Gluing the pieces together: Female adolescents’ construction of meaning through digital metaphoric imagery in trauma therapy

The Arts in Psychotherapy 54 (2017) 92–104

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The Arts in Psychotherapy

Research Article

Gluing the pieces together: Female adolescents’ construction of meaning through digital metaphoric imagery in trauma therapy Deirdre Kruger ∗ , Marna Swanepoel Department Psychology of Education, PO Box 392, University of South Africa, 0003, South Africa

a r t i c l e

i n f o

Article history: Received 7 October 2016 Accepted 24 April 2017 Available online 29 April 2017 Keywords: Adolescent Digital metaphoric imagery Trauma Adaptive trauma reactions

a b s t r a c t This paper describes the construction of meaning through digital metaphoric imagery in trauma therapy with four female adolescents. These artworks supported the creation of a trauma narrative to integrate trauma memories with other memories. Through social constructionism, this art-based research using a case study design uncovered intersubjectively shared, social constructions of vulnerabilities and strengths cocreated by researchers and participants. The digital art trauma therapy sessions integrated into a cognitive-behavioural meta-model of three stages, comprised ten individual, weekly sessions per participant. The creation of four digital metaphorical artworks in the middle stage of therapy directed the participants toward the processing of traumatic material. The results showed that the four participants attached multi-layered meaning to their trauma through the digital metaphoric imagery. The results also showed that the disabled characteristic attributes of the initial metaphors were restored as the participants developed a new understanding of traumatic experiences. Three of the four participants acquired strengths associated with post-trauma growth according to the meaning that they attached to the digital metaphoric imagery. Attaching meaning to trauma memories helped the participants to contain the disorganisation of the trauma in order to integrate their trauma narratives into contextual aspects of their autobiographical memories. © 2017 Elsevier Ltd. All rights reserved.

Introduction According to a Western worldview, psychological trauma is seen as a unique individual experience when a sudden or unexpected incident takes place that exposes the person to death or threatened death, and actual or threatened serious injury or sexual violation (Marzillier, 2014; Sanderson, 2013). Trauma is accompanied by the association of intense fear (Marzillier, 2014), horror, and helplessness (Sanderson, 2013) and it violates the person’s belief and expectations about the world and the self (Boehnlein, 2007; Cohen, Mannarino, & Deblinger, 2017; Sui & Padmanabhanunni, 2016; Van der Kolk, 2007). However, not everybody is affected in the same way: resilience (Alayarian, 2011; Harms, 2015; Konner, 2007); personality and coping strategies (Dass-Brailsford, 2007); religion (Boehnlein, 2007); developmental, family, communal, political and sociocultural contexts (Lemelson, Kirmayer, & Barad, 2007) also determine how the person copes with the trauma. Developmentally, adolescence may compound coping with trauma ‘when teenagers struggle to establish their identities’ (Dass-Brailsford,

∗ Corresponding author. E-mail address: [email protected] (D. Kruger). http://dx.doi.org/10.1016/j.aip.2017.04.011 0197-4556/© 2017 Elsevier Ltd. All rights reserved.

2007, p. 182) as the transformation of adolescence is often already associated with a profound sense of disquiet (Gatta, Gallo, & Vianello, 2014). Although there are various types of trauma (Briere & Scott, 2015), child psychiatrist, Lenore Terr, distinguished singleincident trauma and complex trauma as main types in children (Courtois & Ford, 2013; Marzillier, 2014). This papers deals with complex trauma which is defined as repeated traumas within the caregiver system (Harms, 2015). Trauma should not be reduced only to distressing emotional states; Joseph and Linley (2008) allude to post-trauma growth following adversity or positive changes after struggling with trauma (Kilmer & Gil-Rivas, 2010). The struggle after the trauma has a transformative quality (Lepore & Revenson, 2006). Although the scars of trauma are acknowledged, they do not devaluate the selfidentity and they are not all-encompassing future determinants. The survivor’s life is not over; good things in future are possible (Briere & Scott, 2015; Harms, 2015; Kirmayer, Lemelson, & Barad, 2007; Meyerson, Grant, Carter, & Kilmer, 2011; Rousseau & Measham, 2007; Tedeschi & Calhoun, 1996). Trauma may thus be seen as a process that evokes both vulnerabilities and strengths (Padmanabhanunni & Edwards, 2016; Rousseau & Measham, 2007) as adaptive reactions to survive it.

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Emotional, cognitive and behavioural reactions to trauma may affect normal interactions and daily routines as these reactions break through the normal defences and create a profound state of disorganisation in which meaning collapses (Marzillier, 2014). Contributing to the disorganisation, Avrahami (2006) and Edwards (2013) explain that trauma memories are not integrated with other memories through the usual process of associative connections and information processing. Instead, trauma memories are sorted as isolated fragments of sensory observations and emotional states of visual images (Van der Kolk, 2007). ‘They [trauma memories] consist of sensory impressions rather than thoughts . . . and are triggered by cues that are not semantically related to the trauma’ (Marzillier, 2014, pp. 48–49). The trauma memories that are without narrative organisation (Gantt & Tinnin, 2009) can be accessed through artwork. The latter provides a gateway to the sensory impressions of the trauma that the brain retains (Chilton, 2013) which can then be processed through a trauma narrative (Gantt, 2012). The creation of a personal trauma narrative is necessary to translate and integrate the trauma memories into contextual aspects of the autobiographical memory (a memory about one’s life) to achieve coherence (Marzillier, 2014) and to establish more organised and meaningful cognitions. The process of recounting trauma seems to involve a progressive cognitive reorganisation and reintegration (Kirmayer et al., 2007). Art therapy acts as a safe vehicle for self-expression in the creation of the trauma narrative. It also helps individuals to construct meaning (Terr, 2009) and provides relief from overwhelming emotions or trauma (Appleton, 2001; Gantt, 2012; Malchiodi, 2012; Rousseau & Measham, 2007). Gatta et al. (2014) state that art therapy ‘weaves a web that joins body, mind and emotions’ (p. 1) to contain the chaos of the trauma within the borders of a concrete art product as part of the integration process and the regaining of control (Avrahami, 2006). According to Marzillier (2014), the narrative can allow positive feelings to emerge, ‘a sense of human dignity and virtue, of survival against all the odds’, thus facilitating hope for a good future (p. 265). The personal narrative, however, needs to be created without causing unnecessary trauma or pain to the client. The retelling of the personal narrative involves a controlled re-experiencing of the trauma experience in a caring, stable environment to help heal the emotional, psychological injury caused by the trauma (Briere & Scott, 2015; Van der Kolk, 2007). Using metaphor in art therapy renders the re-experiencing less threatening because of the metaphor’s anxiety-buffering value (Foley, 2015; Reich, 1998), although it still contains imaginal exposure (Johnson, 2009). It also provides ‘glue that links disparate aspects of human mental life, over time and across different contexts’ to help with the creation of a narrative that gives meaning to past and present experience (Bornstein & Becker-Matero, 2011, p. 172). Metaphor has the capacity to tap sensory experience (Reich, 1998), similar to artwork that also provides a gateway to the trauma’s sensory impressions. McGuinty, Armstrong and Carrière (2014) maintain that metaphors are the scaffolding process that is central to therapeutic change in narrative therapy. The purpose of this paper is to zoom in through a metaphoric lens on the digital art of female adolescents residing in a house of safekeeping during trauma therapy. How did digital metaphoric imagery in trauma therapy facilitate the construction of meaning? We also briefly zoom the lens out to give a wide angle of the context in which these metaphors as creative art therapy (CAT) format were integrated into a cognitive-behavioural (CBT) trauma treatment. Although this paper exposes one of the three main directions to explore in trauma treatment, namely to ‘develop CBT-based approaches and formats for the CATs in trauma treatment’, as recommended by Johnson (2009, p. 119), the macro focus remains on digital art. However, the digital art does not contain the entire

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course of therapy. Digital art in this paper refers to artwork created on a computer as many art therapists currently incorporate digital media, which has become part of daily life, into therapy sessions (Alders, Beck, Allen, & Mosinski, 2011; Carlton, 2014; Orr, 2012). Eaton, Doherty and Widrick (2007) have already established that art therapy was used successfully in a variety of contexts as a treatment regimen for traumatised children and adolescents. However, we could not find any systematic enquiry into digital metaphoric imagery as trauma treatment in the ScienceDirect, Proquest and Taylor & Francis databases, hence providing the rationale for this research. We coined the term ‘digital art trauma therapy’ to consolidate the frameworks of CBT trauma treatment, art therapy, and technology. Conceptualising metaphoric imagery in trauma therapy The use of metaphor in therapy lies in the transfer of meaning from one domain to another. It can be thought of as referring to a way of looking at things (Legowski & Brownlee, 2001). It forms a bridge to the client’s inner world and the client can talk about the externalised concept in therapy. The metaphor functions by describing aspects, characteristics or situations indirectly to give them meaning which is often multi-layered (Moon, 2007). The therapist does not interpret the concept or image for the client, but merely asks questions about the metaphor’s description, communication, or actions (Bowman & Macduff, 2015; Goldberg & Stephenson, 2016; Legowski & Brownlee, 2001). Enquiry about the metaphor could explore the feelings and experiences associated with the imagery. We adjusted the externalising metaphors therapy of McGuinty et al. (2014) for our trauma treatment. They developed a short-term treatment based upon metaphor transformation for children and adolescents that impacts on underlying emotion. McGuinty et al. (2014) consider the use of metaphors as the best way to create a distance between the client and the problem. This constitutes a more person-centered and less problem-focused approach (Foley, 2015). Metaphors can also be explored, manipulated, and transformed to bring about therapeutic change. Furthermore, as metaphors mirror the problem, a shift in metaphor may reflect the client’s new understanding of experiences. Corpt (2011) describes it eloquently as ‘a metaphor begins to emerge that might provide the emotional torque of a new bit of understanding’ (p. 216). McGuinty et al. (2014) conclude that metaphors offer a framework with which the client can visualise, assimilate, elaborate, and manipulate to reclaim a sense of identity and gain a novel view of others and life. Externalising metaphors McGuinty et al. (2014) incorporate metaphors in their treatment protocol by combining the therapeutic techniques of Michael White, David Epston, and Richard Kopp. 1. The client creates a client-generated metaphor that might represent the problem which can be discussed, drawn, written, or moulded to physically represent the metaphor. If the client cannot present a metaphor, the therapist may offer suitable suggestions such as a monster or a wolf. The client may choose to adapt the therapist-generated metaphor. The metaphor is then explored through enquiry to determine the client’s sense of self, others or relationship, and life, as well as how the client thinks, feels and acts. The therapist reminds the client to be mindful of the metaphor after the therapy session as it may change before the next session. 2. The therapist and client revisit the metaphor to determine whether it is unchanged, transformed or new. The client could

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create a new metaphor between sessions. If the metaphor did not change, it may be transformed in the session or a new one may be created. If the metaphor was transformed, the transformation continues in the session. If a new, suitable metaphor emerged between the sessions, the therapist and client investigate the possibilities of transformation. If the new metaphor is deemed unsuitable for transformation, it is replaced by a suitable one. With the transformation in place, the therapist and client explore the metaphor against the client’s strengths and the impact of the treatment that also includes relaxation and cognitive restructuring, among others. The therapist may also ask future-oriented questions in relation to the metaphor. The therapist encourages the client to continue working with the metaphor after termination of therapy and reminds the client that the metaphor may continue to change. Metaphors in digital art trauma therapy for traumatised female adolescents We do not encourage the transformation of the initial clientgenerated metaphor at first, but rather facilitate transferred transformation of the client-generated metaphor through the intermediate transformation of the therapist-generated metaphor. Thus, the transformation of the therapist-generated metaphor acts as vehicle for the transformation of the client-generated metaphor. The digital metaphoric imagery is embedded in cognitive-behavioural trauma therapy and implemented halfway through the treatment (see Table 2) in the middle stage or Phase 2, according to a meta-model of three stages, when the client is ‘directed toward the processing of traumatic material’ (Courtois, 2004, p. 418). The meta-model sets out the evolving standard of trauma treatment: Phase 1 involves alliance formation and stabilisation; Phase 2 trauma processing; and Phase 3 functional reintegration (Cohen et al., 2017; Courtois & Ford 2013; Ford, Courtois, Steele, Van der Hart, & Nijenhuis, 2005). The middle stage is trauma focused and involves processing of trauma memory and integration into autobiographical memory (Edwards, 2013). Non-threatening art activities in Phase 1 (sessions 2 and 3) and a trauma-related artwork (session 4) in Phase 2 precede the metaphoric imagery. All the art activities in Phases 2 and 3 are executed in separate sessions; the sequence is indicated in Table 2. The instructions can be rephrased until the client understands what is expected. The activities also involve observation of the client and exploration of the image by asking questions. The client speaks to her own experience and attaches meaning to it. ‘If the therapist interprets the images or suggests images, the meaning of the metaphor may be misconstrued, since a metaphor can have a multiplicity of meanings’ (Legowski & Brownlee, 2001, p. 27). 1. The client creates an artwork using a client-generated metaphor that expresses feelings associated with the metaphor. The artwork enables affective expression and explores the thoughts and feelings evoked by traumatic memories. It serves as a starting point for cognitively processing the trauma. The instruction is: ‘Think back of your past and what happened to you. Change yourself into anything that will best express how you feel when you think of your past.’ 2. The client creates an artwork using a therapist-generated, goaldirected metaphor of a monster that embodies the trauma on a visual level. Responses to questions about the metaphor’s description, communication, or actions form a bridge to the trauma narrative. The instruction for this activity is: ‘Create an image of your trauma, preferably in the form of a monster’. 3. The client re-works the monster artwork by taking control of the monster and finding ways to render the monster harmless. The goal of the transformation of the therapist-generated

metaphor is to promote mastery of the trauma reminders and to improve coping skills over emotional, cognitive, and behavioural reactions associated with trauma. Imaginal re-exposure increase tolerance to re-experiencing the trauma. These changes in the metaphor are ratified to consolidate the changes (Battino, 2002). The instruction is: ‘What can you do to take the power of the monster away?’ 4. The client creates an artwork to depict herself and her life as it currently is, or how she envisions the future. The transformation of the client-generated metaphor is only suggested, should the client wish to include it. The goal is to enhance cognitive reframing so that the client is able to cope with the after effects and memories of the trauma and to improve overall functioning. Battino (2002) maintains that the new life story will change the participant’s life because it will guide future behaviour. The instruction for this activity is: ‘Create an artwork to show yourself and how your life currently is, or how you see the future. You can use the image of the . . . that you have changed yourself into’. These metaphoric imageries are preceded by an art activity in which the client has to think of her past, specifically her trauma memories and accompanying feelings, and depict those in a digital artwork (see Table 2). The therapist compares this artwork of the client’s initial feelings to the artwork of the client’s current life or future to determine progression. Method Design The research is art-based to show the relationship of art to therapy (Carolan, 2001). The systematic use of actual art creations (McNiff, 2008) specifically aimed to address how ‘images [can] be used as a means of developing a relationship with aspects of self or other so that dialogue can develop and new meaning evolve’ (Carolan, 2001, p. 203). The method is social constructionism that focuses on collective generation of meaning which implies some kind of interaction between the inquirer and the knowable when these understandings are created (Lee, 2012). As founding theorist of social constructionism, Gergen (1985) opposed the views of positivism and empiricism which postulate that knowledge is objective. The search for the fundamental nature of ‘truth’ can be traced back to, among others, the German philosopher, Martin Heidegger, who used the Greek word aletheia which means disclosure of meaning (Owen, 1992). Gergen (1985) asserted that negotiated understanding is of critical significance especially in the field of psychology and psychological assessment. The approach that Gergen labelled as social constructionism concerns the intersubjectively shared, social constructions of meaning and knowledge (Crotty, 1998). The data analysis reflects the intersubjectively shared constructions through the cycles of coding in which we, as researchers, had to reach agreement among each other as well as member checking when the participants had to agree with our attribution of meaning. The subjectivist epistemology of social constructionism in which understandings are cocreated (Lee, 2012) is inevitably linked to context. We are situated amidst the 21st century technology revolution in an unstable developing country rife with violent crime and other forms of trauma that affect over 70% of the population (Sui & Padmanabhanunni, 2016). Having more than 20 years of experience in dealing with trauma through metaphor, we looked at adaptive trauma reactions in this paper as a construction that emerged through the interactions of the participants with themselves and others. We contend that humans interpret experiences

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in the large number of life-worlds through relationships and verbal and non-verbal communication, including artwork. We attempted to represent the participants’ realities by entering into the ‘realworld contexts that give human action it meaning’ (Burr, 2015, p.16) through interviews, digital metaphorical imagery coupled with enquiry, and observation as illustrated in Fig. 1. The design was a case study to provide an in-depth analysis of how digital metaphoric imagery facilitated the construction of meaning when integrated into a cognitive-behavioural trauma treatment. The number of participants was too small for a case series. The single-case was bounded by time and activity, and we collected information using a variety of data collection instruments (Creswell, 2013). All these aspects are detailed below.

Participants Four female traumatised participants aged between 13 and 15, residing in a house of safekeeping for abused girls (The House), were sampled using critical case purposive sampling. The participants were placed at The House by court order. Table 1 contains their traumatic backgrounds which are also used as descriptors in this paper to distinguish the participants. We selected participants with a basic knowledge of how to use computers and excluded those with threats of suicide and those who were receiving other forms of psychotherapy at the time of our treatment.

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Procedure The digital art trauma therapy sessions comprised ten individual, weekly sessions per participant that lasted from 45 min to 60 min each. In view of Phillip’s (2014) conclusion, after studying attrition rates, that ‘a firming up of short-term psychotherapy may become the most important and urgent matter in all of psychotherapy’ (p. 17), coupled with Avrahami’s (2006) supposition that visual art therapy allows the trauma to communicate in its own language (to attain more in less time), we limited the therapy to ten sessions. We took an active role and developed a focus for the therapy early in the process (Messer as cited in Barrett et al., 2008), as well as a vigilance that the digital art work did not distract the participants from the therapeutic goals (Carlton, 2014). For example, the novelty effect of becoming a digital artist should not compromise the therapy. The sessions took place in an office at The House, conducted by the researcher who specialises in face-to-face art therapy and online art therapy. (We joined forces as researchers and registered educational psychologists to develop the therapy. One researcher is an expert in trauma therapy and the other researcher has a visual arts background with a Bachelor degree in Fine Arts. Although she has specialised on a Master’s level in art therapy, the Health Professions Council of South Africa does not have a registration category for art therapists under psychology). The integration of digitally created metaphors into a cognitivebehavioural trauma treatment is contained in Table 2. Data collection and analysis

Equipment The digital art trauma therapy equipment consisted of a computer laptop, printer/scanner and two software programmes, namely, Windows Paint (Microsoft Windows 7 Professional 2009, Service Pack 1) and ArtRage (version 3.0.8, 2013). ArtRage software has a wide range of tools (e.g., pens, pencils, oil paint, spray paint, watercolour, glitter, paint rollers, various canvasses) and techniques (e.g., smearing, mixing, superimposing, writing, erasing). Artwork can also be imported from one of these two programmes to the other. An external hard drive served as backup to save each participant’s password-protected artwork in order to ensure confidentiality (Alders et al., 2011). A variety of magazine pictures were available that could be scanned for use in the artworks.

The data collection instruments included interviews, image data with enquiry, and observation. Two face-to-face, semi-structured interviews with each participant (at the beginning and end of the treatment) applied adaptive trauma reactions as guide, although we did not assume that asking questions about trauma reactions would automatically result in disclosure (Courtois, 2004). Reactions to trauma may include, but are not limited to, insomnia, restless sleep, muscle tension, loss of appetite, poor concentration, memory problems, confusion, shock, disbelief, flashbacks, intrusive memories or thoughts, repetition of thoughts, avoidance behaviour, emotional numbness, heightened vigilance, grief, irritability, aggression, anxiety, panic, inappropriate guilt feelings, shame, depression, nightmares, impul-

Fig. 1. Diagrammatic presentation of social constructionism to generate collective meaning.

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Table 1 Participants’ Traumatic Backgrounds. Participant

Age

Traumatic background

Participant 1 (‘grandmother’s abuse survivor’)

15 years

Participant 2 (‘refugee survivor’)

13 years

Participant 3 (‘homeless survivor’) Participant 4 (‘sexual abuse survivor’)

14 years

Her mother abandoned her when she was young, leaving her with family members who took her to live with her grandmother. Neighbours of her grandmother reported instances of abuse and neglect. Social Services removed her from the grandmother’s care when her grandmother poured petrol over her, threatening to set her on fire. She has lived in The House for the past two years. Her family is in South Africa on refugee status from their home country, Burundi, which they fled due to civil war. The family moved extensively in South Africa and she has not attended school since Grade Two. After her mother passed away, she lived on the street. Her older brother is currently serving a prison sentence and the whereabouts of an older sister is unknown. She has been at The House for five months. Her father visits her occasionally. She became homeless after her mother disappeared. She has lived at The House for the past 18 months. She was removed from her home after she had been sexually abused by the mother’s boyfriend and some of his friends over a period of time. The boyfriend perpetrator is currently serving a prison sentence. She has been at The House for 13 months.

13 years

Table 2 Integration of Digitally Created Metaphors into a Cognitive-Behavioural Trauma Treatment. Session

Stage

Course of the treatment

1

1

2

1

3

1

4

2

5

2

6

2

7

2

8

3

9

3

10

3

Establish a base of acceptance and security. Semi-structured interview to identify the adaptive reactions (Sanderson, 2013). Psychoeducation to help participants to understand their reactions better (Cohen et al., 2017; Courtois, 2004; Sanderson, 2013). Affect regulation to label emotions correctly (Briere & Scott, 2015; Courtois, 2004). Manual collage making to depict their present reality and emotions – a non-threatening introduction to the process of creative expression (Diggs, Lubas, & De Leo, 2015). Introduce various functions and tools of both software programmes. Creation of any artwork of choice. Addressing emotions resulting from previous sessions (Courtois, 2004). Work with two software programmes to explore trauma memories and feelings. Participants think of their past, specifically their trauma memories and accompanying feelings, and depict those in an artwork. Psychoeducation on trauma (Cohen et al., 2017; Courtois, 2004; Sanderson, 2013). Trigger awareness in the environment to address flashbacks or intrusive negative feelings on a cognitive level (Briere & Scott, 2015). Distress reduction and affect regulation training (Briere & Scott, 2015) by means of progressive relaxation (clenching and releasing muscles) and breathing techniques (Cohen et al., 2017). Digital artwork of a client-generated metaphor that expresses feelings associated with the metaphor. Progressive relaxation and breathing techniques (Cohen et al., 2017). Digital artwork of therapist-generated metaphor of a monster. Recount trauma, combining facts and emotions. Oral trauma narrative describes the experiences before, during, and after traumatic events. Progressive relaxation and breathing techniques (Cohen et al., 2017). Digital artwork of the transformation of the therapist-generated metaphor to render the monster harmless. Ratification of changes in the metaphor to consolidate the changes. Digital artwork to depict the participants’ current life or how they envisioned the future. Client-generated metaphor can be used. Emphasis on strengths (Courtois, 2004). Manual or digital collage making to symbolically assemble images into a new composition to create a new whole (Avrahami, 2006; Courtois, 2004). Semi-structured exit interview. Reframing of persistent trauma reactions as potentially adaptive (Briere & Scott, 2015).

sive behaviour, affect dysregulation, loss of meaning, dissociation, disturbances of identity, increased sense of vulnerability, psychogenetic pain (chronic pain that cannot be explained medically), and substance abuse (Alayarian, 2011; Briere & Lanktree, 2012; Briere & Scott, 2015; Cohen et al., 2017; Dass-Brailsford, 2007; Kirmayer et al., 2007; Sanderson, 2013; Van der Kolk, 2007). The image data consists of one digital artwork about feelings and four digital metaphoric artworks. The participants’ responses to questions about the description of the artworks were combined with participant observational field notes. These notes also

contained the participants’ application of the software’s tools and techniques as it could be significant. Using the transcribed text and scanned image data, we undertook thematic analysis to organise, code (process, descriptive, ˜ 2016) while applying focused), and categorise the data (Saldana, the iterative framework of Srivastava and Hopwood (2009). The best approach to the perceived problem of coding visual data ‘is a holistic, interpretive lens guided by intuitive inquiry and strategic ˜ 2016, p. 57). Saldana ˜ is a Professor Emeritus of questions’ (Saldana, Theatre at the Arizona State University and his research methods are used internationally.

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Fig. 2. Initial client-generated metaphor of Participant 1 (grandmother’s abuse survivor): a grounded fish eagle.

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Fig. 3. Initial client-generated metaphor of Participant 2 (refugee survivor): black and white flower losing its petals.

Trustworthiness The multi-method data collection strategies were triangulated (see Fig. 1) and supplemented by supporting background data in Table 1. We reached intercoder agreement (Creswell, 2013) after revisiting the data repeatedly. Our subjective analysis of data (reflexivity) was curbed to a certain extent by bracketing. As social constructionists influenced by the hermeneutic tradition, we use the terminology to indicate our open-mindedness (Edwards, 2012). Bracketing was perhaps less challenging for the researcher who was not directly involved in the therapy sessions. We used member checking to determine the accuracy of the findings by taking the categories back to the participants (Creswell, 2013) albeit on a modified level that the participants could understand. Ethical considerations After the University of South Africa had granted ethical clearance for the study, we obtained informed signed consent from the legal guardian and assent from the participants. We explained the risk that privacy may be compromised if the digital equipment was stolen or broken. We obtained the required permission to use the artworks in research (Moon, 2000). We also discouraged the participants from posting the artworks online (Alders et al., 2011). Participants may be so proud of their creations that they may forget the emotional and psychological revealing nature of their work. As the participants were very vulnerable because of their past traumas, their placement in The House, as well as their developmental phase, we closely monitored their psychological and emotional wellbeing by means of observation and a retraumatisation symptoms checklist. Results Initial client-generated metaphors Participant 1 (grandmother’s abuse survivor) changed herself into a fish eagle (Fig. 2). She placed the image of the fish eagle in the centre of the artwork, coloured the background green and proceeded to use various colours to circle and decorate the picture. She also made shapes alongside the image. She made lines over the image and then used the smudging tool to blur parts of the image. While obscuring the image, she remarked that the fish eagle was struggling to fly. She stated that she chose a bird because she would like to be able to fly and be free. She also specified that the fish eagle lived alone in its nest on the ground where it could fall prey to predators, such as lions. When questioned, she answered that

Fig. 4. Initial client-generated metaphor of Participant 3 (homeless survivor): a cheetah lying down.

maybe one day the fish eagle would build a safer nest on higher ground. Participant 2 (refugee survivor) chose a black and white flower losing its petals as metaphor (Fig. 3). She used the paint tool to circle the image in blue and added yellow and additional blue strokes. She also used the pen tool to scribble red lines over the artwork, using short, forceful and heavy movements. Lastly, she employed the smudge tool and smeared some of the colours and the image, rendering it almost unrecognisable. She was not talkative during this process and just stated that she felt grey like this flower. She seemed to be in a reflective mood. She added that the flower was uncertain if it should be in a pot in a house or in a field, but it had no choice in the matter. She said that the flower sometimes did not get enough water and wilted, but this could be remedied by watering. Participant 3 (homeless survivor) used a cheetah for her metaphor because it can run fast (Fig. 4). However, the cheetah was portrayed lying on its side, almost immobilised. When prompted, she decided that the cheetah lived in the bush with other cheetahs. She used the glitter tool to add green grass. She then selected the paint-bucket tool and coloured the background brown. She said the cheetah was lying down because it was tired and she sometimes felt like that as well. Participant 4 (sexual abuse survivor) chose a python as her metaphor (Fig. 5). She opted for a python because then she could kill her enemies and no one could harm her. She drew shapes around the python with the paint tool. She chose the roller tool, maximised its size, and proceeded to cover most of the artwork and part of the snake with blue strokes. When questioned, she stated that she did not like it and wanted to cover it up. When asked about the identity of her enemies, she replied that all other animals were enemies.

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Fig. 5. Initial client-generated metaphor of Participant 4 (sexual abuse survivor): a solitary killer python.

Fig. 6. Participant 1 (grandmother’s abuse survivor): therapist-generated metaphor of a monster.

Fig. 7. Participant 2 (refugee survivor): therapist-generated metaphor of a monster.

Fig. 8. Participant 3 (homeless survivor): therapist-generated metaphor of a monster.

Further enquiry revealed that the python lived in the forest and did not have other python friends or family. However, the python accepted this situation. Therapist-generated, goal-directed metaphors of monster Participant 1 (grandmother’s abuse survivor) selected a silver tin foil background and selected a water paint tool to create a green snake/dragon-like monster with big teeth, a red eye, and yellow stripe on its tail (Fig. 6). She stated that it was a scary monster that hurt people. When asked how it did this, she said it hurt their bodies. She did not elaborate and did not want to discuss anything further. Participant 2 (refugee survivor) used the paint tool to create her monster artwork. She used short, accentuated strokes to form a blue spiky head with red eyes and mouth, and black strokes to portray a body (Fig. 7). Questioned about the artwork she said it was a scary monster that could eat you. When asked if the monster is a threat, she replied: ‘Not really, only when you are on the street at night.’ When requested to create her monster artwork, Participant 3 (homeless survivor) used the pen tool to draw a black monster trying to catch three little pink and purple girls (Fig. 8). She used the spray-paint tool to give the monster a body resembling black and grey bubbles. She then coloured the sky a metallic yellow colour and added the words: ‘Monster eats children’. She made additional spots on the ground with different settings of the spray-paint tool. When questioned about the artwork, Participant 3 said it was a monster that catches children. Participant 4 (sexual abuse survivor) elected to draw a cyclops (mythical giant with only one eye in the middle of the forehead)

Fig. 9. Participant 4 (sexual abuse survivor): therapist-generated metaphor of a monster.

which she coloured green for the most part (Fig. 9). She continued to colour the eye brown and the mouth red. She then used the spraypaint tool to add a grey ground level that appeared like mist. When questioned about the artwork, she said it looked scary. Transformed therapist-generated metaphors of harmless monster Participant 1 (grandmother’s abuse survivor) chose to superimpose an image of her metaphor, a fish eagle, over her monster with the word ‘power’ and exclamation marks (Fig. 10). She drew a red circle around the eagle as well as blue water at the bottom, insinuating that the eagle was hunting. She then wrote the words ‘Kill,

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Fig. 10. Participant 1 (grandmother’s abuse survivor): transformed therapistgenerated metaphor – rendering the monster harmless.

Fig. 12. Participant 3 (homeless survivor): transformed therapist-generated metaphor – rendering the monster harmless.

Fig. 11. Participant 2 (refugee survivor): destruction of family life.

Fig. 13. Participant 4 (sexual abuse survivor): transformed therapist-generated metaphor – rendering the monster harmless.

kill’ and explained that the eagle was killing the monster so that it would never hurt anyone again. Something was clearly bothering Participant 2 (refugee survivor) as she came to the session in angry and irritated mood. She preferred not to share her feelings and not to transform the monster metaphor. Instead, she insisted on using a scanned family photo of her mother, herself and two sisters (Fig. 11). She sat and stared at the image quietly for a long time, then chose the roller tool and rolled black lines over the photo. She undid this and again sat and looked at the image in silence. Then she selected the roller tool again and for a second time covered the image in angry, almost aggressive strokes. She covered everyone’s faces, except her own, which we blurred in order to maintain confidentiality. Participant 2 did not want to discuss her work. Participant 3 (homeless survivor) reworked her monster artwork by firstly adding a house over the three little girls, placing them safely inside (Fig. 12). She erased the words, ‘Monster eats children’ and added clouds instead. She used the paint and the spray-paint tool to cover and hide the monster behind multicoloured flowers. When asked about it, she replied that the monster could not hurt the girls in the house and that he had disappeared because he was covered by the flowers. When asked if she was one of the girls inside the house, Participant 3 replied maybe. Further enquiry into her experience of safety and security at The House yielded a positive response although she added that she missed her mother. Participant 4 (sexual abuse survivor) imported the artwork of her monster into the basic Windows Paint programme and then added thick, straight horizontal and vertical lines to create a type of fence (Fig. 13). She emphasised that this portrayed a cage, not a

Fig. 14. Participant 1 (grandmother’s abuse survivor): the layers of the participant’s life.

fence, from which the monster could never escape. She also used the spray-paint tool to add black swirls and dots. Participant 4 said the swirls and dots represented the monster’s ‘badness’ which was imprisoned in the cage with him. Transformed client-generated metaphors Participant 1 (grandmother’s abuse survivor) was enthusiastic and used the paint tool to create an artwork reminiscent of a rainbow with stripes of colours, ranging from dark to light at the top (Fig. 14). She used the water paint tool to make an additional, almost transparent, layer of grey over some of the bottom layers.

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Fig. 15. Participant 2 (refugee survivor): brightly coloured flower metaphor that expresses joy.

Fig. 17. Participant 4 (sexual abuse survivor): changed metaphor from a python to a bird.

(These artworks were created before the digital metaphoric imagery as indicated in Table 2). All four participants drew sad female faces. Participants 2 and 4 created weeping female figures. One artwork had a broken heart in the middle. Participant 3 chose an image of a girl on a swing with a downturned face to use in her artwork. She added two sad faces on either side with the words: ‘Stay away I am very sad!’ and ‘Sad face’. Discussion Fig. 16. Participant 3 (homeless survivor): metaphor of a strong, proud cheetah ready to run.

She explained by dulling and darkening the colours she was indicating the bad things that had happened in her life. She further stated that her future was now bright and colourful; she had hope. She wrote the words ‘My life’ in white over the layers of colour. Participant 2 (refugee survivor) selected the same black and white flower metaphor image as before. This time, however, she selected the paint tool and coloured the petals in a variety of bright colours (Fig. 15). She made the background yellow and continued to add various shapes, including flowers, with the spray-paint tool. She declared that the artwork made her happy and that was how she felt at present. Participant 3 (homeless survivor) chose to use her metaphor and selected an image of an upright, fierce cheetah (Fig. 16). She surrounded the image with heart shapes in various bright colours. She also added colourful glitter around the image, and over the hearts, and coloured the background a light turquoise. The words, ‘Happy hope love’, were written above the cheetah. She stated that the cheetah was strong, proud, and ready to run. When asked about her future, Participant 3 said that she felt excited and happy about it. Participant 4 (sexual abuse survivor) changed her metaphor from a python to a bird (Fig. 17). She chose to work in the Windows Paint programme again and created a colourful artwork of a bird perched on a ledge with a nest filled with four eggs. Upon enquiry she said that the eggs would hatch. Preceding art activity of trauma memories and accompanying feelings The initial feelings of the participants about their trauma memories in relation to their digital artworks are briefly summarised.

The overall impression of Figs. 2 and 3 is quite chaotic, and could also display the participants’ profound state of disorganisation (Marzillier, 2014). Although some of the artwork may have been experimentation with the software tools and techniques, the participants could have easily erased elements that they intended to depict in a different manner. First cycle coding The process and descriptive coding in Table 3 uncovers the possible adaptive trauma reactions (vulnerabilities and strengths) present in the digital metaphoric imagery. During the first interview, all four participants displayed emotional avoidance behaviour, for example: ‘When I feel angry or sad or unhappy, I just push it away and try and feel happy again’ (Participant 1); ‘If I feel I am starting to feel something, I just push it down. I don’t want to feel that way, so I don’t think about it or feel it’ (Participant 3). This may account for the few emotions, such as sadness and heartache, expressed in the initial feelings’ digital artwork (depicted according to trauma memories and accompanying emotions). In comparison to these initial feelings digital artworks, the four participants attached multi-layered meaning (Moon, 2007) to their trauma through the digital metaphoric imagery as shown in Table 3. Categories Holistic coding as preparatory approach to grasp basic themes ˜ 2016). Focused coding as preceded second cycle coding (Saldana, second cycle coding method was then used in combination with reflexive analytic memos to develop categories in order to answer the question: How did digital metaphoric imagery in trauma therapy facilitate the construction of meaning?

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Table 3 Possible Adaptive Trauma Reactions in the Digital Metaphoric Imagery. Observation or response to enquiry

Figure

Participant

Code (process, descriptive)

Obscuring the image of the fish eagle Distorting the flower Obscuring the python

2 3 5

1 2 4

Denying, suppressing, avoiding

[fish eagle] ‘. . . that battles to fly’ Black and white flower losing its petals ‘The flower has no choice’ ‘The cheetah is lying down’ Curled up python cannot kill (it curls up because of threat)

2 3 3 4 5

1 2 2 3 4

Struggling, lacking power, feeling helpless

[fish eagle] ‘. . . that battles to fly’ ‘The nest [of the fish eagle] is on the ground’ ‘The cheetah is lying down’

2 2 4

1 1 3

Losing characteristic attribute, feeling trapped

‘The fish eagle lives alone’ Enquiry: ‘Does the python have python friends or family?’ Response: ‘No.’

2

1

Isolation, withdrawal

5

4

‘I don’t like it [the python]’

5

4

Low self-worth

‘Dangerous animals like lions can catch it [the fish eagle]’ ‘Sometimes the flower doesn’t get enough water and then it droops’ ‘I [the python] can kill all my enemies, then they can’t hurt me anymore’ ‘It is a scary monster that hurts people.’ Enquiry: ‘How does it hurt people?’ Response: ‘It hurts their bodies.’ Enquiry: ‘Can the scary monster eat you?’ Response: ‘Not really, only when you are on the street at night.’ ‘Monster eats children’ [text] ‘It [cyclops] looks scary’

2 3

1 2

Threatened, fearful, insecurity, exposed, fragile, vulnerable

5

4

6

1

7

2

8 9

3 4

3 3 4

2 2 3

Uncertainty Flattened affect, emotional numbness Exhaustion

5

4

Aggression with behavioural avoidance behaviour, distrust of others

Monster covered with flowers, not completely obliterated Enquiry: ‘Do you feel safe here [at The House]?’ Response: ‘Yes, but I miss my mom.’

12

3

Experiencing insecurity as grief reaction after the loss of a parent

12

3

Fish eagle ‘kill, kill’ [text] monster; it has ‘power!!!!!’ [text] ‘This [pointing to swirls and dots] is all his badness that is now caught in the cage with him’

10 13

1 4

Positive change in perception of the self, stronger

Fish eagle ‘kill, kill’ [text] monster; it has ‘power!!!!!’ [text]

10

1

Ability to handle difficulty

‘My future is light and colourful, I have hope’ ‘The cheetah is strong and proud and ready to run’

14 16

1 3

Established a new path for her life

‘The bad things that have happened in my life . . . that made the colours less bright and darker’ ‘The cheetah is strong and proud and ready to run’ Metaphor shifting from python to bird

14

1

Incorporation of the trauma into her life

16 17

3 4

A greater feeling of self-reliance Improving relations with others

‘I don’t know if the flower is in a pot in a house or in the field’ ‘I feel grey like the flower’ ‘The cheetah is lying down because it is tired. I’m also tired sometimes.’ ‘I [the python] can kill all my enemies, then they can’t hurt me anymore’

Parallels between initial client-generated metaphors and traumas The meaning attached to certain features of the metaphors showed parallels with the traumatic experiences. The flower that was neither in a pot in a house or in a field showed the displacement of the refugee survivor (Participant 2) who had lived on the street in a foreign country. The importance of water for this flower had another meaning in the first interview with Participant 2: ‘When I was living on the street . . . in nursery the children did not want to play with me always, because my clothes were not always so clean. They did not know we had no water or anything.’ Similarly, the fish eagle, alone in its nest on the ground, was at the mercy of other predators as recounted by Participant 1 (grandmother’s abuse survivor) in the first interview: ‘My mother . . . she didn’t want me. Then I had to live with my aunt. She hates me. It was not very nice’. The cheetah which had lost its vigour reflected the sense of loss experienced by Participant 3 (homeless survivor) in the first inter-

view: ‘I lost my things, and my mom, and the flat we lived in long ago’. Participant 4 (sexual abuse survivor) disliked the curled up python and expressed her low self-worth and guilt in the first interview when she referred to the perpetrator of the abuse: ‘He hurt my body. He hurt me a lot. And now we are not together anymore; everything is broken. I am broken . . . I sometimes feel guilty for what happened, like it was my fault, and all that has happened and that we are not living together anymore’.

Disabled characteristic attributes of the initial client-generated metaphors Three of the four participants disabled the characteristic attributes of the metaphor to portray the incapacitating effect of the trauma: the fish eagle was grounded and struggled to fly; the black and white flower was losing its petals; and the cheetah was lying down. During the first interviews all four participants stated that they had changed as a result of the trauma as the following quota-

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tions indicate: ‘I just don’t feel like me, like I always felt’ (Participant 1); ‘Sometimes I just feel very weak or, what is that word? . . . I don’t have any power . . . I can’t do anything about it’ (Participant 3). Shift in client-generated metaphors reflects a new understanding of traumatic experiences The participants transformed their initial client-generated metaphors as follows. Participant 1 (grandmother’s abuse survivor) depicted two shifts: the grounded fish eagle became an attacking fish eagle that displayed aggression towards the abuser that hurt people’s bodies (Fig. 10); and the novel metaphor of her layered life (Fig. 14) conveyed an understanding of both the good and the bad in life. When asked about her abusive family members during the exit interview, she said: ‘I think I am not so angry anymore. Not so much anymore’. She admitted that she still felt anxious although ‘I am here [in The House] and not there, where I am not wanted and treated badly’, but ‘then I think of my monster and how I can squash it. Like the monster it is not real, I must just remember that’. Participant 2 (refugee survivor) transformed the metaphor of a monochrome flower that was losing its petals into a brightly coloured flower metaphor that expressed joy (Fig. 15). Excerpts from the exit interview show how she constructed meaning of the trauma through the digital metaphoric imagery that she extended to self-psychotherapy: ‘I felt sometimes better after I made the drawing. Except that one day, then I felt horrible [referring to Fig. 11 – destruction of family life] . . . after a while I felt better’. In order to preserve her family memories, ‘I started this book, what do you call it where you paste all your stuff and write? . . . All my photos, those I showed you and all the other stuff I have, so that I can remember it and I write as well . . . Since you showed me that program [Windows Paint], I try to do stuff on the computer.’ The transformed metaphor of Participant 3 (homeless survivor), the ‘proud’ cheetah (Fig. 16), gave new meaning to her earlier feelings of stigmatisation ‘because I don’t have a mom or a home’. She asserted in the exit interview: ‘I know I am not bad, so, if they want to think that, I know it is not true.’ The curled up python metaphor (Fig. 5) of Participant 4 (sexual abuse survivor) ‘didn’t want anything of those things to happen, but they did’ and it ‘couldn’t control any of it’. Through the transformation of the monster metaphor, Participant 4 ‘put him in jail where it can never come out and hurt me’, although she did ‘not [enjoy it] at first, but later, yes’. Confronting her feelings associated with the trauma ‘was hard, but sometimes it made me feel better’. Participant 4 felt that she ‘will have a good future’ as depicted in the novel client-generated metaphor of the bird with a nest filled with eggs about to hatch (Fig. 17). Restored characteristic attributes of the transformed client-generated metaphors The meaning that three of the four participants attached through the transformation of their initial client-generated metaphors speaks of healing. The previously disabled characteristic attributes of the metaphors were restored: the fish eagle could fly and attack; the black and white flower was colourful; and the cheetah was strong, proud, and ready to run. All four participants confirmed the positive change in the exit interview. The statements of the first interviews (‘I just don’t feel like me’ or ‘I don’t have any power’) are in contrast with the remarks made during the exit interviews: ‘I think I feel more like myself’ (Participant 1); ‘I feel I have more power; as if I can change things and not just not strong’ (Participant 3). Participant 2 stated: ‘I am liking myself more these days. I feel stronger, like stronger emotionally’. Strengths associated with post-trauma growth According to the criteria of Tedeschi and Calhoun (1996), three participants showed post-trauma growth in their metaphoric

imagery. Participant 1 (grandmother’s abuse survivor) showed the most areas of growth and change. The fish eagle that killed the monster (Fig. 10) displayed more personal strength than the fish eagle who struggled to fly. The incorporation of the darker colours that represented the trauma in the layers of her life metaphor (Fig. 14) also confirmed her growth in personal strength. Furthermore, the same metaphor (the layers of her life) revealed new possibilities. Some of these possibilities embodied comments about a house and a job in the exit interview. The metaphor of the cheetah that is ready to run (Fig. 16) demonstrated new possibilities and personal strength for Participant 3 (homeless survivor). When asked about her losses during the exit interview, she stated: ‘It is still there, but I am learning to accept it’. The bird with the nest and eggs metaphor (Fig. 17) of Participant 4 (sexual abuse survivor) showed growth in her relationships with others as opposed to the initial python metaphor (Fig. 5) that wanted to kill all others. She summarised her experience of creating these artworks as follows in the exit interview: ‘I think it helped me to express—be that the word?—yes, to express myself.’ Adaptive trauma reactions not uncovered through digital metaphoric imagery Feelings of stigmatisation and guilt were expressed in the first interview, but not uncovered through digital metaphoric imagery. For example, Participant 4 (sexual abuse survivor) stated: ‘They think I am a bad girl. They think it is my fault that I am here and my mom had to go away. And maybe, they even think that man is good, and it’s my fault he went to jail’. More exploration of the imagery by probing further could have yielded different results. Fig. 13 of the caged monster (depicting the perpetrator in prison) provided opportunity for exploration; however, Participant 4’s mastery over reminders of the trauma appeared adequate. The metaphor transformation in Fig. 13 served as a vehicle to implicitly shift the ‘badness’ from the survivor to the perpetrator. She confirmed in the exit interview that she was ‘not bad’ any longer and others did not readily assign guilt to her: ‘I don’t think they think so much about me anymore’. Participant 2 (refugee survivor) was still mourning the loss of her family members and was not ready to exert power over the monster in the transformation of the therapist-generated metaphor. ‘Therapy can never be reduced to rigid procedures, especially an approach that emphasizes the poetics of therapy: imagery, exploration, novelty, creativity, and metaphor’ (Kopp, 1995, pp. 4–5). However, it is possible that the monster image facilitated her mourning and alleviated her rage to the point of some resolution as indicated when she covered her family members’ faces, except her own, on the family photo. Conclusion This paper showed how digital metaphoric imagery in trauma therapy facilitated the construction of meaning of four female adolescents residing in a house of safekeeping. Attaching meaning to trauma memories helped them to contain the disorganisation of the trauma in order to integrate their trauma narratives into contextual aspects of their autobiographical memories. The transformations of therapist-generated and client-generated metaphors enabled associative connections with other memories. Hence, the isolated fragments of sensory observations and emotional states of visual images (Van der Kolk, 2007) were integrated into more organised and meaningful cognitions, although some adaptive trauma reactions remained unexplored or obscured in the digital metaphoric imagery. The disabled characteristic attributes of the initial client-generated metaphors were restored in the

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transformed client-generated metaphors as the shift in metaphors reflected a new understanding of traumatic experiences. Three of the four participants showed post-trauma growth according to the meaning that they attached to the digital metaphoric imagery about their current lives or how they envisioned the future. An obvious limitation of the empirical research is the small number of participants: the findings are specific to the sample group and therefore cannot be generalised to a larger population. Furthermore, the sample consisted of female adolescent participants whereas male adolescent participants may have related meaning through digital metaphoric imagery differently. Additional limitations comprise the age range of the participants that did not fully represent adolescence and the digital methods that consisted of two art programmes which imitate mainly fine arts processes like drawing and painting. Future research about digital metaphoric imagery in trauma therapy could involve both sexes as well as other developmental stages. Research to investigate manual versus digital metaphoric imagery in trauma therapy could also contribute to the body of knowledge.

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