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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

https://doi.org/10.1016/j.aip.2017.11.001

http://www.sciencedirect.com/science/journal/01974556

http://www.elsevier.com/locate/artspsycho

http://crossmark.crossref.org/dialog/?doi=10.1016/j.aip.2017.11.001&domain=pdf

mailto:[email protected]

https://doi.org/10.1016/j.aip.2017.11.001

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M. Malka et al. / The Arts in

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
otherapy 60 (2018) 82–90 83

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

8 Psych

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4 M. Malka et al. / The Arts in

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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M. Malka et al. / The Arts in

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 …