Validation and Trustworthiness

Validation and Trustworthiness


Art in Group Work as an Anchor for Integrating the Micro and Macro Levels of Intervention with Incest Survivors

Ephrat Huss • Einat Elhozayel • Ester Marcus

Published online: 6 May 2012

� Springer Science+Business Media, LLC 2012

Abstract This paper outlines a theoretical model for

combining art and group work to integrate the personal and

the social levels of incest trauma, as advocated in feminist

therapy. Incest survivors must deal with deep, present-day

defenses that result from both the trauma and from the lack

of social support. The paper demonstrates how art work

within a group context can be used to simultaneously

confront defenses, change interactive behaviors, and create

social change. This integrates the dynamic and diagnostic

underpinnings of art and group therapy with a socially

contextualized and empowerment perspective.

Keywords Incest survivors � Group work � Social change � Art interventions


The victims of sexual abuse and incest experience a trauma

with both personal and social reverberations. Added to the

difficulties in exposing the abuse, obtaining justice, and

dealing with misogynic social messages—such as the ten-

dency to blame the victim—is the deep erosion of the most

basic trust. Sexual abuse is experienced as chasms within

the psyche that often demand intensive and long-term

interventions to heal, while still reverberating in the present

social life of the victim (Tillman 1995). The healing pro-

cess often includes exposing the incest and taking legal

action while attempting to heal internal scars (Ellis et al.

1990; Gibelman 1999). Because of this, working with

female victims of incest demands the integration of group

work and trauma work. These perspectives are held toge-

ther through an overall feminist social perspective that

focuses on the experience of the lack of gender equality

that enables sexual abuse to occur and to be lightly pun-

ished (this is true, of course, also for the sexual abuse of

male children and adults). To elaborate, group work helps

to address the social reverberations of sexual assault in the

here-and-now of the group interactions. Understanding the

trauma enables the victim to address the resulting symp-

toms or defenses that are behind these interactions. The

overall feminist approach enables defining the problem as

based on social gender roles and power relationships rather

than on personal pathology. A feminist stand, by definition,

integrates both micro and macro levels of experience from

a gendered perspective, and thus synergistically connects

the personal, group, and social perspectives of the trauma

of incest (Brody 1987; Ellis et al. 1990; Hogan 2002;

Parsons et al. 1994). While this may sound like a mix of too

many theories, this paper claims that the integration of

these different perspectives, anchored through art work,

enables a multi-pronged approach. This will be demon-

strated through a multiple-case study of victims of incest

within a group context. The focus will be on the use of art,

with the additional theories of feminist and group work as a

backdrop or guide for the direction of the art activity and

the way that the art is understood. This enables us to

identify both social and personal levels of incest trauma as

expressed within a single art work. The art work is, in turn,

contained within the group work. The group work is also

embedded in, but reaches beyond the symbolic level. Thus,

both the art and the group will be shown to integrate

symbolic spaces with concrete social support and social

change. This creates a model that is based within but that

E. Huss (&) � E. Elhozayel � E. Marcus Charlotte B. and Jack J. Spitzer Department of Social Work,

Ben-Gurion University of the Negev, P.O.B 653,

84105 Beer-Sheva, Israel



Clin Soc Work J (2012) 40:401–411

DOI 10.1007/s10615-012-0393-2



also challenges dynamic theories that are decontextualized

from social concepts.

Literature Survey

Incest is defined as sexual contact between an adult and a

child who is controlled or enforced by the adult and who,

by definition, is not physically or emotionally ready to be

involved in sexual contact (Zeligman and Solomon 2004).

Incest is initiated by a family member and can occur in or

out of the child’s home and can take place on one occasion

or over time (Tillman 1995). While incest has presumably

occurred throughout history, it was only defined with the

rise of social movements expounding the rights of children

and women. With the ensuing research into these areas

over the last century, the silence around this issue was

broken (Herman 1994). Factors affecting the occurrence of

incest are those that weaken the overall sense of control,

meaning, and connection within a family, and can include

traumatic past experiences, family dynamics, social isola-

tion, lack of social support and extreme stress situations,

including drug use, norms about bringing up children, and

overall family violence (Zeligman and Solomon 2004).

A specific characteristic of incest is the secrecy that is

intensified through the need of both sides of the incest to

deny the social and psychological reality of the sexual

contact (Bentovim 2002). The trauma of incest creates an

erosion of a basic trust, towards the aggressor, and towards

those who did not protect the victim from the aggressor

(Johnson 2002). This can create long term and intense

psychological damage, which includes PTSD, and psychi-

atric, somatic, and behavioral difficulties (Cooper et al.

2000; Granefski et al. 2001).

Group Interventions with Incest Survivors

from a Feminist Perspective

Dynamic interventions with incest survivors aim to

strengthen the ego to the point where it can work through

the traumatic event and incorporate it into full conscious-

ness (Courtoise 1996). The therapeutic relationship is used

as a re-internalization of a safe relationship. From a fem-

inist group work perspective, systemic intervention

addresses the family dynamics that enabled the incest,

corrects it in the here-and-now of the group space, and

contextualizes the traumatic experience within a social

reality that enabled it to occur. Social empowerment

includes ways to become actively involved in changing

views of incest that enable its perpetuation (Belsky 1980).

This can include helping survivors to take legal action and

raising public awareness. However, legal intervention is

not always structured to respect the psychological needs of

the victim (Dorado 1996). Group work can be utilized from

all of the above theoretical perspectives while helping to

relearn social interaction and to acquire new coping

methods within a supportive setting. Group work addresses

issues of personal boundaries and safe sharing in the here-

and-now, which is especially relevant for incest survivors

(Yalom 1995). From a social, critical, or feminist per-

spective, an incest survivors group enables the survivors to

create a group narrative that validates the subjective and

silenced experience within a social context that places

blame on society rather than on the individual (Hogan


Art in Therapy

Art in therapy is cited as an effective method for working

with a traumatic experience such as incest (Ellis et al.

1990). Pifalo (2002) found that there was a significant

reduction in trauma symptoms in sexually abused children

after art therapy. A study comparing verbal therapy groups

with art therapy groups for incest survivors found that art

was especially useful for working with the long-term

effects of childhood incest in adults. Creativity reactivates

flexibility and playfulness, reconnecting cognition, emo-

tional experience, and physical sensation, and helping to

counteract the rigidity of traumatic reactions. (Hass-Cohen

and Carr 2008; Huss et al. 2010; Klingman et al. 1987;

Mallay 2002; Nuttman-Shwartz and Huss 2010; Sarid and

Huss 2010).

Art in Social Change from a Feminist Perspective

Butler (2001), among others, describes art as ‘making

waves’ in society, challenging hegemonic stands, and

giving voice to a silenced experience (Butler 2001; Huss

2009a, b ; Liebman 1996). Jones (1997) defines the page

as a space where women can redefine their subjective

experience and make it visible, rather than being the

passive objects of men’s gaze (Hogan 2002). Similarly,

bell Hooks (1992), Shank (2005) describe the concept of

being seen versus actively seeing as an empowering shift

for women that returns the interpretive agency to them.

Thus, art expression can become a political and feminist

act in itself.

What is described above confirms that the use of art is a

suitable method for the integration of therapeutic and social

action because art is, by definition, a meeting point

between the personal and the social (Devi 1988; Huss

2007, 2009a). Art processes combine the reflective levels

of symbolization of experience, as utilized in art therapy,

and the communicative levels of the final art work (Liebman

1996). Finally, art products can communicate messages

directly to society (Butler 2001; Harrington 2004). All of

402 Clin Soc Work J (2012) 40:401–411




these levels can be extracted from or integrated into a

single drawing or art work (Huss 2009a, b).

Art in Groups—Combining Therapy and Social Change


We see from the above listed literature that both art and

group therapy are symbolic containers of traumatic

memories and interpretive zones in which the client and

the group can create a more enabling narrative. Both types

of therapy utilize elaboration, repetition, and reframing of

the meaning of the art product and of the interactions

within the group around the art process (Betinsky 2003;

Lev-Wiessel et al. 2009; Sarid and Huss 2010). Issues

such as boundaries, trust, intimacy, and shared problems

are explored in the dual areas of group interaction and in

the processes inherent to art work (Skiafe and Huet 1998).

For incest survivors who have deep issues with a lack of

trust, it may be easier to interact through the mediation of

symbolic art work than directly with others. Assertiveness,

body image, sexuality, disclosure, boundaries, and control

are all explored within both art making and group pro-

cesses. The use of art within groups thus doubles, or

intensifies the overall therapeutic intervention (Ellis et al.


Research Method

Research Strategy

This research is based on a qualitative multiple case study

design (Denzin and Lincoln 2000; Mason 2002; Yin

1993). It aims to generate thematic and arts-based data as

a base for a theoretical model for integrating micro and

macro perspectives of intervention with sexual abuse

survivors through group art work. Accordingly, the ana-

lytical prism is both phenomenological, capturing the

experiences and understanding of the women themselves

within their social context, and interpretative, capturing

the deep levels of intra-psychic change that the women

can undergo through group and art experience, based on

psychological and projective theories (Betinsky 2003;

Emerson and Smith 2002; Mason 2002; Silver 2003;

Skiafe and Huet 1998).

Field of Research

The field of research of this paper is a group of six women

in Israel who are survivors of incest, and who met for an

hour and a half per week over the course of 1 year for art

therapy. The women ranged in age from 20 to 50 years.

The participants in the group had no former art experience.

The group met in a rape crisis center where a group of

therapists, social workers, and art therapists provided case

management, and individual and group therapy. This spe-

cific group was led by a social worker and an art therapist.

The women were also offered individual therapy and legal

advice. The Huss of this paper was an external supervisor

for the therapists and for the center in general.

Research Tool

The research tool is an art therapy group who met weekly

for an hour and a half over the course of a year. The

meetings took place in a room that included art products

and comprised an introductory circle of verbal sharing, a

half an hour of undirected art work, followed by dis-

cussion of the art work and its relation to the issues

raised in the introductory circle. Materials were available

for all and the women could choose between paint, felt

pens, oil pastels, and modeling clay. All art works were

kept in closed folders and cupboards in the group room

unless the women wanted to take them home. The final

poster was used in conferences and in community exhi-

bition spaces.

Data Sources

The primary data sources include the art work of four of the

group participants and the transcribed dialogue of the

sessions that include reactions to the art of the group

members. The dialogue was transcribed by one of the

group leaders during the session and written up immedi-

ately after each session as it was considered unsuitable to

tape the sessions. This was possible by having two group


The secondary data sources include summaries of each

meeting in terms of the group content and process by the

group leaders, summaries of group supervision meetings by

the supervisor, and the reflective research diary of the

leaders and supervisors. Another data source is the

women’s summary of the process in individual meetings

and their comments on the final paper.

Analytical Strategy

The art work of each women is treated as a separate case

within the group and is analyzed from two perspectives:

Firstly, it utilizes a group phenomenological stand that

bases the analysis on the women’s own interpretations of

their and the others’ art work, creating a group narrative

(Betinsky 2003; Huss 2007; Denzin and Lincoln 2000).

Secondly, an interpretive analysis was conducted by the

three researchers and an external peer group based on

dynamic theories of art as projective content (Silver 2003;

Skiafe and Huet 1998). This dual analysis was chosen so as

Clin Soc Work J (2012) 40:401–411 403




to capture both micro (personal) and macro (social) levels

of the women’s experience of incest (Goldstein 1994).

Validation and Trustworthiness

Validation and trustworthiness was achieved through

external peer analysis and participant analysis of the art

works. Additionally, dual levels of data were analyzed,

including visual and verbal content, and individual and

group theoretical prisms (Mason 2002; Denzin and Lincoln

2000; Yin 1993).

Ethical Considerations

The art group was provided as additional enrichment to

individual therapy and legal advice. It included the explicit

advance agreement of the group participants of researching

the process, although participants could join the group and

choose to be omitted from the research (in fact, two chose

to do this and are not mentioned in the paper). The group

participants signed consent forms, and read the paper at the

end of the year to validate the analysis and to be sure that

they felt comfortable with the level of disclosure in the

paper (Malchiodi and Riley 1996).

As stated above, the group content was transcribed by

one of the group leaders during the session and written up

immediately afterwards as the women did not feel com-

fortable with having the sessions taped but were used to

group leaders taking notes within a session.

Presentation and Discussion of the Data

As described in the research strategy, each member of the

group will be presented as a separate case study, first in

relation to how her art work and group behavior was

understood and reacted to by the group, and second in

relation to how her art work can be understood according to

interpretive theories that are reincorporated into the group

understandings (Denzin and Lincoln 2000).

Janna (Pseudo Name)

Janna was sexually abused by her older brother for a period

of several years as a child. As a member of the religious

community, it was expected that she get pregnant imme-

diately after her marriage, but she failed to become preg-

nant and learnt that she and her husband were in need of

special medical treatment to assist them in this process.

Janna experienced the gynecological treatments as an

additional ‘invasion of her body. She was ambivalent about

pregnancy in general, although she very much wanted

children. This ambivalence was not culturally acceptable

and she could not talk about it with her family or husband.

Transcripts of the group dialogue reveal that analyses of

her pictures were initiated by the other women rather than

by the group leader or by Janna herself (Betinsky 2003).

For example, a member of the group pointed out that the

shapes in her drawings were very neat, did not touch each

other, and they hid the black space in the center. An

additional member continued in this direction, suggesting

that she draw a picture that expressed the ‘‘black’’ element

more fully on a new page. As all the members of the group

had undergone the same experience, the ‘‘black’’ was a

symbol of the incest experience for all of them and there

was no need to verbally define it. This joint symbolization

seemed to enable them to discuss the incest experience

without actually verbalizing it so that it was deeply

understood on a nonverbal level. Someone else stated that

she agreed with the words of the popular song that Janna

had added to her picture ‘‘if only this world could be

repaired…’’. ‘‘The world is bad, but maybe you should be more specific about who is bad, because not the entire

world is bad.’’ Here, we see that she is encouraging Janna

to directly name the ‘bad’ in her life, after visualizing it as

a black symbol.

Interestingly, the group as ‘experts’ or survivors, rather

than the group leader, provided the interpretations. If the

group leader, rather than the participants, had offered such

direct interpretations, it may have been interpreted by the

participants as violating boundaries. Similarly, Janna may

not have used introspection or analyzed her own art

because it is too direct for the levels of denial that she


The group was thus the central therapeutic medium; by

deeply understanding Janna’s experience through their own

experiences, the incest was first symbolized and only then

was the participant encouraged to verbalize her experience

The group directly confronted defenses and provided

concrete suggestions on how to overcome the defense, such

as drawing the black on a separate page, and reframing

reality as not all bad, in addition to naming what is bad.

The nonverbal art work seemed to enable this joint

understanding without words, while still making the trau-

matic experience of incest visible (Hogan 2002). In addi-

tion, the group addressed their present conflict, with

opinions for and against having children that could not be

voiced in Janna’s community.

Over time, Janna decided that she did want to get

pregnant, and the black space in the center of her art work

was replaced by a baby (Fig. 2). As Janna’s trust in the

group grew, colors and shapes started touching and inter-

acting with each other on her page in different ways just as

she started interacting with others in the group in different

ways. The group met at Janna’s home for one of the last

404 Clin Soc Work J (2012) 40:401–411




meetings, as she was sick and could not make it to the

center. Inviting the group to enter her house can be seen as

another decision concerning what can ‘enter’ her personal

spaces. It also challenged the symbolic group boundaries of

the meeting time and place and shifts the group from a

symbolic to a real network, challenging its symbolic


Janna’s art work, from an interpretive stand, shows a

compositional change from Fig. 1 to Fig. 2 (which inclu-

ded many similar pictures in between). This change

includes colors touching and overlapping in a more spon-

taneous manner, and filling in the black space with a baby

in Fig. 2. This process of moving toward more flexibility,

interaction and ‘playing’ with shapes is cited in the liter-

ature on art and trauma as a healing of the rigidity of

traumatic reaction. (Hass-Cohen and Carr 2008; Malley

2002; Sarid and Huss 2010).The repeated shapes and filling

in the entire space are cited in the literature as a self-

calming activity and serves as a distraction from the ‘‘black

center’’ of Fig. 1 (Furth 1998; Kramer 2000). From a

strengths-based rather than pathogenic stand, one could

interpret the strong boundaries between shapes and colors

as a way of regaining symbolic control through fighting

against the boundary violation of incest (Masten 2001).

The addition of words in drawings, as in Janna’s lyrics

written over the page, is cited as signifying a lack of belief

in the possibility of being heard or understood (Furth 1998

Silver 2003). The use of words from popular religious

songs, as in the use of graffiti, is cited as indirect resistance

against the ‘unjust’ world’ portrayed in the lyrics and in

Janna’s personal experience (Nuttman-Schwatz and Huss


To summarize, this case demonstrated how the group

used its members rather than its group leader as the primary

interpretive voice that confronted defenses and directed the

participants to overcome them. The incest was understood

non-verbally by all by the symbol of a black area. Para-

doxically, the double distancing enabled the women to

touch upon the incest. The art work itself allowed experi-

mentation with different boundaries, and a move to more

flexibility and touching within both the art and the group.

Thus, change in the here-and-now—on the page, and in the

group relationship—were synergistically enabled by the

group and by the art process. It is not clear if the group

processes of getting closer enabled the art shapes to merge

in a more flexible manner, or vice versa. Hass-Cohen and

Carr (2008) points to the importance of a relational setting

of trust for change to be risked in the symbolic zone of the

art work.


Leah was sexually abused by her older brother, who lived

at home: She presented a ‘tough’ tomboy facade. Within

the group, she often told stories of situations of intense

danger and of near-rape, but was emotionally disconnected

from these stories. Her present concerns that she raised in

the group were her ambivalence about staying with her


As in Janna’s case, the group mainly interpreted Leah’s

art and commented on the extreme polarities between a

black world and an ideal world that she repeatedly drew, as

shown in Fig. 3. Fig. 1

Fig. 2 Fig. 3

Clin Soc Work J (2012) 40:401–411 405




‘‘There are colorful ideal bits of your drawing, but also

black bits, and there is no connection between them…you sure do see the world in terms of black or white’ as they


The group also commented about Leah’s dissociation

when talking about the unsafe sexual situations that she

constantly put herself into.

‘‘When you tell such a scary story, I don’t feel your


‘‘Yes it sounds as if you are talking of someone else’’.

Over time, Leah became less cut off and polarized. She

found a steady boyfriend, and asked if she could bring him

to the group, using the group as a surrogate family of


Interestingly, the art and the group processes reflect each

other and both are concerned with integration rather than

splitting or dissociating. Both Leah’s art work and reported

behavior shows this split. This double manifestation

enabled a more intense addressing of integration. Over

time, Leah drew a mandala shape that signifies ‘wholeness’

of the self, according to projective theories (Furth 1998;

Jung 1974). The mandala integrates black and color, and

different shapes within a single circle.

Similar to Janna, Leah’s case showed the group mem-

bers were the primary interpretive voices, rather than the

group leader. In this case, they addressed the polarity and

the dissociation in the art within the group; each around

separate contents but manifesting the same defenses. The

art work itself showed an effort to integrate the extreme

thinking just as the group helped to modify the extreme

acting out behaviors (such as exposure to sexually dan-

gerous situations that are typical of incest survivors)

(Courtoise 1996). Again, we see how this integrative and

modifying process was duplicated and thus intensified by

simultaneously utilizing the symbolic zones of the group

and of the art. This double intensity approach may be what

is needed when addressing such dangerous defenses as

polarity, dissociation, and acting out that are typical of

intense traumas such as incest (Ellis et al. 1990 Fig. 4).


Ada is a very beautiful young girl who was abused by a

father figure who looked after her because her mother had a

psychiatric disorder. She is very attached to her dog who

goes everywhere with her. She always smiles and main-

tains superficial levels of communication. As in the above

cases, the group members confronted her superficial com-

munication within the group zone by calling her a ‘Barbie

doll’ and she herself agreed that she felt ‘‘like ice inside’’.

At the beginning, Ada drew disconnected shapes, similar to

Leah, above. In Fig. 5 Ada’s box-like shapes repeat and fill

in different empty spaces providing relief and distraction,

similar to Janna, above (Rubin 1999). They also create an

optical illusion of squares or boxes. However, they are

cannot contain anything.

Anna (another participant in the group and is described

below) pointed this out:

‘‘They are open, like those cardboard boxes in the

supermarket that fall open if you put too much into them.’’

Over time, Ada added the picture of what she defined as

‘‘…a little girl…’’. She did not add words. When asked, she stated that the hands reaching out

toward the girl were trying to help her.

Janna confronted her, pointing out that ‘‘The hands are

not helping—they could also be understood as attacking… the hands are attacking and no one is helping…’’ Leah pointed out that the red spot on the skirt of the women in

the picture is similar to blood.

The ambivalence over the hands—that help or abuse—

can be understood as a reflection of the ambivalence of

children of incest who both love and fear the perpetuator. The

discussion in the group context enabled the hands to be

defined as ‘‘not helping’’ by the group. In other words, the

abuse was once again confronted, named, and defined

through the art work rather than through direct confrontation.

We see that the group members verbally confronted

Ada’s indirect drawing of the incest experience. We see

that Ada, as compared to Janna and Leah, was able to

Fig. 4 Fig. 5

406 Clin Soc Work J (2012) 40:401–411




verbalize her ‘lack of feeling’ and to subconsciously allow

herself to draw a picture of the incest experience.

The group encouraged her to be angry, messy, and ‘real’

as one member defined it, both in her art and in her

interaction with the group members. She drew a picture of

a red and black dot, enlarged from her shapes, that is in oil

pastel and thus ‘‘messy’’.

Ada began a positive relationship with a young man and,

with the support of the group, allowed it to develop rather

than breaking it off as she usually did. In other words, she

achieved tolerance of intimacy or ‘realness’ with the help

of the group.

Ada’s boxes can be interpreted dynamically as symbols

of Ada’s mother, (who suffered a psychiatric illness) and

could not be a protective and strong container for her


Her oil pastel shape not only became larger and

‘messier’ it eventually closed and was able to contain the

red inside, as compared to her decorative open boxes.

To summarize, Ada’s case, similar to the cases of Janna

and Leah, demonstrated how the group members became

the confronters of the defenses in both the art and group

zones. In Ada’s case, they addressed the lack of contain-

ment in her abstract shapes and the ambivalence over the

perpetuator of incest as ‘helpful’ or as attacking’. If Janna

used the art to let parts touch each other, and Leah used the

art to integrate polarities and splitting, Ada used the art to

become more authentic and to ‘touch’ the confusion over

the incest experience. The group exchanged the open boxes

that could not contain her with real support as a corrective

family. Here, as in Janna’s case, the issue of the incest is

treated indirectly through the art.


Anna is a woman in her 50s and was older than the others,

and married with children. She was abused by her father as

a child, and had only now started remembering this. Her

father had since died and she nursed her ailing mother

(Fig. 6).

At first, Anna refused to draw at all, just as she refused

to talk and take up ‘‘space’’ in the group although she gave

advice and nurtured others. Eventually she represented

herself by placing a small black dot on a tiny piece of paper

which she than turned over and covered with many other

items which were on the table. She exclaimed ‘‘There,

that’s me, I don’t exist…’’. As compared to others, we see that Anna, perhaps

because she was older, did utilize introspection about her

picture. Janna stated that ‘‘You do exist, because you are

always prepared to be our mother, but you can also get help

from us’’ …Anna, replied, ‘‘But when I talk about myself, I feel selfish, I feel bad (Figs. 7, 8).’’

The group confronted this by insisting that she draw an

image of herself, and that she tell them about her own

problems as well. Eventually she transferred her original

black dot to a slightly larger white circle, defining the black

as the background or context, rather than as herself- who

was reframed as a white dot (Fig. 9).

Anna remained very reticent, and did not shift in her

mothering or advising role. She also did not start drawing;

however, she did become active on the social change level.

She began meeting with groups of professionals and policy

makers and assisted them in understanding the needs of the

childhood abuse survivor. She was the one who encouraged

Fig. 6

Fig. 7

Fig. 8

Clin Soc Work J (2012) 40:401–411 407




the group to make a poster to use to raise awareness of the

problem, using all of their pictures (Fig. 9). Placing herself

in the public sphere of social activism enabled her to

indirectly take up space and confront her experience.

The dynamics of art interpretation are in the process

rather than in the product of the art work. The ability to

make a sign on the page, as a representation of ‘self-

becoming visible’ was in itself a huge challenge to Anna

(Jones 1997). However, the reframing of herself as a large

white dot rather than a small black dot is a meaningful shift

from being ‘bad’ to positioning the ‘badness’ outside of

herself and within society, where she addressed it through

social action and a general rather than personal story of

incest, which also utilized the positive parts of her moth-

ering or mentoring role. The spatial medium of art made

the issue of taking up space, and the content of that space,

concrete, with the page becoming a type of confrontation in


To summarize, we see that Anna’s case is different than

the others due to her different developmental stage. How-

ever, as in the other cases, the group became the con-

fronters of Anna’s defense of helping others as a way to

avoid her feelings that were experienced as ‘bad’.

The art’s spatial characteristics became the confronta-

tion of her difficulty in taking up her own space. The

support of the group in this case was not as corrective

parents but as corrective children.

Group Poster

As stated in the introduction, the group chose to end their

year creating a group poster that would be used to raise

public awareness of sexual abuse in society. As can be

seen, elements of the pictures shown above and others were

incorporated into this poster, as were words asking for

revenge, a listening ear, and the right to exist. The women

together decided to create a bouquet of flowers made of up

pictures chosen by each woman that expressed a moment

of change in her style or experience as described in the

single case studies above.

This ‘‘family’’ metaphor of a bouquet of flowers con-

tained within a vase, may symbolize the group space and

turns the personal experiences, which are the content of the

petals of the flower, into an abstract format this is both

hidden and shown. This enables self-expression within the

boundaries of privacy (Skiafe and Huet 1998). This

abstraction demonstrates how the women utilized flexible

boundaries and did not deny, dissociate, or defend them-

selves or society against the pain of sexual abuse.

When discussing the poster, the women defined it as

exhibiting their creativity and colors, which, in turn, was

defined as more than the incest that they survived. This is

strengthened by the flower metaphor that symbolizes purity

and growth as opposed to the ‘damaged goods’’ messages

that the women often receive from society, and from their

inner experience of sexual abuse (Mize 1995). It seems that

the poster was empowering and emphasized positive

messages. The shift from process to a product that stands

alone, or from art as therapy to art as art product, or, in

other words, the public versus private product is experi-

enced as empowering in that it is a strong statement on a

social level. It focuses not only on the women’s pain, but

also on their strengths.

This poster has been presented by Anna and the other

women of the group at conferences and in community

exhibition places, with explanations about the experience

of incest and the importance of addressing it as a social

problem. The culmination of using a group poster to ini-

tiate social change can be understood as social action on

the one hand, and as part of the therapeutic work of

recovery and reconciliation processes in the contexts of

traumatic events, on the other. In other words, the process

works simultaneously inwards and outwards.

Discussion and Summary

The multiple case design of this research produced themes

common to all of the women and variations of these

themes. These themes will be discussed first from the

perspective of the art therapy, continuing to the group work

and the interaction between them.

A theme common to all of the women was the graphic

depiction of defenses within the art work. Janna protected

herself by controlling and camouflaging, and refused to

Fig. 9

408 Clin Soc Work J (2012) 40:401–411




allow things or people to ‘touch’ her. This was manifested

in the art and in her behavior. Lea drew her polarization,

split, and dissociation and Ada drew the defenses of a false

self, lack of containment, and disconnection from emo-

tions. Anna, by not drawing at all, protected herself by

becoming invisible and not taking up space both on the

page and in the group.

However, only two of the women produced a symbolic

depiction of the actual abuse. Janna depicted the abuse as a

‘black hole’ and Ada described it as a girl with raised

hands, suggesting her confusion over the abuser as a friend

or an attacker. The omission of the abuse was apparent in

Leahs’s art, where the defenses of polarity were drawn, and

in Anna’s art where she could not depict herself at all.

Interestingly, we see that those who managed to symboli-

cally depict the experience drew weaker defenses. The

implications of this are that the direct incest experience

may not have to be portrayed or ‘discussed’ but that is

more important that the defenses used against this pain is

the area to be addressed as the most disturbing in the here-

and-now. This follows the literature on interventions with

incest (Granefsky et al. 2001).

These defenses were graphically depicted in the art

compositions and contents, such as types of boundaries

(elements touching each other on the page), levels of

control (levels of neatness, distance); experience of lack of

control as mess (types of textures and compositions),

defenses against remembering and against anxiety (filing in

the page, repetitions), symbolic meanings of colors (black

as a symbol of hidden trauma), camouflaging elements

(concealing things through pattern and aesthetics), and

choosing art materials that enabled a high level of control,

such as felt pens and oil pastels, rather than less control-

lable materials such as clay and paint. The above uses of

compositional and tactile elements to express inner

defenses are well documented in art therapy literature

(Furth 1998; Hass-Cohen and Carr 2008; Kramer 2000;

Silver 2003; Waller 1992; Zumer and Zumer 1997).

The second theme common to all is that the women

changed their art work over time—in the direction of

heightened touching of colors, visibility, flexibility of

shapes, and the ‘messiness’ of the art work. This theme

points to a healing process and to the use of art processes to

enhance the general reintegration of flexibility that recon-

nects cognition, emotional experience, and physical sen-

sation. This is cited as important in overcoming traumatic

memories and moving to enabling narratives (Hass-Cohen

and Carr 2008; Huss et al. 2010; Klingman et al. 1987;

Mallay 2002; Sarid and Huss 2010; Nuttman-Shwartz and

Huss 2010).

Moving from the art s depictions to the group space, a

third common theme is that the women used the group as

the central interpretive voice. This may be because

introspection was too direct, difficult, and even invasive.

Other women who had undergone the same traumatic

experience provided interpretations and strong confronta-

tions with the defenses that they identified within each

other’s art work On this level, the art work became a group

testimony and an indirect target with which to address

issues too painful to address directly (Hogan 2002).

The importance of using a double symbolic space—the

interactions between the group members as symbolic

space, and art as symbolic space—are apparent in all of the

case studies and well documented in group art therapy

literature (Zumer and Zumer 1997). Here, the dual method

enables an intensity of intervention that is specifically

recommended in the context of traumatic reactions that are

very resistant to therapy.

A central potential catalyst for interpretation in group

work is the group leaders. Interestingly, in our study, the

data shows how the group leaders, while enabling the

group space and boundaries, did not initiate or address the

interpretations or confrontations of these defenses. From a

feminist stand, this can be understood as respecting the

deep understanding of the experience itself as enabling

interpretive Hussity and of positioning themselves as out-

side of the experience. The use of fellow survivors as

experts is based in feminist theories of group work. From

this perspective, allowing the women to interpret their own

art works enabled them to experience a genuine ‘reinte-

gration into society’ that was initiated by them at their own

pace, as described by Weinberg et al. (2005). In addition,

the self-interpretation of art, as compared to diagnostic or

‘expert’ interpretation, can be seen as a feminist stand that

aims to reclaim and share subjective experience of social

injustice (Hogan 2002). However, this lack of interpreta-

tion by the group leader could also be understood as the

personal style of the leaders who did not exhibit strong

enough interpretive or leadership voices. This lack of

strong leadership may have inhibited the feeling of safety

that was experienced by the group. Further research using a

multiple-case design can explore this point and reach

clearer conclusions.

The implications of this study are that individual insight

based interventions may be less effective for incest survi-

vors in confronting defenses than therapy within a group of

fellow sufferers. Weinberg et al. (2005) stress the impor-

tance of reintegrating trauma survivors back into society,

and the group context enables the practicing of this rein-

tegration in a controlled environment, as described above.

We see that the women directly confronted defensive or

destructive behavior in the here-and-now, and outside of

the group. For example, Janna gained legitimization for

feelings and actions (such as postponing having a baby)

with the help of the group’s social legitimization. She was

reminded by the group that there was good in the world and

Clin Soc Work J (2012) 40:401–411 409




not only negative experiences. Leah was constantly con-

fronted with the danger of her behavior by others who

acted as her ‘mother’. Ada was confronted with the truth,

that her abuser was not helping her but attacking her, and

that she was living as a false disconnected ‘‘Barbie Doll’’.

Anna was confronted with the fact that her over-nurturing

was a method used to avoid experiencing or fulfilling her

own needs. Here, the group became her children who

‘‘corrected’’ her over-nurturing. Again, all group members

shifted in their behavior.

In tandem with the group therapy, the art work, as a

symbolic or distanced medium, enabled the women to

address the trauma in such an indirect way that it could be

tolerated. These two elements—group and art—worked

synergistically; using others as interpreters and using

drawings as symbols enabled a double addressing of the

trauma. On the one hand, the art ‘‘illustrated’’ the above

group process, and on the other, the group process was

enabled by the art work. It is clear that, as stated, the

interaction between the art and the group created a ‘‘dou-

ble’’ symbolic and concrete space for interpretation and

change. It could be that with such strong defenses as those

experienced by incest survivors, one needs to create such

dual zones that synergistically reignite both symbolic

interaction, and ‘here-and-now’ interaction of group,

moving simultaneously both ‘inwards and ‘outwards’.

Hass-Cohen and Carr (2008) describes the importance of

creativity within a relational setting as enabling new

solutions to be tried out in the context of trust.

This dual level of confrontation may have enabled the

group to go beyond symbolic boundaries. For example, the

women of the group went to visit Janna when she was sick,

and the women introduced boyfriends to each other within

the group. Similarly, the images at the group’s initiative

were used in a poster to initiate awareness of sexual abuse

within the community and were exhibited in conferences

and community centers. The art became ‘‘real’’ art just as

the group became a ‘‘real’’ family. On the one hand, from a

dynamic perspective, it seems that the symbolic group

boundaries were violated, maybe repeating the violation of

boundaries that the women underwent in their incest

trauma (Yalom 1995; Zumer and Zumer 1997). From this

perspective, the group leaders may not have been strong

enough to hold onto the group boundaries. On the other

hand, from a feminist or social change perspective, the

women succeeded in creating a genuine surrogate correc-

tive family and support system, and they successfully

enacted social change strategies. They used art to com-

municate with others as well as with self (Shank 2005;

Zelizer 2003; Stewart and Herman 2002; Hogan 2002). A

limit of this research is its preliminary nature and scope

within a single group. Further research could replicate, fine

tune and formally evaluate the model with additional

groups. However, a feminist theoretical model emerged

that can be a base for integrating the power of art, group,

and social action, in the context of trauma. This enables a

socially based recovery and reconciliation processes, in the

contexts of traumatic events, to occur simultaneously

within the individual and also between the victims and

society. This study demonstrated how art within group

work enabled a group of incest survivors to integrate the

psychological and social levels of the deep trauma from an

ecological perspective that intensified the overall inter-

vention. This points to a model for combining the micro

and the macro levels of healing the trauma of incest.


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Author Biography

Dr Huss is part of the faculty of Ben Gurion University social work department: She is the director of its creative tools for social workers

MA specialization and has published extensively on the subject of art

and clinical social work as a way to focus on resilience within cultural


Clin Soc Work J (2012) 40:401–411 411




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  • c.10615_2012_Article_393.pdf
    • Art in Group Work as an Anchor for Integrating the Micro and Macro Levels of Intervention with Incest Survivors
      • Abstract
      • Introduction
      • Literature Survey
        • Group Interventions with Incest Survivors from a Feminist Perspective
        • Art in Therapy
        • Art in Social Change from a Feminist Perspective
        • Art in Groups—Combining Therapy and Social Change Perspectives
        • Research Method
          • Research Strategy
          • Field of Research
          • Research Tool
          • Data Sources
          • Analytical Strategy
          • Validation and Trustworthiness
          • Ethical Considerations
      • Presentation and Discussion of the Data
        • Janna (Pseudo Name)
        • Leah
        • Ada
        • Anna
        • Group Poster
      • Discussion and Summary
      • References

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