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Journal of Substance Use, December 2011; 16(6): 439–451
ISSN 1465-9891 print/ISSN 1475-9942 online © 2011 Informa UK Ltd.DOI: 10.3109/14659891.2010.495817
TJSU1465-98911475-9942Journal of Substance Use, Vol. 1, No. 1, Jul 2010: pp. 0–0Journal of Substance UseORIGINAL ARTICLE
The use of drawings to explore young people’s views of a service for those affected by parental alcohol misuse
Helping young people affected by parental substance misuseS. E. Wall & L. J. TempletonSARAH E. WALL & LORNA J. TEMPLETON
Mental Health Research & Development Unit, University of Bath and AWP Mental Health Partnership NHS Trust, Bath, UK
AbstractBackground: As services for young people affected by parental substance misuse evolve, it is import-ant that young people are invited to express their views on the service they receive.Method: As part of the evaluation of a new service for young people living with parental alcoholmisuse, a self-report drawing method was used with 11 young people to elicit their views of the service.Findings: The most common changes noted were: feeling happier and less confused, and having amore harmonious family life with families spending more time together. Many of the young peopleplaced parental alcohol misuse centrally in their drawings.Conclusions: Self-report drawing enabled the young people to reflect on change, and thus is a power-ful tool for further research in this area.
Keywords: Young people, parental alcohol misuse, self-report drawings.
Introduction
Historically, research has been about young people, rather than directly involving them inthe research. The “views” of young people tended to be captured indirectly through adults,usually parents (or other caregivers) or professionals (Kirk, 2007). More recently, how-ever, partly driven by policy agendas, such as Every Child Matters and the National ServiceFramework, and the appointment of the Children’s Commissioner, there has beenincreased interest in ensuring that young peoples’ voices are heard. Their views are nowincreasingly seen as valid and important (Worrall-Davies & Marino-Francis, 2008). As aresult, it is now recognized that young people should become “active” in research, ratherthan “passive objects” (Kirk, 2007).
Increasing recognition is being given to the impact of substance misuse on children andyoung people. Current estimates for the United Kingdom suggest that there may be
Correspondence: Dr Sarah E. Wall, Mental Health Research & Development Unit, 22–23 Eastwood, University of Bath, Bath,BA2 7AY, UK. Tel: (+44) 1225 383652. E-mail: [email protected]
Received for publication 12 January 2010. Accepted 20 May 2010.
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3.5 million young people under 16 years old affected by parental alcohol misuse andone million by parental drug misuse (Manning et al., 2009). Young people can be affec-ted by parental substance misuse across the life course. Their experiences, often told intheir own words, portray a wide range of harms and show how burdened children canbe by their family experiences (Tunnard, 2002; Kroll & Taylor, 2003; Barnard &McKeganey, 2004; Gorin, 2004; Templeton, Zohhadi, Galvani, & Velleman, 2006;Barnard, 2007a). Parental substance misuse can have widespread implications for thephysical and mental health, and emotional well-being, of young people, as well as fortheir development and education, although it should be noted that this is not the experi-ence of all families (Bancroft, Wilson, Cunningham-Burley, Backett-Milburn, &Masters, 2004; Velleman & Templeton, 2006, 2007). These problems can be exacer-bated by other family problems, which commonly co-exist alongside parental substancemisuse. Domestic violence/abuse and parental mental health problems are particularlyprevalent and concerning (Cleaver, Unell, & Aldgate, 1999; Gorin, 2004; Cleaver,Nicholson, Tarr, & Cleaver, 2007). In the United Kingdom, there is particular concernabout the extent of parental substance misuse within Children and Family Services(Forrester & Harwin, 2006; Cleaver et al., 2007) and of the numbers of children whoare coming to the attention of these services because of associated child protection risks,including abuse and serious neglect.
The Hidden Harm (Advisory Council on the Misuse of Drugs, 2003, 2007) and“Bottling it Up” reports (Turning Point, 2006) have prioritized the needs of children andyoung people affected by parental substance misuse, providing momentum for UK policyand practice in these areas. The increase in services for children and young people affectedby parental substance misuse is welcomed (Forrester, Copello, Waissbein, & Pokhrel,2008; Templeton, Novak & Wall, in press), although evidence of a “postcode lottery” ofprovision has been highlighted (Best, Homayoun, & Witton, 2008). Given that these serv-ices are for young people and such practice is in relative infancy, it is important to exploreyoung people’s views of these services to ensure that service development and deliverymatches need, particularly in a field where there has been a tradition of not listening to theneeds and experiences of children (Templeton et al., 2006; Robinson, 2008).
What is the best way to capture the views of children and young people about servicesfor those affected by parental substance misuse? Various authors have argued that differentresearch methods are often needed with children to ensure that they can be ethically, com-fortably and naturally involved in research (Morrow & Richards, 1996; Punch, 2002;Barker & Weller, 2003; Kirk, 2007; Bagnoli, 2009). This paper describes a drawingmethod which has been used to ask young people about their views of a new service foryoung people affected by parental alcohol misuse.
Drawing has been variously used as both an ice-breaking, rapport-building activity priorto an interview/focus group and as an integral part of the research process (Coyne, 1998;Bagnoli, 2009). It can enable young people to become more actively and productivelyengaged in the research process (Morrow & Richards, 1996; Bagnoli, 2009). For many it isa natural and enjoyable task. However, not all young people enjoy drawing, and this maybe dependent on their perceived and/or actual ability to draw: some may be “inhibited by alack of artistic competence” (Punch, 2002, p. 331). Although some argue that age deter-mines willingness to engage in drawing tasks, Coyne’s (1998) experience suggests that thisis not the case. Instead, some young people like to draw and others do not, whatever theirage, and this determines whether they will be willing to actively engage using such a tech-nique. As a result, a warm, encouraging approach is essential to maximize young people’s
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participation, ensuring that they understand before they start that the quality of the draw-ings is not important. It may be necessary to firmly establish rapport prior to the drawingactivity, rather than using the drawing for rapport-building per se.
Drawing is central to how young people learn to express themselves (Barker & Weller,2003; Hamama & Ronen, 2009) and has been used in research studies to explore a rangeof issues (Veale, 2005; Bagnoli, 2009) including parental divorce and stepfamilies (Berger,1994; Cordell & Bergman-Meador, 1991) and car journeys to school and other places(Barker & Weller, 2003). Art has also been used to ask young people about the impact ofparental addiction on them (Barnard, 2007b). To our knowledge, such methods havenever been used to explore young people’s views about services which are helping them todeal with parental substance misuse.
The development and evaluation of services responding to the needs of young peopleaffected by parental alcohol use is in its infancy. It is important, therefore, to investigatethe best ways to elicit the young people’s views of such services. This study pilots the use ofdrawing as a novel way of capturing the young people’s opinions, providing insight intotheir views on the service’s impact. The method used in this paper was based on Hamama& Ronen’s (2009) study, who demonstrated that drawing can be effectively used as a self-report measure of perceived therapeutic change following a group intervention aimed atreducing aggressive behaviour in 10- and 11-year-olds with oppositional defiant disorder.At the end of the intervention the children were asked to draw themselves as they werebefore the intervention and how they see themselves now. Rather than the researcher inter-preting the pictures, the children were asked to describe what they had drawn, thus gainingtheir view on the change they perceived. Such a method may address the power imbalancethat may be experienced when adult researchers explore the world of children (Morrow &Richards, 1996). The use of drawings and the children’s descriptions proved an effectiveway for Hamama and Ronen to learn about the children’s world; learning about their per-ception of change, emotion and behaviour directly from the children themselves. Althoughasking a young person to retrospectively draw how they were at the start of the programmemay result in some inaccuracies and bias, it does allow for the young person to reflect onthe change for themselves and further allows for a more direct comparison between“before” and “now”.
Method
All young people participating in this study were current clients of Base Camp, a service foryoung people whose parents misuse alcohol. Established by Turning Point in three of theirservices in light of the Hidden Harm reports (ACMD, 2003, 2007), and Turning Point’ssubsequent report on the impact of parental alcohol misuse on children (Turning Point,2006), the service provides short-term support (generally up to 6 months) for youngpeople aged between 8 and 18 years (their drinking parent may also be receiving treatmentfrom a Turning Point adult alcohol service). Individual and/or group work is offered to theyoung people; some family work is undertaken if appropriate, although the central focusfor the service is the young person. As part of their evaluation of Base Camp the authorsconducted individual semi-structured interviews (or occasionally interviews with siblingpairs) with a number of the young people. Whilst the young people were able to speakabout their experiences of the service and to give examples of how it had helped them andtheir family (Templeton et al., in press), the authors and the Base Camp team felt thatother novel and innovative approaches might provide a further opportunity for the young
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people to describe how the service had helped them. Therefore, the drawing method,outlined below and based on Hamama & Ronen’s study (2009), was introduced afterethics approval had been given by the University of Bath. Young people gave informedconsent to take part in the activity; parental consent was also obtained. The drawingactivity was lead either by one of the Workers or a Researcher, although the same proce-dure was followed in each case. In some cases the drawing activity was followed by abrief interview.
The young person is asked to draw a picture depicting how he/she was before he/shestarted attending the service (Hamama & Ronen, 2009). They are told that they can drawin whatever style they want and using as many colours as they like. The researcher/workerstressed that the quality of the drawings was not important. Once this picture is complete,they are then asked to draw another picture depicting how he/she is now (Hamama &Ronen, 2009). Once this second picture is complete, the researcher/worker asks the youngperson to describe what they have drawn (Veale, 2005; Hamama & Ronen, 2009). Theyare not asked to interpret or explain, but only to describe the picture. If willing and able,the young person is asked to write their description with the picture. If not, this informa-tion is recorded by the researcher/worker.
The sample
Eleven young people provided a pair of self-report drawings. The young people wereaged between 9 and 14 years old, two-thirds were female and all were White British. Athird of the sample (36%) was living with paternal alcohol misuse, just over a quarter(27%) with maternal alcohol misuse and 27% with both parents misusing alcohol. Theremaining young people were affected by the drinking of a grandparent (18%). Theyoung people had been in the service for a mean of 5 months, hence, they had had con-siderable contact with the service and a number were approaching the end of their timewith the service.
Analysis
A cognitive-constructivist approach was adopted for this analysis; the individual is thoughtto be the most valuable source for obtaining an understanding of their own world(Mahoney, 1995). Hence, rather than interpreting and analysing the pictures per se, theyoung people’s descriptions of the drawings formed the content of the current analysis.The drawings provide powerful support to their descriptions. Hamama and Ronen (2009)discuss the importance of allowing the young person to provide a context for their drawingand errors that can arise when their view is not invited. Thematic analysis was conductedon the young people’s descriptions of their drawings.
Results
The young people were successfully able to draw a picture, which represented them beforethey started work with the service, and then a second picture that represented them “now”(on the day the drawings were done); the instructions were deliberately broad to enablethem to enable them to reflect on the most significant change(s). The young people’sdrawings and descriptions of change during their time with the service fell into two maincategories; personal change and familial change. Within these categories were a number of
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sub-themes. The young people’s quotations used throughout this paper remainunchanged, although spelling errors have been corrected.
Personal change
The young people illustrated and described various ways in which they felt they had per-sonally changed. For example, an 11-year-old girl used a range of words to describe howshe feels she has changed after going to Base Camp for a while (Fig. 1). She described her-self in the first picture as, “quiet . . . worried . . . wondering why my mum’s drinking . . .miserable . . . alone . . . upset . . . confused”. Subsequently, with her second picture shedescribed herself as, “HAPPY . . . excited . . . normal . . . not worried so much . . . okay . . .not alone because I’m with my friends in school”. A 14-year-old girl illustrated that themost pertinent change for her has been in her own drinking behaviour. Alongside a pictureof a bottle of vodka in her first picture she described “always drinking”. The second pictureillustrated her friend “always drinking”, but she is not drinking. Other young people dem-onstrated that they now felt differently or that they communicated or reacted differently tothings that were going on at home (see below).
Change in feelings
A number of the young people illustrated that they are now feeling happier. One 9-year-oldgirl described that before the service she felt “sad” as she was “bottling things up . . . didn’tfeel I have anybody to talk to”, but she is now feeling happier and able to tell her motherand father things (Fig. 2). She also said that she does not get as angry as she used to. An11-year-old girl drew herself smiling in both pictures, but the descriptions she providedgave insight into how she perceives she has changed (Fig. 1, see above).
Another 11-year-old girl drew various pictures of herself before the service; one showingher “happy” when she is dancing or singing, and another showing her “unhappy when mydad was drinking”. Her second picture showed her being happy because, “my Dad hasstopped drinking”; she also added that she is getting on better with her Dad. Other youngpeople similarly described happiness in the first picture in the context of activities or friend-ships, whilst their happiness in the second picture was put in the context of the family.
Familial change
Although the service predominantly works with the young people, rather than the family asa whole, of the 11 children participating in this study 7 illustrated and/or describedchanges in their family since they have been attending the service.
Getting along better. Four young people illustrated that there is now greater harmony in thefamily; they are getting along better. A 13-year-old girl illustrated (Fig. 3) that beforeattending the service she used to argue with her grandmother, who she lives with. Her pic-ture and description show how previously “. . . we’ve just had an argument. So theninstead of calming down I just start shouting things at her like ‘I hate you’ and all that”.Her second picture shows a calmer situation, with the girl saying “well ok, I’m goingupstairs to think, but ‘I’ feel you’re not being reasonable”. She describes how she is nowable to go away to calm down and then come back to speak to her carer, rather than imme-diately arguing with her. An 11-year-old girl described that she now “get[s] on better with
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Figure 1. Personal change (young girl aged 11).
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Figure 2. Changing feelings (young girl aged 9).
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Figure 3. Change in communication (young girl aged 13).
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Dad”; she is not so “cheeky” and is “better behaved”. A 9-year-old girl drew a happy pic-ture and described “things are excellent at home. Everyone is getting along”.
Spending time together. Two 11-year-old girls drew and described very clearly the changesthat have occurred in their family, primarily how the families are now spending more timetogether. One of the girls drew each member of her family separately; her step-father drinking,her mother watching television, her sister playing in the garden, and herself in bed watchingtelevision (Fig. 4). In the second picture, however, she drew them altogether and added,“we all talking and watching TV”. The unity and shared time with her family was clearlyan important change for her. The other girl’s first picture showed her “happy happy . . .playing at the park with a friend”. The second picture showed a range of different activities,with her descriptions explaining “went bowling with my family” and additional text stating“not what I normally do”. She clearly values the time that they now spend together as afamily, and is “having fun” and is “happy”.
Change in parent/carer alcohol use. A number of young people also referred to change intheir family in terms of changes to their parent/carer’s alcohol use. Six young people madereference to the change in drinking. One 11-year-old boy drew a picture of his family,depicting his carer with a can of drink. In the second picture he said “the can is gone”. A9-year-old girl said that “mum is cutting down with her drinking”. As described above, an11-year-old depicted herself as happy because her father has “stopped drinking”. Thepictures in Fig. 4 show that the step-father was spending time drinking before, whereasnow the family are spending time together. A 9-year-old girl similarly drew and labelled abottle next to herself looking “sad”, but in the second picture she is “happy” and the bottleis very clearly crossed out.
Figure 4. Change in family life (young girl aged 11).
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Discussion
The drawing method, as introduced into the evaluation of this new pilot service, hasprovided an extra level of insight into how the young people viewed the parentalalcohol misuse, the impact it was having on them and their family life, and how thingschanged after they had been engaged with Base Camp for a few months. Whilst it isnow widely agreed that young people should be actively involved in the researchprocess, the most appropriate way to do this is less clear. This pilot study demonstratesthat this novel drawing approach could be used to successfully elicit the views of avulnerable group of young people. As well as its introduction as part of the externalevaluation of the service being undertaken by the authors, it is now an ongoingtechnique which is used by the Workers as part of the support they offer young peopleand their own self-evaluation of the service.
The drawings demonstrated that the young people had self-awareness of the situationsthey were in, were able to make links between thoughts, emotions, and behaviours, andhad an understanding of the process of change (Hamama & Ronen, 2009). The sampleof drawings analysed for this paper indicate that both personal and family changeoccurred for the young people. The most common changes noted were for young peopleto report feeling happier and less confused, and for family life to be much more harm-onious, with less arguing and families spending more time together. Many of the youngpeople also, and perhaps unsurprisingly, placed alcohol centrally in their drawings and inthe change which had taken place. Their family member’s reduction or cessation ofalcohol consumption was often an important factor in the positive change that had takenplace.
Furthermore, some of the changes which the young people illustrated through theirdrawings suggest that a service such as Base Camp can mediate known protective factorsand processes, which can be evidence of resilience (Bancroft et al., 2004; Velleman &Templeton, 2006, 2007). For example, one of the primary protective factors is positive andstable parenting (or more generic support) from an adult. Several of the young people inthis sample gave examples of this in their drawing and described how there was better com-munication and less arguing at home, and how they now got on better with a parent/careror spent time with their parent(s) and siblings doing things together as a family. Further-more, there was evidence of the resilience that such protective factors can encourage, suchas having higher self-esteem and being better able to cope with or respond to negative lifeevents, such as arguments at home or pressure from peers to drink. Moreover, there werealso examples from the drawings of how a service like Base Camp can support children todevelop in line with the five core outcome areas of the Every Child Matters agenda (namely,be healthy, stay safe, enjoy, and achieve, make a positive contribution, achieve economicwell-being). For example, the young people spoke about safer and healthier family environ-ments (less arguing and doing things as a family), being healthier through choosing not todrink excessively, engaging in a range of activities (such as going bowling or to a museum),being happier and making friends.
The main strength of the research reported here is that it is believed to be the first timethat drawings have been used to find out what young people think about a service, which isfocused on supporting them because they are living with parental alcohol misuse. Onelimitation of the research is that because many of the young people’s drinking parents (orother close family members) were in alcohol treatment, it was sometimes hard to isolate towhat extent the change could be specifically attributed to Base Camp. Nonetheless, several
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of the drawings and descriptions given by the young people mentioned or clearly referredto Base Camp, indicating that it had an important role to play in the positive changesnoted by them. For example, one girl said that the groups she attended had helped her andthat she also had lots more information. Another 9-year-old girl said that she no longerbottles her feelings up, but has learnt to tell others (she specifically mentions her parents)how she feels. Similarly, an older girl (aged 13) has changed how she behaves after an argu-ment with her grandmother following the help she has received at Base Camp. An 11-year-old boy said that, before Base Camp, he didn’t know what was going on and drew himselfas confused, but after attending Base Camp he drew himself looking happier saying that hehad been to a museum and got to know some of the other people at the service, and wasless confused because he had more understanding of what was going on. A further compli-cation is that young people are often keen to please, thereby potentially describing onlypositive changes resulting from their contact with the service. A possible addition forfurther research is to ask the young person to produce two “now” pictures; one showinghow things have got better, the other showing how things have got worse. This may alsofacilitate further understanding as to how the service has directly impacted upon the youngperson. It may be, however, that for those who have never had any support before, it ishard for them to suggest things that have got worse.
It is also the case that the young people could opt out of the evaluation and the drawingcomponent and, as such, the young people who contributed drawings could be a self-selected sample better able to express themselves through drawings and most likely todemonstrate through art that positive change had taken place for them and their family.Alternative qualitative approaches were considered, however drawing was felt to be mostsuited to this particular group of young people. Nevertheless, additional qualitativeapproaches that yield a similar output may be valuable for those young people who areunwilling to provide drawings. For example, the young person could be asked to “graffiti”words on pieces of paper to describe how he/she was before and after attending the service.It may be beneficial to offer a number of different creative techniques that appeal to arange of interests, such as drawings, creative writing, and photography, although someyoung people may simply prefer a more traditional interview approach. Finally, all theyoung people participating in the research remained in receipt of a service from BaseCamp, and thus were likely to be those with a positive experience of the service, a commonproblem in research of this kind.
In a climate which is placing increased importance on hearing directly from children andyoung people, this paper has demonstrated that a drawing method can powerfully givechildren a voice. Services for children and young people, in their own right or with theirfamilies, are a relatively new development. As these developments evolve it is vital that allinvolved are given the opportunity to give their views on the services and how they help.For the evaluation and development of services for children affected by parental alcoholmisuse, drawings have an important role to play.
Acknowledgments
Most importantly, we would like to thank the children and young people for taking part inthe evaluation of Base Camp and for providing such valuable and insightful drawings. Wewould also like to thank Sue Winterburn, Val Day, Graham Woods and the Base Campworkers, for supporting the evaluation generally and the drawing component specifically.The evaluation is funded by the Big Lottery.
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Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for thecontent and writing of the paper.
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