Triggers or Prompts? When Methods Resurface Unsafe Memories and the Value of Trauma-Informed Photovoice Research Practices

Abstract

In this article, we describe a case study in which the method and approach to understanding internalizations of stigma may have both triggered and prompted suppressed memories and past trauma to reemerge. Drawing from trauma informed care approaches, we outline strategies to bear in mind for future studies.

In the midst of a massacre, in the face of torture, in the eye of a hurricane, in the aftermath of an earthquake, or even, say, when horror looms apparently more gently in memories that won't recede and so come pouring forth in the late night quiet of a kitchen, as a storyteller opens her heart to a story listener, re-counting hurts that cut deep and raw into the gullies of the self, do you, the observer, stay behind the lens of the camera, switch on the tape recorder, keep pen in hand? Are there limits of respect, piety, pathos that should not be crossed, even to leave a record? But if you can’t stop the horror, shouldn’t you at least document it?

-Ruth Behar, The Vulnerable Observer (Behar, 1997, p. 2)

Psychological trauma results from an event or a series of events and circumstances that are perceived as hurtful and/or threatening. Trauma effects are the lasting mental, physical, social, emotional and/or spiritual impacts on a person’s functioning and well-being (SAMHSA, 2014). It is nearly a universal experience among people with mental health or substance abuse disorders (SAMHSA, 2014). Given the harmful and long-lasting impact of trauma, many service organizations – especially those that help marginalized populations – have moved towards a model of trauma-informed care (TIC). Guided by TIC, agency staff are aware of and sensitive to trauma and its harms, and actively work to dismantle processes that may retraumatize (e.g., invasive procedures or questioning) the people that they help (SAMHSA, 2014).

There are six principles of trauma informed care: (1) safety – setting and interactions promote safety; (2) trustworthiness – decisions are transparent with the goals of keeping or building trust with those served; (3) peer support – stories of peers are used in healing and recovery; (4) collaboration – shared power is a priority; (5) empowerment – strength and resilience are built upon; and (6) respect for cultural and historical issues – movement past bias, responsive to the racial, ethnic and cultural needs of those served (SAMHSA, 2014). A small number of people have begun to apply these principles to policy work (Bowen & Murshid, 2016) and research with marginalized communities (Isobel, 2021; Roche et al., 2020; Shimmin et al., 2017; Voith et al., 2020)

As qualitative researchers, however, as Behar’s quote at the start of this manuscript signifies, we often delve deep into the inner most places and souls of historically disenfranchised populations (Behar, 1997). The approaches we use can discern rich experiences from participants. Yet, in doing so, we often also directly or unexpectedly ask participants about their traumatic experiences. What happens when the line of questions or method brings up hurtful memories or experiences from the past? As Behar notes, is it helpful enough to simply document this (Behar, 1997)? Should we do more to protect participants? Are we facilitating the healing process? In this article we describe a case study in which the method and approach to understanding internalizations of stigma may have both triggered and prompted suppressed memories and past trauma to reemerge. Drawing from TIC approaches, we outline strategies to bear in mind for future studies.

Participatory Research and Photovoice

Participatory research – or research that engages participants in research design and implementation decisions collaboratively, and that focuses on benefit to both the researchers and the participants, is aligned with some of the trauma informed principles (e.g., collaboration, empowerment, cultural relevance) (Cornwall & Jewkes, 1995). Yet there is a need to incorporate trauma informed practices more formally into research designs to protect marginalized participants (Roche et al., 2020).

Photovoice is a participatory method used to understand research participants’ lived experiences via photography. Participants typically use a camera to take pictures of images to identify and explore their perspectives about a given topic. These images are shared in small groups to facilitate shared knowledge, discussion, and problem-solving. Generally, exhibits of the participants’ work present their ideas with change makers and ultimately influence new policies or programs (Wang, 1999).

The method is often used among marginalized groups who desire and deserve more of a voice in the service programs designed to help them, or to explore difficult experiences that are hard to convey through words alone (Wang, 1999). It is not uncommon for such groups to have experienced trauma. Photovoice is appropriate for exploring difficult and traumatic issues because it can facilitate participant empowerment and provide a safe space for conversations to ultimately evoke individual reflection and community change. It also involves deep conversations about one’s lives; images can unearth traumatic experiences and discussions. And, although photovoice is an action method with intent to influence individual and or group change, there is no guarantee that this will happen (Sanon et al., 2014).

Application of photovoice with CBPR partnership/project

In 2019, Snap Out Stigma (SOS) was implemented in Memphis, TN (Pichon et al., 2022). Thirty-five people living with HIV (PLWH) consented to take 5–10 pictures depicting internalizations of stigma, to discuss the photos in a large group setting, and to participate in one-on-one more intimate discussions with the two lead researchers. Participants’ photos were exhibited at the local health department, community agency providing support groups, community events during HIV Observance days (e.g., World AIDS Sunday, National Black HIV Awareness Day), health fairs, a Women and Girls Church Conference, and following Sunday worship services. Throughout the photovoice process, there were a few scenarios when the process brought up past trauma among participants.

Discrimination

Several of our aging population discussed a time when health care staff discriminated and disrespected Black PLWH and Black trans women at places of their employment (e.g., health clinics, social service agencies). For instance, during the sexual risk history taking assessment a participant said the provider left the door open to the examination room and spoke loudly for others nearby to hear. Other participants described how providers made accusations of some men having sexual relations with underaged minors. The participants reflected on being misgendered and gave examples of staff incorrect pronoun usage to refer to them. In several cases, these events happened years or even decades ago but the photovoice assignment prompted these memories and examples – See Figure 1.

Figure 1.

Discrimination

Abuse

Some participants also decided to revisit childhood homes where abuse occurred or places in the community where they sought shelter during periods of homelessness – See Figure 2. They discussed how they had not gone back to these physical environments in years but the photovoice exercise motivated them to return to the places to remind them of personal growth. Admittedly, some participants still were reconciling past trauma via group therapy and still working on moving forward from the past.

Figure 2.

Abuse

Religious trauma

Living in the U.S. Deep South, religious influence is embedded in the southern culture. Most participants were grounded in a faith tradition as a child and some shifted to no longer practicing due to personal harms from the church. One participant talked in great length about the sexual abuse taking place at their childhood church home. Images of a house, church, and tree were used to convey the participant’s story – See Figure 3. As an adult this person has never looked back. However, the photovoice experience prompted the participant to take photos of a time in their former years that shaped the internalizations of stigma relating to sexuality and struggles with substance abuse.

Figure 3.

Religious Trauma

All qualitative methods intended to gather rich data from participants should never further exacerbate sensitive topics or issues for those engaged. However, photovoice may unintentionally bring up feelings that were once suppressed by individuals. While the utility of Photovoice has significant potential to evoke or inform community change [to respond to HIV stigma] and empower community research participants, below we outline what we did and what more could be done to protect participants by applying the principles of TIC to photovoice research (Table 1).

Table 1.

Application of TIC to Photovoice

Principle (SAMHSA, 2014)	What We did	What Else We Could Have Done
Safety – ensure physical and emotional comfort	- Hosted group meetings in homes, a trans friendly organization, and other community-based organizations (CBOs) with living room style spaces (e.g., one is a renovated home transformed into non-profit and day care) familiar to participants who frequent these establishments for other supportive services	- Have project protocols and interview questions reviewed by trauma experts for suggestions
	- Met with some clients where they felt safe in public spaces like restaurants where we blended in with other customers and business patrons
	- Used a formal informed consent process and did not record or link names to the project to minimize risk and potential disclosure	- Show participants examples of pictures that would and would not disclose their identity
	- Reiterated throughout interview process that questions could be skipped, and that we could stop the interview at any point especially when participants were visibly emotional
	- Offered crisis intervention and counseling referrals	- Offer onsite consultation with a counselor for all sessions
	- Had a counselor present for some of the sessions
Trustworthiness – make project decisions with clarity and transparency	- Were transparent about how the research team was going to use participant personal information, maintain anonymity, and that we would block out faces for those who chose photos that may reveal themselves; confirmed that we would not link names to interview transcripts or images	- Allow participants to choose if they wanted to share images with the churches or opt out - Give people who want to share their name with their image – who want public credit for their image – the option to do so - Be transparent that change is not promised via photovoice
	- Were transparent about how we would use the data/narratives to address stigma in churches
	- Were transparent that group sessions would include other PLWH and did not require attendance	- Inform participants about some of the themes arising from past photovoice projects (e.g., discrimination, abuse, and religious trauma) to underscore the sensitive nature of group discussions as part of the informed consent process
	- Offered options such as 1-1 meetings for participants who were not comfortable in a group session
Peer support – allow participants to support each other	- Explained that the purpose of the project was to honor the expertise of participants experiences via photos and discussions	- Train participants in conducting exhibits to enhance sustainability of the project once funding expires
	- Group sessions helped participants share ideas and problem solve together; promoted sharing of healing from addiction and trauma	- Hold participant-chosen exhibits outside of project required exhibits (churches)
Collaboration – prioritize partnership	- Exercised joint decision making and shared leadership with participants (e.g., cowrote grant to secure funds, worked together on a project logo)	- Allow participants to write captions to be shared and use audio voiceover
	- Worked together with participants to create ground rules like confidentiality
	- Worked closely with transgender- and men who have sex with men (MSM)-serving organizations and the project’s advisory board to build client rapport and maintain trust; made decisions by consensus with the group on time and location to meet for sessions
Empowerment – promote strength, power, and resilience	- Chose photovoice for its potential to facilitate empowerment and skills among participants	- Define photovoice as a participatory action-oriented method for participants and include previously collected participant discussion of empowerment in discussion sessions from other published work (Teti, 2013; and Kennedy, 2016)
	- Encouraged unity and group exchange of ideas
	- Promoted discussions of resilience as expressed by images shared in the larger group discussions
	- Recognized and affirmed (aloud) the strengths of participants during discussions
	- Did not require shy or reluctant participants to speak
Culture – offer culturally responsive services	- Offered referrals to counseling and trauma care	- Include team and participant discussions around how systems of privilege could harm or interrupt healing
	- Used interviewing techniques that were affirming and supportive of discussions of trauma
	- Had team meetings to discuss and problem-solve potential bias, racism, and microaggressions related to program delivery
	- Considered southern norms and stigma towards the LGBTQ+ community in composition of groups	- Incorporate an equity lens as a standard component of the project, given the themes emerging relative to discrimination and religiosity/homophobia
	- Closed one of the trans groups to create a safer space for participants who knew and/or were comfortable with each other
	- Expanded the group to different age groups upon participants’ requests to include people at varied stages of trauma and recovery

Conclusion

Our project demonstrates our research on the sensitive subjects of HIV stigma may be both cathartic and triggering for participants. We took many measures to increase the trauma sensitivity of the project: increased participant safety by holding meetings in spaces that seemed most comfortable and familiar; built trust through continual transparency; elevated the role of peer support and collaborative decision-making for project ground rules; ensured group discussions concentrated on participant strength and resilience; and refined group compositions in response to identified cultural needs of group members. Though we believe these trauma-sensitivities facilitated the successful commission of our project, we observed the need to more intentionally integrate further trauma responsiveness as part of Photovoice. For future Photovoice projects, we will also work with a trauma specialist during all stages of our work (i.e., to develop interview guides, engage participants in the project, and as part of group discussions in which participants are processing their experiences); further emphasize participant choice relative to if, how, and when their pictures/stories are shared; build on the role of peers by encouraging participants to consider holding their own exhibitions; and incorporate an equity lens as part of the project’s core so that participants are mentally prepared for discussions about privilege and trauma related to forms of discrimination.

A rich literature shows trauma is a pervasive experience among people living with HIV (PLWH). Therefore, our project illustrates one example of how psycho-educational projects and research for PLWH are likely equally as triggering as they are empowering. Consequently, we recommend HIV care providers and researchers consider how trauma-informed principles may be woven into projects as to maximize the empowerment participants experience while minimizing emotional difficulties.

ORCID iDs

Latrice C. Pichon https://orcid.org/0000-0002-2035-8267

Michelle Teti https://orcid.org/0000-0002-3943-3810