Article Critique

252  |  wileyonlinelibrary.com/journal/capr Couns. Psychother. Res.. 2019;19:252–263.© 2019 British Association for Counselling and Psychotherapy

1  | INTRODUC TION

The assimilation model suggests that psychotherapeutic progress involves building semiotic meaning bridges between previously dis‐ connected parts of the person (Stiles, 2011). A meaning bridge is a sign (e.g., a word and a gesture) or a system of signs (for instance, a story, an interpretation) that has similar meaning to both author and addressee, allowing them to share each other’s experience to some degree. This case study investigated whether and how com‐ puter‐generated digital images might serve as therapeutic meaning bridges, supplementing verbal meaning bridges in psychotherapy. The study focused on a 14‐year‐old boy who participated in a trial of video game‐like avatar software in school counselling. This was a qualitative theory‐building case study (Stiles, 2007; Stiles, 2009a).

We sought theory‐relevant observations on the client’s use of the imagery, which might support or contradict the theory or suggest elaborations.

1.1 | The assimilation model

According to the assimilation model, a person’s experiences leave traces, which may later be reactivated. Reactivated traces may act and speak, and are described, metaphorically, as voices. Normally, traces of people’s experiences become interlinked into constella‐ tions of related experiences, forming, metaphorically, a community of voices, which comprise the person’s usual self (Honos‐Webb & Stiles, 1998; Stiles, 2011). Such assimilated voices are smoothly ac‐ cessible and available to the pesrson as resources.

Received: 2 October 2018  |  Revised: 17 April 2019  |  Accepted: 24 April 2019 DOI: 10.1002/capr.12230

S P E C I A L S E C T I O N A R T I C L E

Digital images as meaning bridges: Case study of assimilation using avatar software in counselling with a 14‐year‐old boy

Biljana van Rijn1  | Evi Chryssafidou2 | Caroline J. Falconer3  | William B. Stiles4

1Faculty of Research Strategy and Innovation, Metanoia Institute, London, UK 2Faculty of Research Strategy and Innovation, Metanoia Institute, London, UK 3Psychology, University College London, London, UK 4Miami University and Appalachian State University, Glendale Springs, North Carolina

Correspondence Biljana van Rijn, Faculty of Research Strategy and Innovation, Metanoia Institute, London, UK. Email: biljana.vanrijn@metanoia.ac.uk

Funding information sbri healthcare

Abstract Objectives: According to the assimilation model, psychotherapeutic progress in‐ volves building semiotic meaning bridges between disconnected parts of the person. Previous research has focused on verbal meaning bridges; this case study investi‐ gated whether and how digital imagery might serve as well. Design: This was a qualitative theory‐building case study. Method: The client was a 14‐year‐old boy with autism spectrum disorder seen in school counselling for 60 sessions. Assimilation analysis was applied to screen re‐ cordings and accompanying voice recording nine sessions, drawn from an early part of his treatment, during which he participated in an evaluation of video game‐like software designed for therapy and coaching. Results: The client created avatars representing aspects of himself and significant others, and scenes representing his problems and coping. The imagery and meanings evolved across this segment of treatment, providing a channel of interpersonal and intra‐personal communication. Conclusion: Observations showed how digital imagery can serve as meaning bridges between client and counsellor, and between internal parts of the client.

K E Y W O R D S

adolescent psychotherapy, assimilation theory, autistic spectrum disorder, qualitative methods, technology in psychotherapy

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Some experiences, however, remain unassimilated because they are incompatible with the usual self or are threatening, frightening or painful. In successful psychotherapy, clients build meaning bridges to such problematic experiences, first with the therapist and then with his or her own community of voices, reducing distress and al‐ lowing smooth access. A series of theory‐building case studies has suggested that assimilation follows a developmental course sum‐ marised in the assimilation of problematic experiences sequence (APES; Basto et al., 2018; Brinegar, Salvi, Stiles, & Greenberg, 2006; Stiles, 2011; Stiles & Glick, 2002), described later.

Meaning bridges may be simple words or phrases or they may be self‐narratives or interpretations (Brinegar et al., 2006; Stiles, 2011). Whereas previous assimilation research has focused on verbal meaning bridges, this case study explored whether and how visual imagery might also be used to share and link experiences.

1.2 | Counselling for autistic spectrum disorder

Autistic spectrum disorder (ASD) is classified by the DSM‐5 (APA, 2013) amongst the group of neurodevelopmental disorders, which have an early developmental onset and result in impairments in social and personal functioning. ASD leads to a range of symp‐ toms resulting in difficulties in social interactions and functioning, and repetitive patterns of behaviour, interests and activities (APA, 2013). These symptoms have impact on developing and maintain‐ ing reciprocal social relationships. ASD can range in the levels of severity and the requirements for support in everyday functioning. However, by the time children reach secondary school, they perform less well than their peers in nearly all areas of school adjustment and are rated as more anxious and withdrawn, as well as more opposi‐ tional and aggressive (Ashburner, Ziviani, & Rodger, 2008). Research by Samson, Huber, and Ruch (2011) found that 45% of adults diag‐ nosed with Asperger’s syndrome experienced fear of being laughed at, compared to only 6% of adults without the diagnosis. Although aggression has been identified as an issue for adolescents with ASD, there is also evidence that they are perceived as different and be‐ come a target for bullying. This is particularly the case for those with high functioning ASD, who attend mainstream schools (Auger, 2013). In addition, social isolation exacerbates the effects of bullying (Humphrey & Symes, 2010).

In the UK, school counselling is one of the prime settings to deliver mental health interventions for young people, with a po‐ tential to reduce its associated stigma (Kavanagh et al., 2009). Humanistic school‐based counselling is the most common type of counselling for young people in the UK (Cooper, 2013), focusing on empowering clients to make changes in their life by exploring their inner world and expressing emotions with an empathic and attuned adult.

1.3 | Avatar software as a therapeutic tool

To investigate the use of images in therapy, we drew one case from an evaluation study (Cooper, Van Rijn, & Chryssafidou,

2018; van Rijn, Cooper, & Chryssafidou, 2018) of a proprietary video game‐like tool developed for therapy and coaching, which we call avatar software. The software allows clients to create digital visual representations of their inner worlds, and life situ‐ ations, including avatars (virtual people) representing themselves and others. A more detailed description of this avatar software is presented later. Results of the evaluation study showed that taking part in the intervention, which involved access to the soft‐ ware for approximately 10 counselling sessions, was associated with small‐to‐medium reductions in personal distress and an in‐ crease in self‐compassion for male clients and for those starting a new episode of therapy. The intervention was experienced as more satisfying and helpful by male clients than by female clients, and by those who reported they had been diagnosed with learn‐ ing difficulties, including ASD (Cooper et al., 2018; van Rijn et al., 2018). We speculate that the attractiveness to learning disabled and ASD‐spectrum clients might meet the predominantly visual thinking style of this group (Anderson & Morris, 2006; Donoghue, Stallard, & Kucia, 2010; Paxton & Estay, 2007).

This avatar software was of the sort described as the “client as avatar” model (Rehm et al., 2016), in which the client is rep‐ resented as an avatar, along with other representations of the client’s external reality or internal self. The therapist’s role is to help the client to navigate through and reflect on the scenes. The therapist is not necessarily represented in the virtual world. In a study of using this avatar software as an adjunct to face‐to‐face group therapy in a prison setting, qualitative analysis of interviews suggested that the intervention was acceptable to both the pris‐ oners and the counsellor; and that it facilitated the development of reflection, insight and empathy (van Rijn, Cooper, Jackson, & Wild, 2015). The same software was used in a case study of two adolescent boys, showing that it could be integrated into clinical practice and that it enhanced communication with young people who found communication difficult (Falconer, Davies, Grist, & Stallard, 2019).

The use of digital avatars is an emerging adjunct to psycholog‐ ical therapy (Espie et al., 2016). Avatar‐based approaches, usually in the form of a virtual world populated with avatars on a com‐ puter screen and manipulated using a keyboard and mouse, have been used to investigate positive inter‐ and intra‐personal relating (Hoch et al., 2012; Yuen et al., 2013). For example (Craig et al., 2015; Leff, Williams, Huckvale, Arbuthnot, & Leff, 2013), ther‐ apists instructed clients to customise avatars to represent their auditory hallucinations. A role plays where the therapist spoke the words of the avatar offered an opportunity to interact with their auditory hallucinations in a constructive way. The proposed psy‐ chological benefits of digital approaches to therapy, of which ava‐ tar‐based approaches are a subset, include greater self‐disclosure due to the disinhibition through psychological distance, access to alternative channels of communication and expression, an arena to explore identity and capitalising on some clients’ familiarity with digital media (see Gorini, Gaggioli, Vigna, & Riva, 2008; Rehm et al., 2016).

254  |     van Rijn et al.

2  | RESE ARCH AIMS

We investigated the use of digital imagery in school counselling by Richard (a pseudonym), a 14‐year‐old boy previously diagnosed with ASD. Our aim was to investigate how the digital imagery was used in counselling. We used assimilation analysis (Stiles & Angus, 2001) to examine a series of sessions drawn from a longer course of coun‐ selling. We were particularly interested in how the digital images might be used as meaning bridges, that is, for communication be‐ tween Richard and his counsellor, and for Richard’s understanding of himself. Showing how visual imagery can serve as meaning bridges would be a significant elaboration of the assimilation model.

We did not attempt to evaluate the efficacy of the avatar soft‐ ware for use in counselling. Indeed, the material we studied did not afford such an evaluation. To engage in depth with how the software was used during therapy, we used a methodology that would help us to explore the process of change in avatar‐assisted therapy. Theory‐ building case study (Schielke, Fishman, Osatuke, & Stiles, 2009; Stiles, 2007) and assimilation analysis (Stiles & Angus, 2001) pro‐ vided an appropriate approach. Theory‐building case study research seeks to evaluate and strengthen a theory by examining many as‐ pects of the theory in particular cases rather than testing one aspect across many cases, as in statistical hypothesis testing. Generality is specified by the theory (in our case, by the assimilation model), not extrapolated from the (single) case (Stiles, 2009a; Stiles, 2017; Stiles & Horvath, 2017). We sought observations relevant to many aspects of the assimilation model, mindful that the observations could sup‐ port or contradict the theory or suggest possible elaborations.

3  | METHOD

3.1 | Client

Richard, a 14‐year‐old White British boy, received counselling at school. He had previously been diagnosed with ASD, listed as the reason for his referral. We estimated that his cognitive abilities were in the average range; he presented with fluent language skills, and he was succeeding academically in a regular school environment, though feeling odd and unaccepted amongst his peers at school. Problems and concerns identified in his initial assessment included long‐standing anxiety, self‐esteem and identity issues, anger, and behaviour problems. He had interest and extensive experience in video games, which was relevant to his comfort with the avatar soft‐ ware and to the content of his counselling.

3.2 | Counsellor and treatment

The counsellor had an Advanced accredited Diploma in Humanistic Counselling and a Certificate in Psychodynamic counselling, with over 6 years of post‐qualification experience. This approach focuses on building the therapeutic relationship, empathic enquiry and ac‐ cepting clients and their experience. The counsellor appeared to use this approach; however, there was no formal adherence check.

Sessions took place in a quiet room, the usual setting for counselling in Richard’s school.

3.3 | Investigators

The four investigators included a female psychotherapist and a coun‐ selling psychologist in her 50s, a female researcher in her 40s who had a background in education background, a female researcher in her 30s who had a background in cognitive psychology and virtual reality research, and a male clinical psychologist in his 70s. All four were authors of this report.

3.4 | Avatar software

The avatar software was designed by ProReal, Ltd. (http://www. prore al.co.uk/), a British company, as a therapeutic tool for coun‐ selling and coaching. The action is set in a rural, somewhat mediae‐ val landscape containing hills, fields, a forest, a river and a castle. Androgynous avatars can be created to represent self or others; these can be assigned names, emotions, postures (movements miming attitudes, e.g., “stressing/regretting/OMG”), colours, sizes, and inner voices or thoughts. A variety of props, including bridges, walls, milestones, gravestones roadblocks, treasure chests, plat‐ forms, shields, bombs, mirrors and elephants, can be added and labelled. The interactive landscape can be viewed from any ava‐ tar’s perspective, or from a “roaming” perspective in or above the landscape.

In preparation for the evaluation study from which Richard’s case was drawn, counsellors were given guidelines, detailed in a ProReal User Manual (ProReal Ltd, 2015), and trained in using the software by the members of the ProReal Ltd team. During sessions, when the software was in use, the client and counsellor sat facing a single computer screen, side‐by‐side, but at an angle so that they could see each other as well as the screen. At the beginning of each session, the counsellor would normally invite the client to represent his or her world within the landscape. However, clients were not required to use the software, and clients varied in how much they used it.

3.5 | Ethical procedures

We sought consent in stages. Participants, parents and counsel‐ lors gave initial informed consent for the software evaluation study (Cooper et al., 2018). Following the evaluation study, we asked all the participants for consent to contact them again for potential inclusion in the case study research. Having chosen Richard, we asked him, his parents and his counsellor for consent to use the recorded material in the case study. We removed the personal details, used a pseu‐ donym and kept the school details confidential. In the post‐analysis interview, we shared our analysis with Richard and the counsellor, gave them a final opportunity to add or remove any data, and re‐ quested and received their consent to use their materials and report our findings.

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3.6 | Case selection

We sought a case in which the client used the avatar software for at least six sessions, to allow us to potentially observe changes in the use of the imagery. Three clients met all the criteria and gave all the permissions, and we chose Richard, mindful that the evaluation study suggested the avatar software might be particularly accept‐ able for male clients and those with learning difficulties.

Prior to beginning the software evaluation study, Richard had had 10 sessions with his counsellor. During the study, Richard had 11 sessions (one beyond the study’s intended maximum). We have numbered the sessions in sequence to his whole therapy, so his first session at the start of research was his session 11. His final session during the project was his session 21. He used the ava‐ tar software during all or part of nine of them. He chose not to use the software in his sessions 16 and 19. After the end of the study, Richard continued in counselling for approximately another 40 sessions.

On the standard measures used in the software evaluation study, Richard showed little change across the 11‐week period we studied. However, as noted earlier, Richard was still in the first third of his 60‐session course of counselling.

3.7 | Case materials

We used video recordings of the onscreen images and accompany‐ ing audio recording of the dialogue in the portions of the nine coun‐ selling sessions during which Richard used the software, and we made verbatim transcripts of the audio recordings. In sessions 11– 15, Richard used the software for all or most of his 50 min. However, in session 11, there was no audio recording due to a technical failure. Richard did not use the software at all in sessions 16 and 19, and in sessions 17, 18, 20 and 21, he used it for only 25, 16, 22 and 27 min, respectively. We did not have recordings or transcripts of other por‐ tions of these sessions or of any other sessions. We also used tran‐ scripts of the semi‐structured interviews with Richard and with his counsellor.

3.8 | Assimilation of problematic experiences sequence

The APES describes the developing relation of a problematic experi‐ ence (or voice) to the person’s usual self (or community of voices) across successful treatment (Stiles, 2011; Stiles & Angus, 2001). The current version includes eight stages or levels, numbered 0–7:

(0) Warded off/dissociated, (1) Unwanted thoughts/active avoidance, (2) Vague awareness/emergence (often with considerable distress), (3) Problem statement/clarification (naming the problem, so it can be

talked about and worked on), (4) Understanding/insight (or, equivalently, mutual understanding

between voices),

(5) Application/working through (adjusting the understanding in daily life),

(6) Resourcefulness/problem solution (using the formerly problem‐ atic experience as a resource) and

(7) Integration/mastery (the experience/voice is a part of the self).

Clients may enter therapy at any stage, and any movement through the sequence may be regarded as progress (Stiles & Glick, 2002; Stiles et al., 1991). The APES is considered a continuum, and inter‐ mediate stages are possible (for instance, 2.3, 3.6). Brinegar et al. (2006) distinguished a series of sub‐stages between stages 3 and 4 that proved useful in this study:

(3.2) rapid crossfire, as the problematic and dominant community voices express their contrasting views,

(3.4) entitlement, as the problematic voice asserts its position more forcefully,

(3.6) respect and attention, as the voices listen to each other and (3.8) joint search for a mutually acceptable formulation.

The APES has sometimes been used as a formal rating scale. However, we did not do formal ratings but instead used it only to specify our own interpretations.

3.9 | Assimilation analysis

The four investigators applied assimilation analysis (Stiles & Angus, 2001) to the recordings of the onscreen imagery with background audio and transcripts. This procedure can be described in four steps. These steps were conducted by each investigator independently, with periodic video conferences to discuss impressions and progress (Schielke et al., 2009).

3.9.1 | Familiarisation

The investigators intensively studied the recordings and read the transcripts, making notes and/or using qualitative analysis software.

3.9.2 | Theme identification

Based on the acquired familiarity and notes, the investigators identi‐ fied salient and therapeutically important themes and worked to‐ wards a consensus formulation of a focal theme.

3.9.3 | Extraction of theme‐related material

Session material, including screenshots and dialogue relevant to the focal theme, was excerpted and examined in sequence to highlight Richard’s work.

3.9.4 | Interpretation and writing

The observations were described and interpreted in theoretical terms. APES stages were used to specify estimates of the problem’s

256  |     van Rijn et al.

degree of assimilation. Initially, the investigators maintained sepa‐ rate versions of the descriptions and interpretations of session events and drafts of the report. Periodically, investigators posted their current versions on a shared server. In this way, ideas and text were shared freely, while being independently retained if each in‐ vestigator felt it represented the best interpretation (Schielke et al., 2009). Later, these separate accounts were integrated.

The interpretations drew on familiarity with all sessions. Meanings that might not have been apparent in an isolated moment or image could be understood in the context of material that oc‐ curred earlier or later.

The process of interpretation was not quick, simple, straightfor‐ ward or linear. Each investigator alternated between the material and interpretations, drawing on each other’s growing understanding. In the end, Richard’s work seemed understandable, even systematic, and we have tried to represent this understanding in reporting the results.

3.9.5 | Post‐analysis interviews

One of the investigators presented a synopsis of the interpreta‐ tions, illustrated with screenshots, and interviewed Richard and the counsellor separately for about 40 min each. The interview was semi‐structured and consisted of open questions, probes for agree‐ ments or disagreements, and invitations to rephrase the interpreta‐ tions. Both were again asked for (and gave) their consent to publish the analysis. Their comments were integrated into this report.

4  | RESULTS

4.1 | Focal theme: Being different

We focused our analysis on Richard’s problematic experience of being different, which was salient in all the sessions we studied. This theme encompassed his longing to be “normal”, and experiences of not be‐ longing and not fitting in. Richard attributed his difference mainly to his ASD diagnosis. He reported that his peers at school sometimes “mocked” him, treated him as different or odd, and laughed at him for reasons he did not understand, at least initially. On the other hand, amongst his video gaming peers (for instance, in an after‐school games workshop he frequented and in online groups), he was accepted and even admired in some respects. In the post‐analysis interviews, both Richard and his counsellor agreed that being different was the central problem addressed in the whole treatment, not only in the segment we studied. In terms of assimilation theory, Richard’s distressing ex‐ periences of being different were at odds with his dominant self (com‐ munity of voices), challenging his sense of self‐identity and self‐worth.

4.2 | Richard’s use of the avatar software

Richard took quickly to the avatar software, requiring little orientation, perhaps partly because he had extensive online gaming experience. He used avatars to represent aspects of himself and others, and props as metaphors for his problems and ways of coping. In contrast, Richard’s

verbal responses were usually brief, agreeing or occasionally disagree‐ ing with the counsellor’s verbal reflections and summaries or giving short responses to questions and comments by the counsellor.

Richard constructed 13 main scenes, which are listed in Table 1, numbered in the order constructed. These are illustrated with screen‐ shots in an Appendix S1 (we recommend viewing these along with the text of the results). The first five scenes, which seemed to artic‐ ulate Richard’s focal problematic experience of being different, were constructed in session 11, the first session where he used the soft‐ ware. He returned to these five scenes and modified them in subse‐ quent sessions to reflect changes in his circumstances and feelings. To respect space limitations, we present only scenes 1, 4 and 5 which show developments in his focal problematic experience; and scenes 6, 9, 12 and 13, which show key aspects of his dominant commu‐ nity of voices and the process of change. We have briefly described scenes 2, 3, 7, 8, 10 and 11 in Table 1 and in the Discussion.

4.2.1 | Scene 1. Inside the secure castle walls

Richard first created a scene within the walls of the castle, later de‐ scribed as a “secure base”, in which he placed a black avatar rep‐ resenting himself. He added avatars that he named Objective 1, Objective 2 and so forth, later identified as peers with whom he wanted more positive social contacts. He also added three milestone props labelled with recent accomplishments, including “gained cop‐ ing strategies,” “joined CCF workshop” (a gaming group) and “saw super moon” (witnessed a rare astronomical event). A campfire prop in the middle, labelled “happiness,” seemed to confirm that this first scene referred to contents of his usual self, inside the walls where he felt safe. A screenshot appears as Scene 1a in the Appendix S1.

In retrospect, the juxtaposition of his achievements (milestones) with his objectives (making positive contact with peers) seemed a meaningful step. This was not yet a clear statement of the central problem, but it noted some important elements (APES 2.8).

In session 13, he piled many platform props on top of each other to build a stairway to the top of the castle wall, giving him a view of the world outside the castle. He added a further black avatar, which he named Spectator, at the top, initially with a neutral emot‐ icon, later changed to happy, and a speech/thought, “everything is peaceful” (Scene 1b in Appendix S1). In response to the counsellor’s questions, Richard characterised the Spectator:

It’s like how I’d watch everything within like, this, in the same sense that I’m watching it from the outside. So, I guess spectator represents myself in reality watching all of this.

4.2.2 | Scene 4. The treasure of normality

Still in session 11, Richard chose a sunlit forest glade and added a section of wall, which he labelled “cannot get past it,” with a treasure chest behind it labelled “normal.” (Scene 4a in Appendix

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S1). He added a black avatar named Fitting In on the other side of the wall from the chest with a “crying and stressed” emoticon, a posture of “stressing/regretting/OMG,” and an inner voice say‐ ing, “I can see it but I cannot achieve it.” To us, this was an elo‐ quent and poignant representation of his problematic experience of being different (APES 3.0; problem statement/clarification).

Early in session 13, Richard returned to this scene and increased the number and size of the treasure chests, all labelled “normal” (Scene 4b in Appendix S1):

Counsellor: What does that mean for you today?

Richard: Like, because I’ve been hard to fit in amongst everybody else… Like, because everything that like, hap‐ pens is like, it always happens like, different for other peo‐ ple other than myself. And then it’s like, always seem like other people and then I get treated like really differently.

Counsellor: Okay. So what does the normal mean today in that treasure chest? Is that what you would like to be then?

Richard: Yes.

…

Counsellor: So is that the goal then? Is that the trea‐ sure, the feeling like you’re fitting in?

Richard: Yes.

Richard seemed to use the images as part of his inner dialogue about the problem.

Counsellor: So I’m just wondering, is the significance of having more treasure chests, or bigger treasure chests, means that your desire to be normal is bigger, or that you feel more normal?

Richard: It’s the desire to be normal is bigger.

Counsellor: Is that because you feel less like you’re fitting in then?

TA B L E 1   Overview of principal scenes with relation to focal theme and assimilation of problematic experiences sequence (APES) stage

Overview of scenes Appendix Focal theme APES stage

Scene 1. Inside the secure castle walls

Scene 1a. Inside the secure castle walls Scene 1b. Spectator avatar above the castle walls

Representation of feeling safe

2.8 Formulating the problem

Scene 2. Roadblocks to cope with anxiety

Scene 2. Roadblocks to cope with anxiety Avoiding anxiety and self‐criticism

2.8 Formulating the problem

Scene 3. Riverbank. Dealing with distractibility

Scene 3. Riverbank (dealing with distractibility)

Difficulties with atten‐ tion and concentration

2.8 Formulating the problem

Scene 4. The treasure of normality

Scene 4a. The treasure of normality Scene 4b. More treasure chests

Inability to reach “being normal”

3.0. Problem statement and clarification

Scene 5. Minefield of memories

Scene 5. Minefield of memories Difficult memories of being laughed at

3.0. Problem statement and clarification

Scene 6. Elephant as games server

Scene 6. Elephant as games server (gaming community)

Acceptance within the gaming community

3.0. Problem statement and clarification

Scene 7. Gravestones and Halloween

Scene 7. Gravestones and Halloween Experiences of not fit‐ ting in

3.4. A problematic voice is allowed space for reflection

Scene 8. Games workshop Scene 8. Games workshop (enclosed and secure)

An activity centre where Richard feels accepted.

3.0. Problem statement and clarification

Scene 9. Pacing through the landscape

No individual image Reflection on how pac‐ ing onscreen enabled Richard to stay still in the session

3.2. Rapid crossfire between prob‐ lematic and dominant voices

Scene 10. Bridge with beacons

Scene 10. Bridge with beacons Feeling connected 3.6 Accepting the problematic expe‐ rience of being different

Scene 11. Angry troll in the tunnel

Scene 11a. The tunnel Scene 11b Angry troll in the tunnel

Expressed but unac‐ knowledged anger

No APES rating

Scene 12. Dancing around the fire

Scene 12. Dancing around the fire (friends as health boosts)

Positive experiences of gaming

3.6. Continued work on problem statement and clarification

Scene 13. Monument and a mirror

Scene 13a. Monument and mirror Scene 13b. Everything is peaceful

Beginnings of self‐acceptance

3.8. Joint working between domi‐ nant and problematic voices

258  |     van Rijn et al.

Richard: Yes.

4.2.3 | Scene 5. Minefield of memories

Still in session 11, Richard created an avatar named Spectator. In a patch of grass, he placed a sign saying “memories,” two treasure chests labelled as “good” and three bombs (round, with lit fuses) labelled as “bad.” A Spectator avatar looked at the scene, while an inner voice said, “some things are okay and others are not” (Scene 5 in Appendix S1).

In session 12, he returned to this minefield and deleted two bombs. The counsellor commented:

Counsellor: Okay, so that was different from last week, so … you’ve got two less of those bombs and you still kept the memories, which is your treasure chest as well. All right. Okay, but there’s still a bit of a bomb going on there but not as much.

Richard: I had them all here because … at the moment I keep, like, accidentally doing things that seem to… That other people find funny, like, at my expense.

Counsellor: Okay, what, like, in school, do you mean? What, like what, for instance?

Richard: I said something, like, I didn’t… Nothing rude or anything. I, like, shared my opinion. Then it was, like, a whole bunch of people started laughing at me.

Counsellor: Okay, so that’s, sort of, representing that fitting in thing, then?

Richard: Yes.

In APES terms, Richard seemed to be trying to make sense of why his peers laughed at him, working on the problem in the range of APES 3.

4.2.4 | Scene 6. Elephant as games server

In session 12, Richard introduced his involvement in the gaming sub‐ culture. He used an elephant to represent an online games server. He put three avatars on the back of the elephant to represent other gamers and coloured them “yellow, like warning chevrons” (Scene 6 in Appendix S1).

Counsellor: And you said before that it’s easier in some ways, talking to people online than in reality?

Richard: Yes. See, they don’t know who I am, so they don’t have anything to mock me for before they meet me.

Counsellor: Is that the dangerous, hazardous yellow bit then, mocking?

Richard: Yes.

We understood this image as Richard’s dominant community con‐ veying a context where he was not different, offering a positive side to the dialogue about his experience of being different.

4.2.5 | Scene 9. Moving through the landscape

Throughout his treatment, Richard often moved his perspective rap‐ idly through the virtual landscape (Scene 9 is not in the Appendix S1 because it could not be adequately represented in a still screenshot). This was particularly evident when difficult topics emerged. Richard offered an account in session 14:

Counsellor:… but what I’ve noticed is you’ve been running around quite a lot, and…

Richard: Yes, otherwise I’d end up like goofing around a lot in reality; like I am the bloke pacing around in circles. Like if I wasn’t sat down I’d be walking around the table, and I probably would have done it about 200 times by now.

Counsellor: So that, so the… so you’re using the avatar to do the pacing for you?

Richard: Yes. I don’t need to exercise ‐ the avatar can do that.

In session 15, following his constructing a cosy image representing his games workshop (scene 8), Richard described an online game he called “Minecraft for autistic people,” where he also felt he fitted in. As he did this, he used an avatar to run and jump through the landscape. The counsellor encouraged Richard to reflect on his ASD diagnosis.

Counsellor: If you’re talking about your difficulty with having that diagnosis, is there any way you can por‐ tray that, I suppose, how you feel about it. Is it a dif‐ ficult thing to…?

Richard: (moving to a different scene) Not really. I can jump off here now (referring to the avatar), like, it’s huge. Right, that’s big.

The sudden changes in subject might be understood as APES 3.2 (rapid crossfire between voices; Brinegar et al., 2006). The counsellor persisted, and eventually, Richard settled into the discussion:

Counsellor: Okay, what’s the worst thing about being autistic for you?

|  259van Rijn et al.

Richard: Because it’s like I’m not normal and basically, compared to everyone else, I’m mentally defected.

…

Counsellor: is it because that’s the thing that’s diffi‐ cult for you, sort of, making sense of the rest of the world and other people, because they’re different?

Richard: Yes.

Counsellor: Because in a way, to you, they’re the ones that are different, aren’t they?

Richard: Yes, but I know that I’m actually the one who’s different. It feels like they’re different but then it’s actually me…

This exploration was the most direct verbal exploration of Richard’s focal theme in the material we studied.

4.2.6 | Scene 12. Dancing around the fire

In session 18, Richard constructed a still more positive image of his experiences in gaming. He recreated a scene from an online game with friends that depicted their avatars dancing around a fire (Scene 12 in Appendix S1). He explained that the act of coming together provided a “health boost” to the virtual characters. Richard gave his avatar the posture of “celebrating/cheering,” while the two friends were given the postures “showing direction/leading” and “open/ being up for it.”

Counsellor: What do you mean health boosts?

Richard: Like in the game it like heals you, your char‐ acter, but then it also looks funny because your char‐ acters actually do dance…

…

Richard: [This feels good because] it’s a lot more so‐ cial than things in real life tend to be, I guess. …

Counsellor: Well, I guess the point is that it makes you feel like you’re interacting and having fun with other people, which I guess is, creates a feeling of what, wellbeing or happiness with you.

Richard: Yes.

To us, “health boosts” seemed an apt metaphor for the social acceptance Richard gained from his par‐ ticipation in gaming, a positive contribution by his

dominant community of voices to the dialogue with his problem (perhaps APES 3.6).

4.2.7 | Scene 13. Monument and mirror

In session 21, to be sure he had used all the available props, Richard built a complex, pyramid of them, called a “monument,” and put an avatar representing himself at the top (Scene 13a in Appendix S1). During this process, he discovered a mirror prop, and this led to an exchange concerning how he felt about himself:

Counsellor: Is there anything you like when you look in the mirror?

Richard: Yes.

Counsellor: What do you like?

Richard: Myself, but not for appearances.

Counsellor: You like your internal self?

Richard: Yes.

Counsellor: That’s a really good thing, isn’t it?

Richard: Yes.

To us, this explicit self‐acceptance suggested coming to terms with his experience of being different, the sort of mutually accept‐ able formulation by problematic and dominant voice characteristic of APES 3.8. Towards the end of the session, he used the “every‐ thing is peaceful” Spectator avatar to climb his platform stairs to the top of the castle wall and survey the scenes he had built (Scene 13b in Appendix S1).

4.3 | Post‐analysis interviews

In the post‐analysis interview, Richard examined the screenshots, read parts of the synopsis and responded to questions. He clearly remem‐ bered his use of the software and the specifics of the scenes. He con‐ firmed that the theme of being different was central in his counselling and generally agreed with most interpretations of the scenes, such as the castle being a “secure base,” the game server representing a sense of belonging to the online gaming community and the scenes with the walls and the bombs referring to his struggles with being different.

The counsellor also generally agreed with our interpretations of Richard’s imagery as well as with Richard’s experience of being dif‐ ferent as the central problem addressed in the therapy. She could not recall the scenes and labels as easily as Richard could.

In response to questions about progress over the whole ther‐ apy, Richard said he thought not much had changed, whereas the

260  |     van Rijn et al.

counsellor said she saw large improvements in self‐confidence and reductions in distress.

5  | DISCUSSION

The digital imagery clearly and sometimes poignantly conveyed Richard’s problematic experience of being different. As Richard created his digital world, the counsellor followed, reflected, in‐ quired and verbalised the experiences to which the images referred. Richard seemed to use the images to conceptualise and work with the focal theme as well as to convey his experiences, suggesting they were meaning bridges intra‐personally as well as with the counsellor. The images were also meaning bridges to the investigators, vividly conveying Richard’s experience to us and, we hope, to you as read‐ ers. This expansion of the concept of meaning bridges is a new addi‐ tion to the assimilation model (Stiles, 2009a, 2009b; Stiles, 2011). In effect, the images provided an additional metaphor for the traces of experiences previously described (metaphorically) as voices within the assimilation model.

5.1 | Richard’s path

According to our interpretation, in the segment of treatment we studied (sessions 11–21 out of about 60), Richard worked first to for‐ mulate his problematic experience of being different from his peers and not fitting in and his desire to be normal. He began session 11 by representing his interpersonal objectives as avatars and his recent achievements as milestones in the safe interior of the castle (scene 1). Next, in a more exposed location outside the castle walls (scene 2), he represented protecting himself (an avatar) from anxiety (another ava‐ tar) by avoidant coping mechanisms (roadblocks). He represented his unsuccessful efforts at overcoming his attention problems as trying to reach treasure chests (ideas and concepts) on the opposite bank of a river (scene 3). In scene 4, he represented himself (an avatar) as distraught because he was prevented by his ASD (impassable walls) from being normal (treasure chests). And in scene 5, he represented himself as a spectator surveying a minefield of his own good and bad memories (treasure chests and bombs). In our judgement, during this sequence, Richard’s problematic experience of being different moved from partially formulated but still a bit vague (APES 2.8) to being clearly stated using the digital images (APES 3.0).

Richard returned to each of the five initial scenes from time to time, elaborating them or depicting new developments in his life. And he created new scenes to represent aspects of this work. He examined how he appeared different or odd to other people. For example, gravestone props (scene 7) led to an examination of others’ negative reaction to a previous Halloween costume as a cultist. Pacing through the digital landscape (scene 9) expressed his restlessness and led to a discussion of his inability to keep still. Feelings arising from intersession negative experiences were ex‐ pressed in imagery (e.g., feeling like an angry troll in a dark tunnel in scene 11b).

Other images expressed being accepted in his computer gaming community, which seemed increasingly positive sessions. Scene 6 expressed some ambivalence about gamers with unknown attitudes (an elephant ridden by avatars coloured yellow to signal risk). Scene 8 expressed safety with known gamers (a cosy representation of the games workshop). And scene 12 expressed joy and energy (dancing around a fire).

These visual representations of his problem, his difference and ways he was normal seemed to be parts of a potential meaning bridge that could encompass both Richard’s self‐esteem and his ex‐ periences of being treated as different. It was not what he wished, but by accepting his symptoms and experiences of being different, he could accept himself more fully, just as María came to assimilate and accept her incurable physical symptom of dizziness in another assimilation study (Gabalda, 2006). A representation of connection in scene 10 (beacons visible across the landscape) following a dis‐ cussion of his autism seemed to acknowledge a self that included ASD. Likewise, his reaction to the mirror prop (that he liked himself, “but not for appearances”; scene 13) could be a metaphor for com‐ ing to terms with his different. We judged his problem had reached about APES stage 3.8 by session 21; his dominant community and problematic voices were working jointly towards an acceptant un‐ derstanding of being different.

5.2 | Being different in adolescence

The desire to be normal and fit in is typically salient in adolescence (Coie, Terry, Lenox, Lochman, & Hyman, 1995; Somerville, 2013), but Richard’s concerns were probably exacerbated by his ASD. Some of the distinctive behaviours he discussed (for instance, con‐ stant movement, repetitive behaviours, distractibility) and limited social sensitivity are consistent with an ASD diagnosis (American Psychiatric Association, 2013). Young people diagnosed with ASD are often seen as odd or different and may be socially excluded, misunderstood, bullied and laughed at (Cousins, 2002; Humphrey & Lewis, 2008; Jackson, 2003; Jones, Zahl, & Huws, 2001; Portway, 2006; Willey, 1999; Wilson, 2017).

5.3 | Using digital imagery in psychotherapeutic work

We learned Richard’s visual language only slowly, and undoubtedly, we and the counsellor missed or misinterpreted some of his mean‐ ings. On the other hand, after spending months with Richard’s im‐ ages, we may have understood some meanings that Richard himself did not fully appreciate.

It seemed to us that Richard used the images to formulate his prob‐ lem and to work on it. We and the counsellor translated the images into words to understand what was going on, but this did not seem essential for Richard. Digital media may be particularly valuable for clients on the autistic spectrum, who may have a predominantly vi‐ sual thinking style (Anderson & Morris, 2006; Donoghue, Stallard, & Kucia, 2010; Paxton & Estay, 2007). The images clearly and sometimes

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poignantly conveyed Richard’s dilemma, though it took us a while to learn his visual language. Theoretically, as he used the images to share his experience with the counsellor, Richard could also see his own pro‐ ductions, making his experience more salient or clearer to his other inner voices, allowing him to reflect on his own psychological changes.

Naturally, Richard’s counselling involved words as well as images. His verbal responses were usually brief, but he responsively agreed (or occasionally disagreed) with the counsellor’s more detailed re‐ flections and summaries. Richard’s virtual pacing through the digital landscape increased when he talked about distressing events, but this pacing seemed to help him sit still and stay on topic. Perhaps his re‐ petitive use of platforms in scene 1 and bridges in scenes 11b and 13a was a sign of his ASD. The avatar software also offered handy ways to change the topic when the discussion of a problem exceeded the upper limit of his comfort zone (Leiman & Stiles, 2001; Ribeiro et al., 2014); frequently, he began talking about features of the software when the counsellor asked about potentially distressing material.

Richard’s Spectator avatars (in scenes 1, 5, and 13 and elsewhere) were always apart, observing from the top of the castle, from a river‐ bank or from behind a wall. These avatars could refer to an experience of separateness and difference. Alternatively, they could refer to what some theorists have called an observer position (Leiman, 2004), a man‐ ifestation of reflective functioning, mindfulness or an observing ego, which can be contrasted with an enmeshed, experiencing position. Richard’s spectators observed scenes representing his internal world, so in a sense, they represented thinking about his own mental pro‐ cesses, a positive prognostic sign. Theoretically, they may represent the internal voice of the aggregated experience of self‐observation built from his experiences in the treatment itself. In his post‐analysis interview, Richard disagreed with the interpretation that the spectator avatars were a metaphor for being an outsider. Rather, he described them merely as a way to view things from above—closer to the inter‐ pretation that the Spectator represented an observer position.

Our observations did not speak to the effectiveness of the digital imagery in reducing symptoms, but to its effectiveness in facilitating communication. Richard was articulate in describ‐ ing his problems and shifting attitudes using the digital imagery. Sometimes the imagery conveyed his feelings directly (albeit metaphorically); other times, it was a springboard for verbal ex‐ ploration. Richard entered counselling adept at using digital im‐ agery through his gaming experience. Many clients would not be so adept. Alternatively, digital imagery might provide a resource for other clients unaccustomed to communicating psychologically difficult material verbally, such as adolescent boys and those on the autistic spectrum (Anderson & Morris, 2006; Donoghue et al., 2010; Paxton & Estay, 2007).

6  | LIMITATIONS

This study was limited by the relatively narrow window of observa‐ tion—parts of only nine sessions drawn from a 60‐session treatment. We knew little of Richard’s personal circumstances or history and

had no diagnostic evaluation. Our APES ratings were not independ‐ ent and should be regarded as specifying rather than supporting our interpretations.

In theory‐building research, one does not generalise from ob‐ servations; the theory specifies its own range of application (Stiles, 2009a; Stiles, 2009b). Our observations do suggest an elaboration that assimilation theory could encompass imagery as a supplement to verbal expression for constructing interpersonal and intra‐per‐ sonal meaning bridges. Of course, like all theoretical formulations, this elaboration is tentative and requires support in further research.

ACKNOWLEDG EMENTS

We would like to thank counsellors and clients who took part in this project. This research was grant funded by SBRI health care https :// sbrih ealth care.co.uk who support the development of new technologies in health care in the UK. ProReal Ltd., the software developers, were the receivers of the grant. They commissioned the independent research team, of which all four authors were members, and provided the soft‐ ware. None of the researchers was directly employed by ProReal Ltd.

ORCID

Biljana van Rijn https://orcid.org/0000‐0003‐0313‐6459

Caroline J. Falconer https://orcid.org/0000‐0002‐6707‐5184

William B. Stiles https://orcid.org/0000‐0001‐7740‐0609

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SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at, https://onlinelibrary.wiley.com/ action/downloadSupplement?doi=10.1002%2Fcapr.12230&file=‐ capr12230‐sup‐0001‐AppendixS1.pdf.

How to cite this article: van Rijn B, Chryssafidou E, Falconer CJ, Stiles WB. Digital images as meaning bridges: Case study of assimilation using avatar software in counselling with a 14‐year‐old boy. Couns. Psychother. Res.. 2019;19:252–263. https ://doi.org/10.1002/capr.12230

BIOG R APHIE S

Biljana van Rijn is a Faculty Head of Research Strategy and Innovation at Metanoia Institute in London, a psychotherapist and a counselling psychologist.

Evi Chryssafidou is a Researcher at the Faculty of Research Strategy and Innovation working on several research projects, at‐ tached to the Metanoia Counselling and Psychotherapy Service (MCPS). She has an interdisciplinary research background in ed‐ ucation and computer‐mediated interventions and is currently completing her training in Integrative Psychotherapy.

Caroline J. Falconer is a post‐doctoral researcher at the University of Nottingham specialising in technological advances for psycho‐ therapy. She is also currently a Trainee Clinical Psychologist at University College London.

William B. Stiles is Professor Emeritus of Psychology at Miami University, Oxford, Ohio, USA, and Adjunct Professor of Psychology at Appalachian State University, Boone, North Carolina, USA.