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
also challenges dynamic theories that are decontextualized
from social concepts.
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
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.
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.
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-
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.
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).
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
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
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
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.
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
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
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
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.
Belsky, B. (1980). Child maltreatment, an ecological integration.
American Psychologist, 33, 320–335. Bentovim, A. (2002). Dissociative identity disorder: A developmental
perspective. In V. Sinason (Ed.), Attachment, trauma and multiplicity: Working with dissociative identity disorder. New York: Brunner Routledge.
Betinsky, M. (2003). What do you see? Phenomenology of therapeu- tic art experience. UK: Jessica Kingsley.
Brody, C. (Ed). (1987). Women’s therapy groups: Paradigms of
feminist treatment. In Springer series: Focus on women, Vol. 10. (pp. 198–216). New York: Springer.
Butler, M. L. (2001). Making waves. Women’s studies international forum, 4(3), 387–399.
Cooper, B., Kennedy, M., & Yulle, J. (2000). Dissociation and sexual
trauma in prostitutes. Variability of responses. Journal of Trauma, 2, 27–36.
Courtoise, C. (1996). Healing the incest wound: Adults survivors in therapy. London: Norton books.
Denzin, N., & Lincoln, Y. (2000). Handbook of qualitative research. California: Sage Publications.
Devi, S. (1988). Symbolization and creativity. New York: Interna- tional University Press.
Dorado, S. (1996). Legal and psychological approaches towards adult
survivors of childhood incest: Irreconcilable differences? Women and Therapy, 19(1), 93–108.
Ellis, J., Laidlaw, T., Malmo, C. (1990). Healing voices: Feminist
approaches to therapy with women. In The Jossey-Bass social and behavioral science series (pp. 243–271). San Francisco: Jossey-Bass.
Emerson, M., & Smith, P. (2002). Researching the visual: Images, objects, contexts and interactions in social. London: Sage Publication.
Furth, G. (1998). The secret world of drawings: A Jungian approach to art therapy. Toronto: Inter City Books.
Gibelman, M. (1999). The search for identity: Defining social work,
past, present, future. Social Work, 44(4), 298–310. Goldstein, H. (1994). Ethnography, critical inquiry and social work
practice. In E. Sherman & W. Reid (Eds.), Qualitative research in social work. New York: Columbia University Press.
Granefsky, N., Kraaij, V., & Spinoven, P. (2001). Negative life
events, cognitive emotional regulation and emotional problems.
Personality and Individual Differences, 30, 1311–1327. Harrington, A. (2004). Art and social theory. Sociological arguments
in aesthetics. London: Polity Press Ltd. Hass-Cohen, N., & Carr, R. (2008). Art therapy and clinical neuron-
science. London: Jessica Kingsley.
410 Clin Soc Work J (2012) 40:401–411
Herman, L. (1994). Trauma and Recovery. Tel Aviv: Am Oved. (Hebrew).
Hogan, S. (2002). Gender issues in art therapy. UK: Jessica Kingsley. Hooks, B. (1992). Black looks: Race and representation. London:
Huss, E. (2007). Imagining symbolic spaces. Journal of Humanistic Psychology, 47(3), 289–306.
Huss, E. (2009a). ‘‘A coat of many colors’’: Towards an integrative
multilayered model of art therapy. The Arts in Psychotherapy, 36(3), 154–160.
Huss, E. (2009b). A case study of Bedouin women’s art in social
work: A model of social arts intervention with ‘traditional’
women negotiating Western cultures. Social Work Education 28(6), 598–616 [Special Edition: Cultures in Transition].
Huss, E., Sarid O., & Cwikel, J. (2010). Using art as a self-regulating
tool in a war situation: A model for social workers. Health and Social Work. (In Press).
Johnson, K. (2002). Understanding sexuality in childhood. Kiriyat Bialik: Ach publishing (Hebrew).
Jones, M. (1997). Alice, Doran and Constance from the eve of history.
In S. Hogan (Ed.), Feminist approaches to art therapy (pp. 65–79). London and New York: Routledge.
Jung, C. G. (1974). Man and his symbols. London: Aldus Books. Klingman, A., Koenigsfield, E., & Markman, D. (1987). Art activity
with children following disaster: A preventative-oriented crisis
intervention modality. The Arts in Psychotherapy, 14, 153–166. Kramer, E. (2000). Art as therapy. London: Jessica Kingsley. Lev-Wiesel, R., Goldblatt, H., Eisikovits, Z., & Admi, H. (2009).
Growth in the shadow of war: The case of social workers and
nurses working in a shared war reality. British Journal of Social Work, 39(6), 1154–1174.
Liebman, M. (1996). Arts approaches to conflict. London: Jessica Kingsley.
Malchiodi, C., & Riley, S. (1996). Supervision and related issues. Chicago: Magnolia Street Publishers.
Mallay, J. N. (2002). Art therapy, an effective outreach intervention
with traumatized children with suspected acquired brain injury.
Arts in Psychotherapy, 14, 140–153. Mason, J. (2002). Qualitative use of visual methods. London: Sage
Masten, A. S. (2001). Ordinary magic: Resilience processes in
development. American Psychologist, 56, 227–238. Mize, L. (1995). Surviving voices: Incest survivors’ narratives of their
process of disclosure. Journal of Family Psychotherapy, 6(4), 43–59.
Nuttman-Shwarz, D. & Huss E., (2010). The experience of forced
relocation as expressed in children’s drawings. Clinical Social Work Journal. (In press).
Parsons, R. J., Jorgensoen, J. D., & Hernandez, S. H. (1994). The integration of social work practice. Pacific Grove, CA: C.L. Publishing.
Pifalo, T. (2002). Pulling out the thorns: Art therapy with sexually
abused children and adolescents. Art Therapy, 19, 12–22. Rubin, J. (1999). Approaches to art therapy. Philadelphia: Brunner-
Sarid, O., & Huss, E. (2010). Trauma and acute stress disorder: A
comparison between cognitive behavioral intervention and art
therapy. The Arts in Psychotherapy, 37(1), 8–12. Shank, M. (2005). Transforming social justice: Redefining the
movement: Art activism. Seattle Journal for Social Justice, 3, 531–559.
Silver, R. (2003). Art as language access to thoughts and emotions through stimulus drawings. Philadelphia: Brunner-Routledge.
Skiafe, S., & Huet, V. (Eds.). (1998). Art psychotherapy groups: Between pictures and groups. London: Routledge.
Stewart, A., & Hermann, A. (2002). Theorizing Feminism: Parallel trends in the humanities and social sciences. USA: Westview Press.
Tillman, S. (1995). Sexual abuse of children: Theory and intervention methods. Kiriyat Bialik: Ach publications (Hebrew).
Waller, D. (1992). Group interactive art therapy. New York: Rutledge.
Weinberg, H., Nuttman-Shwartz, O., & Gilmore, M. (2005). Trauma
groups: An overview. Group Analysis, 38, 187–205. Yalom, I. (1995). The theory and practice of group psychotherapy.
New York: NY Basic books.
Yin, R. (1993). Applications of case study research. London, Newbury Park: Sage Publication.
Zeligman, T., & Solomon, R. (2004). Introduction to incest: ‘‘There is no truth and no mercy and no pity’’. Tel Aviv: Tel Aviv University Press (Hebrew).
Zelizer, C. (2003). The role of artistic processes in peace building in
Bosnia-Herzegovina. Peace and Conflict Studies, 10(2), 62–75. Zumer, A. & Zumer, L. (1997). Psychodynamic elements of art works
in dissociative disorders. Sichot, 11(3), 20–34.
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
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
- Art in Group Work as an Anchor for Integrating the Micro and Macro Levels of Intervention with Incest Survivors
- 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)
- Group Poster
- Discussion and Summary
- Art in Group Work as an Anchor for Integrating the Micro and Macro Levels of Intervention with Incest Survivors