as shown by the above participant’s later images of playgrounds and makeup as a devel- opmental transition. Overall, the camera enabled both autonomy and individuation on the level of taking photographs, and recog- nition and validation on the level of sharing them in the group. These basic developmental milestones are hard to reach within the symbiotic parental or chaotic roles in an addicted family with high levels of denial.

The first theme connects to the second theme, the way that pho- tography made it possible for the children to indirectly confront and share the parents’ addiction and associated feelings. Photog- raphy helped the children to start ‘seeing’ for themselves from a safe distance behind the camera. The use of a camera rather than a cellphone helped to create this aesthetic separation, as the cam- era made the choice of the picture more intense than automatic photographing on a phone. Rather than using lies to define the experience or ‘not seeing’ (a behavior learned from the addicted parent), the children learned a structured way to ‘see’, as when a participant photographed empty wine bottles but did not want to talk about them. Within the group space, words were gradu- ally found to further articulate and define symbolically and visually caught experiences of parents’ addictions at the child’s own pace. This became an adaptive communication skill that reconnected to the first theme of developmental milestones. This process, as shown in the data section, was gradual and was not easy: The children experienced the camera as threating their ‘secrets’ and there were many expressions of resistance; they were afraid and embarrassed; they asked for very directed art work and often forgot the camera or refused to show their images. However, within the group space, the camera provided multiple options for dealing with denial. By choosing which images to show and which not, or by utilizing the multiple options to erase a photograph, or by showing a photograph to some but not to others, or by showing but not talking about images, the camera enabled a range of strategies to self-regulate disclosure of the secret of addiction to oneself and to others. This added a level of control over what was photographed, although they had no control of the content. This combination enabled a gradual exposure of the truth. To elaborate, photographs are a broad enough visual symbolic space to enable multiple verbal interpretations of reality, from hiding the secret, to partial, to full disclosure, for exam- ple, photographing wine bottles in the store rather than the home, and discussing whether they entered the home or not. The indi- rect metaphors, together with the photographing of real places and objects (such as alcohol bottles) made this range possible. However, although the spaces are real, a photograph is always a projected and subjective choice of elements. On this level, the photographs showed the children’s emotional reactions to the addiction through the elements that they chose to photograph and explain, for exam-

ple, showing a wine bottle next to a crack in the wall and saying that drinking breaks up the family, or using the image of an aban- doned dog to describe one’s abandonment by addicted parents. As stated above, there is a first level of disclosure by photographing

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n image, and a second level, by explaining the image in the group pace: This also helped to gradually expose the addiction to one- elf and to others. Beyond the secret of addiction, the photographs an also capture and concretize the defenses used by the children n expressing their parents’ addiction. This was shown in the use f general rather than home spaces, and describing these spaces s ‘the garbage in our area’. Other strategies included a blurred hotograph, cracks in the wall to signify cracks in the family, and thers.

From the above, what specific methodological contributions oes photovoice make for groups of children with addicted par- nts? These are outlined in the following list:

Theme 1: Photovoice as enhancing developmental mile- tones within the group space

Photovoice became a concrete tool and a new skill that was devel- opmentally appropriate.

The distancing of the camera made it possible to observe rather than participate in symbiotic relationships with addictive par- ents.

The private space of the camera permitted the creation a zone of self-experience that was private and controlled by the photogra- pher.

Sharing of images enabled the group members to share their experiences and to have them confirmed.

The externalizing of inner experience through an external metaphor was shown to be a safe space to meet the self.

The art activity was a positive way to fill in empty spaces or lack of content (rather than using addictive substances as learned at home)

Theme 2: Photovoice as enabling self-regulated disclosure of he secret

The photography helped the children to start ‘seeing’ the addic- tion for themselves from a safe distance of behind the camera.

The use of a camera rather than a cellphone helped to create this aesthetic separation as the camera made the choice of picture more intense than automatic photographing on a phone.

Rather than using lies to define experience or ‘not seeing’ (a behavior learned from the addicted parent), the children learned in a structured way to ‘see’.

Another element that enabled regulation of self-disclosure is that photography enabled a level of control over what was pho- tographed, although they had no control of the content.

Within the group space, exposure of contents could be regulated by the child: That is, images can be talked about or only shown or not shown. This included the option to erase an image or to share it selectively.

Others images could help soften denial because of the shared reality and metaphorical quality of the images.

The indirect metaphors, together with the photographing of real places and objects (such as alcohol bottles) made a range of con- crete, but also emotional disclosures possible. In other words, the images showed feelings and reality at the same time.

To summarize, we see that, in therapeutic terms, these etaphorical methods created a projected distanced symbol of the

ulnerable emotional self, but also, of the reality of self-in-family. he metaphors worked as a projective space for all group members ho have a shared reality. This, in itself, becomes a healing element

n that the children feel that they are not alone. However, within

hat shared external reality, the photograph, in its subjective choice f real, symbolic, and compositional elements, helped to show how ach child reacted to or experienced this reality individually. Thus, oth a subjective, but also objective space was created that res-

otherapy 60 (2018) 82–90 89

onated with the person in the context approach to social work. This inherent paradox of photovoice, that it is simultaneously symbolic and constructed, but also ‘real’ created an overlap between subjec- tive and social experience, or a depiction of how one experienced one’s social reality. In the group, this element was strengthened by the informative component of the meetings where children were taught about addictions as part of the shared reality level of the group.

The creation of an exhibition at the end of the group process further highlighted this paradox. The exhibition enabled two pro- cesses: On the overt level, the exhibition created a normalizing destigmatizing activity in which the children invited their parents to their photography show. On the other, more covert level, the children were indirectly talking to their parents about the problem of addiction through the images in a public space that helped to release the secret in a regulated metaphorical way. We saw that the parents could still experience this as an intense confrontation. This points to the inherent complexity but also the power of pho- tovoice in presenting an inner symbolic world that is embedded in the context of the real physical reality of the photographer. In other words, it creates a phenomenological depiction of a social reality

A limitation of this paper is that it followed a single case study, and it did not measure effectiveness in a controlled way. Future research can do so. However, its thematic case study analyses made it possible to show complex developmental and group processes that were enabled by including photovoice within the group. The literature on the effect of arts in group work also enabled theoriza- tion of these processes.

This is an exploratory paper. Its contribution is that it has highlighted the dual role of photovoice in enhancing natural devel- opment and enabling children of addicted parents to approach their pain and defenses in an indirect but concrete manner. This abil- ity to work “inside” but also “outside” was shown to be especially relevant for many groups of children in complex realities. This con- nection between micro and macro levels of experience can help to externalize rather than internalize the source of the problem for the children. This is concurrent with the aim of clinical social work, that is, to present emotional problems within their social contexts, and on this level, photovoice is particularly relevant to social epis- temologies of combining micro with macro perceptions, an area that needs to be articulated more clearly in social work.

We hope that these findings will create a clear rationale as well as a suggested protocol and approach for clinical social workers to include photovoice in group work with children of addicted par- ents.

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