Using Vignettes in Interviews to Enhance Reflexivity and Sense Making of Violence With Persons With Cognitive Disabilities

Abstract

People with cognitive disabilities are often excluded from research due to the inaccessibility of methods and assessment tools. Critical challenges include ensuring self-determination, developing inclusive recruitment methods, and enabling effective communication, all of which are essential to inclusive research. This article describes the use of graphic vignettes—illustrating various forms of violence—combined with semi-structured interviews as a multimodal approach to promote sensemaking and reflexivity related to violence against persons with cognitive disabilities. This methodological study is based on a reflexive thematic analysis conducted with 17 participants with cognitive disabilities (18 years or older). It describes the development of the vignettes and interview strategies designed to elicit participants’ own understanding of violence while supporting their decision-making and sense of control over the interview process. The article also discusses the implications and value of using vignettes and interviews as a multimodal research approach that not only maximizes accessibility and flexibility but also enhances self-determination and actively builds trust; key aspects that support sense-making of sensitive topics, such as violence. In doing so, this study provides key methodological insights that uniquely facilitate reflection and the direct participation of this population in research about their lives.

Keywords

inclusive research multimodal violence cognitive disabilities reflexivity

Introduction

Despite growing recognition of the importance of inclusive research practices, persons with cognitive disabilities continue to be excluded from research, program development, and evaluation (Dinora et al., 2020). This exclusion is primarily due to the lack of accessible methods and assessments, which are often too extensive or demanding for diverse cognitive and communication needs (Dinora et al., 2020; Stranz et al., 2015). As a result, people with cognitive disabilities are frequently denied opportunities to share their experiences and influence research that directly affects their lives (McDonald et al., 2013).

Including people with cognitive disabilities in research presents several challenges. These include ensuring people’s right to self-determination (Vaucher et al., 2019), ensuring that recruitment strategies are inclusive, and addressing concerns about whether potential participants can fully understand what their involvement entails. These concerns are often intensified because cognitive disabilities can be difficult to perceive, requiring individuals with cognitive disabilities to constantly navigate shifting and sometimes conflicting social expectations. Such continual negotiation can lead to significant psychological strain, including experiences of exhaustion (McConnell et al., 2021).

Cognitive disabilities are associated with biological factors, including various forms of brain injury, developmental conditions, and genetic disorders, that can substantially affect functions such as learning, memory, problem-solving, attention, and social interaction (Ball & Wolbring, 2014). As a result, this population is highly heterogeneous, and the communication and processing challenges linked to, for example, intellectual disability, acquired brain injury, or ADHD can be qualitatively different. Such differences may influence how individuals engage with data collection tools like graphic vignettes or process interview questions. Therefore, while qualitative research values heterogeneity for its ability to capture diverse experiences, it is important to acknowledge that, to support each person’s unique strengths and support needs, flexible strategies are crucial (Cook & Hole, 2021).

Effective communication is fundamental to inclusive research and practice. Yet, for people with cognitive disabilities, communication barriers often prevent their voices from being fully heard, especially in the field of violence. Despite recognition of this issue, a lack of knowledge and practical methods persists in supporting effective communication. For example, research shows that inadequate communication is a major obstacle in the reporting of violence by people with cognitive disabilities (McGilloway et al., 2020). Professionals in health and social services often report uncertainty about how to communicate with people with cognitive disabilities (Adaszak et al., 2025; Namatovu et al., 2024). Without adapted, flexible approaches, it becomes difficult to assess risks, identify victims, and provide timely support to victims (Adaszak et al., 2025; Hoppstadius et al., 2021; Namatovu et al., 2024). These communication gaps are particularly alarming, considering society’s role in safeguarding this group and their increased vulnerability to violence.

Research shows that people with cognitive disabilities experience similar types of violence as the general population—physical, sexual, emotional/psychological, and financial—but also disability-specific forms, such as denial of essential care or neglect (García-Cuéllar et al., 2023). Further, studies report that people with cognitive disabilities across the lifespan remain more exposed to violence than the general population, highlighting systemic gaps in prevention, identification, and support (Starke et al., 2025). Studies have also shown that cognitive impairment significantly increases vulnerability to exploitation, including sexual, financial, and criminal exploitation, particularly where individuals depend on others or experience relational power imbalances (Lambert et al., 2025). This intersection of vulnerabilities is intensified by diverse barriers to seeking support, especially when caregivers are also perpetrators. Victims may fear not being believed, losing autonomy, or facing repercussions (Klint et al., 2024; Lambert et al., 2025; Robinson, 2024). Moreover, internalized societal discrimination may manifest in poor self-esteem, which, when combined with a strong desire to have a partner, increases people’s vulnerability to remaining in abusive relationships and developing feelings of self-blame related to the abuse (Hassouneh-Phillips & McNeff, 2005). These dynamics can make it difficult to recognize, report, or even name experiences of violence, particularly when such violence can be normalized in everyday care relationships (Lightfoot & Williams, 2009). Consequently, many individuals face ongoing victimization and revictimization (McGilloway et al., 2020).

To address the intersectional vulnerabilities affecting this group, it is crucial to develop research strategies that foster direct participation and trust through methodological innovation that facilitates communication beyond language and multimodal sensemaking of violence. This should be grounded in qualitative research, which has shown that adapting communication to match cognitive prerequisites, such as using pictures, simplifying language, or shortening sentences, can facilitate communication and meaning-making processes by overcoming cognitive difficulties related to abstract thinking, information processing, and memory (Antoniadou, 2017; Hollomotz, 2018). Accessible and multimodal formats, such as images, gestures, and even the use of space, can remove barriers and support meaning-making by providing unique and complementary ways for images and oral interaction to come together. This enhances reflexive higher-order thinking and amplifies the voice of individuals with cognitive disabilities (Irvine, 2010; Olney & Kim, 2001), thereby minimizing the manifestation of cognitive disabilities or at least reducing their impact (Dee-Price et al., 2021).

Vignettes have traditionally been employed in quantitative research, such as surveys; however, their application within qualitative research has received relatively little attention. Nonetheless, vignettes have been shown to be helpful in examining issues, such as HIV, stigmatisation, violence, and in specific vulnerable populations, such as children and drug users (Barter & Renold, 2000; Gourlay et al., 2014; Woolf & Maisto, 2008). Additionally, there has been limited focus on their design considerations for addressing sensitive topics (Kandemir & Budd, 2018), primarily involving people with disabilities as the main participants (Symeonidou & Chrysostomou, 2025), and on the possibility of employing multimodal qualitative collection methods with this population.

This article explores the use of graphic vignettes—illustrating various forms of violence in the form of images and text/stories—combined with semi-structured interviews as a multimodal approach to promote sensemaking concerning violence against persons with cognitive disabilities. It is based on a reflexive thematic study exploring understandings of violence with 17 participants with cognitive disabilities. The findings of this reflexive thematic analysis have been published elsewhere. In the following sections, the development of vignettes and interviews is presented, along with a discussion of methodological strategies that support self-determination, reflexivity, and trust-building. These strategies also have implications for designing research that not only improves accessibility but also promotes the direct participation of people with cognitive disabilities in the sensemaking process of violence.

Vignettes as a Multimodal Approach

Vignettes are short stories including images, videos, or other forms of stimuli, or a combination of these, ranging from written prompts to live events (Hughes & Huby, 2002). Traditionally developed using insights from previous research or real-world examples, they create scenarios that participants can relate to, generating insights that are not easily captured by other data generation methods (Aldamman et al., 2024). Recent discussions on multimodal qualitative data generation extend this rationale, emphasizing how text, visuals, oral interaction, and other stimuli can elicit emotional nuances, interpretation, and sense-making (Antoniadou, 2017; Fried, 2025). For instance, a study using filmed vignettes found that complex visual stimuli can evoke strong emotional responses in people with cognitive disabilities, fostering sympathy for the person in the vignette and supporting deep engagement with the physical environment presented (Hellzen et al., 2018). In this context, vignettes, as part of a multimodal approach, offer layered insights into neurodiverse experiences by capturing emotional dynamics through engaging with a situation in a reflective yet distanced manner. (Fried, 2025).

Such distancing is one of the vignette method’s key strengths, enabling the presentation of situations that would be challenging or ethically problematic to recreate in real life. By focusing on third-person narratives, vignettes allow participants to explore thoughts, attitudes, and behaviors by making sense of the situation presented without requiring direct personal disclosure (Barter & Renold, 2000). This distancing is especially important when working with persons with cognitive disabilities who may have experienced violence. Direct discussions of such experiences may feel intrusive in interviews or too personal to disclose in focus groups. Vignettes, by contrast, offer a more indirect and controlled approach, enabling participants to choose how much to disclose, make sense of the situation in their own terms, and remain within the boundaries of the vignette’s narrative. In this way, the vignette can function as a ‘safe blanket’ that participants can return to as needed (Barter & Renold, 2000), protecting privacy while supporting broader reflection beyond personal circumstances (Schoenberg & Ravdal, 2000).

The flexible, multimodal nature of vignettes (Schoenberg & Ravdal, 2000) makes them particularly valuable when working with people with cognitive disabilities. Textual and visual elements can be adapted to participants’ communication and processing needs, while also enhancing accessibility and comprehension. Contemporary multimodal research emphasizes that visual content, e.g., graphics, photographs, or filmed scenes, does more than simply present information: it actively supports meaning-making, scaffolds interpretation, and deepens emotional resonance (Antoniadou, 2017; Fried, 2025). This provides a robust theoretical justification for using graphic or visual vignette formats when exploring complex topics such as violence. Hughes and Huby (2004) underscore that realism, relevance, and timing are essential design principles; well-crafted vignettes, including visual ones, can elicit meaningful responses even from participants with limited verbal or cognitive capacities.

Despite their benefits, vignettes possess certain limitations. A prevalent concern is the potential discrepancy between participants’ responses to hypothetical scenarios and actual behavior (Barter & Renold, 2000). However, like any research tool, vignettes cannot fully capture the dynamism of everyday life (Hughes & Huby, 2002). This limitation is less problematic when the aim is to examine perceptions, beliefs, or processes of meaning-making. In such instances, vignettes can serve as valuable tools for examining how individuals interpret and understand complex phenomena, such as various forms of violence. Research also shows that simpler visual representations reduce cognitive processing demands compared to more complex multimedia formats such as videos or multi-image displays (Bali et al., 2026). This reduced cognitive load is particularly beneficial for people with cognitive disabilities, supporting the use of vignettes as a more accessible method within a multimodal framework.

Another critique relates to the artificiality of the research setting. Although vignettes are grounded in real-world situations, their discussion typically occurs in structured environments that may seem disconnected from everyday life, raising questions about their generalizability. A counterargument is that social processes are inherently complex; vignettes help manage this complexity by isolating specific elements for focused examination (Barter & Renold, 2000). This simplification can facilitate the contextualization of abstract concepts (Aldamman et al., 2024), which can be particularly beneficial for participants with cognitive disabilities, for whom generalization may be less important than the opportunity to interpret situations that support understanding, communication, and reflection on different forms of violence and their own preferences for participating in research.

An additional concern pertains to the potential that participants may initially provide socially desirable responses they perceive as socially expected or appropriate (Barter & Renold, 2000). This challenge is not limited to vignettes; it can also influence interviews and focus groups. For participants with cognitive disabilities, socially desirable responding may reflect a desire to please the interviewer or conform to perceived social norms. This tendency can be mitigated by actively building trust and designing ‘non-judgmental’ vignettes that clearly communicate that all responses are valuable, regardless of their intent, to elicit more authentic replies. Such strategies can help participants feel secure, thereby encouraging more authentic responses.

Developing a Multimodal Approach Combining Vignettes and Interviews

Vignettes, combining text and images with interviews, create a rich and complex visual-oral interaction that can enhance not only accessibility but also facilitate sense-making and understanding of violence. Whether used with other methods, such as film or art (Fried, 2025), the information embedded in the vignettes provides a consistent point of reference for comparing participants’ responses to similar scenarios, while acknowledging that distinct sub-groups may differ in their communication and processing abilities. Consequently, vignettes can be designed to present complex visual stimuli that can strongly affect participants in a controlled manner, enabling them to make sense of their experiences. Together with oral interaction through interviews, vignettes can facilitate cognitive and emotional engagement with complex events, such as violence, and across groups of people with varied cognitive disabilities.

Vignettes

Given that vignettes are constructed to simulate real-life scenarios, researchers have emphasized the importance of soliciting input and feedback from experts in the field and from those with direct experience, thereby enhancing content validity (St Marie et al., 2021). In this paper, the development of vignettes was supported by experts in the field of cognitive disabilities See (Figure 1). The vignette design was based on previous studies that employed vignettes with adults with cognitive disabilities, particularly those by Khemka and Hickson (2021) and Hollomotz (2018). The research group selected and contacted experts using their research networks to establish a reference group. The group consisted of five experts working in the field of supporting victims of violence or advocating for people with cognitive disabilities, and four experts in the field of communication with people with cognitive disabilities (n=9). The researchers held two separate online meetings with the groups of experts (i.e., one with those in the field of supporting victims and one with those in the field of communication) to discuss and refine the vignettes. The refinements primarily focused on reducing and clarifying information and enhancing the credibility of the situations (i.e., vignettes). In this way, the development of the vignettes aligns with previous recommendations (St. Marie et al., 2022).

Figure 1.

Phases in vignette development with the expert group

After receiving comments from the experts, four situations were selected, which included a variety of perpetrators and victims (See Table 1). To make the vignettes easy-to-follow, each vignette included one main character (victim) who experienced one type of violence (i.e., psychological, financial, sexual, and physical). In the first scenario, V1, a male perpetrator, uses psychological violence against a female victim. In V2, a mother is manipulating a daughter and her male partner financially. In V3, a male perpetrator uses sexual violence against a female character. In V4, a female employee is physically violent against a female caretaker.

Table 1.

Overview of the Four Vignettes Constructed for the Interviews

Main character (Victim)	Type of violence	Relationship to perpetrator	Gender of perpetrator	Summary of the situation
V1. Mia (female)	Psychological	Her colleague at work	Male	A colleague tells Mia what to do, and she disagrees. It escalates when the colleague screams and threatens Mia, who gets scared.
V2. Leon (male)	Financial	His partner and mother-in-law	Female	Leon’s partner and her mother persuade him to take out a car loan against his will. He wants to make his partner happy.
V3. Natasha (female)	Sexual	A new acquaintance was thought to be a new friend of hers	Male	Natasha invited a man into her home to look at pictures, but he touches Natasha’s body against her will and argues that this happens when someone invites others to their home.
V4. Victoria (female)	Physical	Her support provider	Female	An assistant wakes Victoria in her apartment in a stressful, loud manner, which escalates into a threatening situation as the assistant handles her roughly.

Since participants with cognitive disabilities may have challenges with abstract terms, such as symbolic language, the vignettes provided a concrete frame of reference for the interviews (Hollomotz, 2018), featuring easy-to-read text accompanied by pictures from Bildstöd. Bildstöd is a Swedish software program that develops visual aids accessible online to enhance communication and clarify informational materials, provided as a free resource. The vignettes were laminated to enable participants to manipulate and physically control the timeline of the situations presented by pointing to different elements or referencing earlier points in the timeline of the story. See Figure 2 for examples of two of these vignettes. The boxes within the vignettes were designed to be read sequentially, top to bottom, on separate pages.

Figure 2.

Examples of Mia’s and Natasha’s vignettes with easy-to-read text and pictures

The development of vignettes in this study is consistent with previous research concerning the optimal length of text to accompany vignettes to prevent information overload when used with people with cognitive disabilities. Research also shows that individuals with learning and cognitive difficulties benefit from simplified linguistic structures, such as single words or short sentences (Bailey & Im-Bolter, 2025). Consequently, it may be advantageous to limit vignettes to short stories consisting of single words or short sentences (Hughes & Huby, 2002).

Interviews

The interviewing techniques used in this study included repetition, rephrasing, and summarizing responses, as well as providing hints towards elaborations on their experiences (Antaki, 2013; Sigstad & Garrels, 2018). Using the same terms as the participants when rephrasing was also important to avoid introducing new information. These techniques strengthened the validity and trustworthiness of the data collected during the interviews by reducing the interviewer’s influence on participants’ responses (Sigstad & Garrels, 2018).

Another significant interview strategy employed in this study was allowing pauses and moments of silence, recognizing that participants with cognitive disabilities may require additional time to process interview questions and formulate appropriate responses (Sigstad & Garrels, 2018). Although such latency may pose challenges for the interviewer in interpreting, as it can arise from factors such as a misunderstanding of the question, the need to revisit the vignette, or a slower processing pace, the interviewer was mindful of the importance of maintaining silence and refraining from pressuring participants to respond. This is important since repeating or rephrasing the question without providing sufficient time for initial processing may disrupt the participant’s thought process (Sigstad, 2014), hinder the formulation of an appropriate response, and potentially demotivate participants from continuing the interview.

The interviews lasted approximately 60 to 90 minutes per participant, with a 15 to 20-minute ‘fika’ (Swedish for coffee break) included in the middle of the session. A timer was available for participants who wished to utilize it during the interview. Additionally, a ‘stop’ sign was available for participants to indicate they needed to stop the session or take a break. Each vignette was subsequently followed by open-ended questions, commencing with short phrases such as ‘Tell me what is happening,’ ‘What do you think about this situation?’, ‘What do you think they are feeling?’, ‘Is it OK to do this?’, ‘What do you think someone should do if this occurs?’, ‘Was any of this violent?’, ‘If so, why?’, and ‘What was the worst part of what happened in the vignette?’ Follow-up questions were tailored to participants’ responses. It is notable that the open-ended questions used were concise and focused on the specific situations presented in the vignettes. Otherwise, open-ended questions can pose difficulties for individuals with cognitive disabilities because of their lack of structure, hindering their ability to respond (Antaki, 2013). The concluding questions aimed to help participants compare the types of violence depicted in the vignettes and assess whether any situations were more serious or severe than others.

In summary, the semi-structured interviews conducted in this study facilitated participants’ diverse analytical and reflective processes concerning the situations depicted in the vignettes. It is worth noting that, due to the varied cognitive profiles and distinct communication needs among participants, this multimodal approach enabled them to revisit the timeline of the situation as needed during the interview process. In this context, the use of physical prompts, such as laminated vignettes, was particularly relevant as tangible aids during the interview, providing concrete reference points to help participants revisit elements of the situation.

Implications

Self-Determination by Providing Choices

In the field of disability, self-determination is largely conceptualized as individuals’ right and ability to control their own lives (Vaucher et al., 2019). The notion of control is often associated with a person acting autonomously and making their own decisions. However, this view of self-determination gives little consideration to people with cognitive disabilities, who may need help to make decisions or express their preferences (Skarsaune et al., 2021). This issue is particularly intricate for persons with cognitive disabilities who have experienced violence, as coercion and manipulation may have previously been employed against them. In the study that serves as the foundation for this paper, self-determination and perceived coercion were central themes for reflection and discussion among researchers throughout the research process.

Self-determination can be facilitated by eliciting opinions from people with cognitive disabilities and making their voices heard through various means beyond words (Vaucher et al., 2019). Consequently, gestures and signs were vital tools in this study, assisting participants in expressing their choices. For instance, informed consent was an ongoing process throughout the interviews. All participants had the legal capacity to provide consent to participate. During the interviews, a stop sign was introduced and positioned in front of the participants to facilitate communicating the need to stop or pause the interview. Participants could also choose between two versions of the same vignettes: one with text and fewer pictures, or the version with pictures and easy-to-read text (Figure 2). Since all participants chose the latter option, it appears that the pictures and easy-to-read text fitted the needs of the participants in this study.

Additionally, professionals with disability services were asked to be available to provide comfort and express the participants’ needs. The decision regarding whether, by whom, and how support should be provided remained at the participants’ discretion. People with cognitive disabilities have described the importance of support from professionals in achieving the goals they set for themselves (e.g., participate in research) as an important aspect of self-determination (Vaucher et al., 2019). As recommended by McDonald and Patka (2013), participants were asked, prior to the interview, whom they trusted and, if applicable, whether they would like to include this person as support. By allocating sufficient time for this decision, researchers can allow participants to access their preferred supports. For example, in this study, one participant chose to have professional support available via telephone, as the participant preferred to be alone with the interviewer.

Another aspect of self-determination, involving autonomy and respect for individuals’ integrity, was the use of vignettes to discuss instances of violence and share these experiences voluntarily (Barter & Renold, 2000). This allowed participants to withhold personal experiences if they preferred, while maintaining control over the process and keeping a depersonalized approach. This approach ensured that the interviews and vignettes focused on the depicted situations, utilizing the names of the individuals in the vignettes. It also enabled them to explore their understanding of the situations or make sense of them by verbalizing what they were seeing in the vignettes while processing their own personal experiences.

Building Trust From the Start

Acquiescence is defined as a tendency to respond ‘yes’ regardless of the question posed. Such a response may also be viewed as a form of compliance, wherein participants respond in accordance with what they perceive as expected (Sigstad, 2014). This form of compliance can be related to the unequal power dynamics present in interviews with participants who have cognitive disabilities, as the social position of the researcher can exert an intimidating influence on participants (Irvine, 2010). Participants may seek to learn about the research from people they trust, select trustworthy persons to provide input, and assess whether they can trust researchers (McDonald & Patka, 2013). Consequently, to foster a relationship of trust from the outset of this study, the research team (i.e., the principal investigator and interviewer) was introduced through visual aids such as portrait pictures. This introduction can also be made by utilizing video recordings featuring the interviewer to provide participants with an idea of who they will meet during the interview. It is advisable to plan ahead and maintain the same interviewer who has already been introduced for the interview, as changing interviewers could lead to confusion or loss of trust.

Additionally, involving professionals whom participants trust to introduce the study may facilitate the dissemination of the study’s purpose and the implications of their participation. In this study, professionals working in disability services were involved in the recruitment process. These professionals possessed established trust and prior knowledge of the participants’ needs and potential motivation to participate. By entrusting professionals (as gatekeepers) with the recruitment process, researchers may lose control over how the study and volunteering are presented, even though both parties have agreed upon the procedures. Furthermore, recruitment through trusted professionals may be perceived as coercive, as individuals with cognitive disabilities might fear that declining participation could result in the loss of contact with the professional, or they may trust the professional’s judgment about who could benefit from involvement. However, if researchers have the opportunity to meet potential participants to introduce themselves or the study, and to allocate sufficient time for participants to decide on their preferred supports, potential coercion can be minimized or countered by providing multiple options for support in their decision to withdraw or continue participation.

It is equally important to recognize that flexible recruitment strategies—such as using videos, written information with illustrations, allowing time for decision-making, and employing various methods of information presentation—can significantly enhance trust within this population and thereby improve engagement in research. As previous studies have highlighted, planning adequate time and resources is crucial for enhancing access and trust in the research process (Dinora et al., 2020).

Reflexivity as an Evolving Process

According to existing models of adjustment, persons with cognitive disabilities gradually integrate new levels of understanding into their overall self-perception (Olney & Kim, 2001). Consequently, they may experience periods of doubt regarding the accuracy of their experiences of violence or may downplay their significance. Furthermore, they may encounter denial of their experiences from family members or support persons. In this context, persons with cognitive disabilities and victims of violence may experience shame and ambivalence concerning their experiences (Olney & Kim, 2001). An understanding of this ambivalence and denial, and of the gradual processing of their experiences, is essential in research involving this group, as it indicates that understanding and reflection on their experiences may require time and may not develop in a linear manner.

This temporal, no-linear unfolding is also consistent with trauma-informed qualitative methodology, which emphasizes safety, trust, participant choice, and pacing to avoid re-traumatization and support meaning-making over time (Alessi & Kahn, 2023). Trauma research additionally shows that traumatic memories often emerge in fragmented, non-linear forms, requiring repeated, participant-led reflection to integrate sensory, emotional, and contextual elements into a coherent understanding. Therefore, the circular pattern observed in how participants make sense of things can be explained from a trauma-informed perspective rather than as an unexpected anomaly.

In this study, time for reflection and recalling events was essential for participants to make sense of their experiences. Some participants did not identify the situations presented in the vignettes as violent. Some tended to downplay the seriousness of the situation or mitigate the gravity of the perpetrators’ intentions, such as framing it as an accident. It was observed that most participants needed time to reflect on the situation on their own, during the interviews, and to connect the vignettes to their past experiences. They first articulated what they were seeing, then identified the type of violence, severity, sometimes minimizing it, and then either confirming or neglecting it as an act of violence in a circular process.

This iterative reflection aligns with a multimodal approach, integrating text, images, and oral interaction to reduce perceived threat and support navigation by actively constructing and negotiating identities as victims or survivors over time. This process of negotiation is known to be dynamic and non-linear, where people often move between victim, survivor, and ‘in-between’ positions, depending on context, emotional readiness, and social validation (Boyle & Rogers, 2020). Participants’ navigation involved reviewing all vignettes to better compare and support their grading of violence severity and type. They also revisited earlier vignettes to find the ’right’ word to refine their initial description of the situation (e.g., from a ‘disturbing moment’ to ‘sexual harassment’). One participant articulated this as, “I changed my mind because I remembered the word.” This process also reflects trauma-informed guidance that encourages flexible pacing, allowing participants to revisit earlier material, compare scenarios, and adjust their articulation as their cognitive and emotional processing unfolds (Alessi & Kahn, 2023). This is crucial for further studies, as it is important for the interviewer to remain open to these processes, especially since individuals with cognitive disabilities may find it even more challenging to grasp the concept of violence initially, due to ableist expectations and communication barriers constraints. Therefore, it is crucial to make room for participants to share their initial thoughts, revise or refine them, and relate them to personal experiences before developing a more nuanced understanding or sense of the situation.

Equally important was providing participants with sufficient time to articulate their feelings of shame or self-blame as part of their reflexive process. Most participants reported experiencing self-blame—feeling ‘stupid or foolish’ due to misinterpretations of the perpetrators’ intentions, believing what the perpetrators said, or fearing repercussions—which in turn increased their shame. This aspect appears to be a significant component of the participants’ reflective process as they shifted their understanding of the situation from being ‘not ok’ to recognizing that the fault could be attributed to the perpetrator. These dynamics are well-supported by trauma literature showing that shame and self-blame commonly inhibit recognition of violence but can decrease when survivors reconstruct meaning in supportive, non-judgmental contexts (Bhuptani & Messman, 2021).

Limitations

The limitations of the presented vignettes primarily include their reliance on heteronormative illustrations, which may inadvertently marginalize the experiences of people with cognitive disabilities within LGBTQ+ communities. The fact that most vignettes featured only two characters may have led participants to focus solely on a micro-level, individualistic analysis of the situations. Furthermore, for some participants with difficulties with abstract thinking, their responses could have been directed towards the specific situation, excluding their own similar experiences. Nonetheless, elaboration and reflection were encouraged through the use of silence, pauses, hints, and prompt questions during the interviews.

Despite adaptations, participants still encountered difficulties in processing information, including memorization, relating to abstract concepts, and maintaining focus. These challenges have previously been described in the literature (Hollomotz, 2018). It is important to acknowledge that such processing challenges vary considerably across different cognitive disability sub-groups (e.g., intellectual disability, acquired brain injury, ADHD). Although this population is hard to reach, combining these distinct cognitive profiles may mask meaningful differences in how subgroups interact with the graphic vignettes and interpret interview questions. This diversity could therefore be acknowledged in the analysis of the data (e.g., stratified or adapted analyses) and in the results of studies including this population.

As mentioned, participants also exhibited tendencies towards self-blame and initially downplayed the severity of their experiences of violence. This was mitigated by allowing sufficient time for participants to reflect on the situations and revisit them as required. This approach enabled participants to express their initial judgments and feelings of self-blame without receiving comments from the interviewer. Similarly, this approach can facilitate recognition that one has been subjected to violence or enable an understanding of the gravity of the situation. Consequently, appropriate support should be planned and provided if necessary.

Conclusion

The use of vignettes in conjunction with interviews constitutes a promising multimodal approach for facilitating circular reflection that goes beyond linear accommodation to a comparative movement that can lead to negotiation or construction of a new sense-making of violence. This constitutes a significant methodological contribution, challenging and retheorizing the use of interviews and vignettes. It contends that pacing and trust are not merely ethical courtesies but essential strategies for ensuring data validity and accurately assessing the severity of violence by people with cognitive disabilities. In this context, a multimodal approach including vignettes and interviews challenges the use of strategies such as pacing, responding to silence, rephrasing, and non-judgmental silence as mere accommodation. Instead, it frames these strategies as prescriptive measures aimed at enhancing data validity, in line with trauma-informed inquiry.

This study also revealed that the use of heteronormative illustrations within vignettes can inadvertently constrain participants’ interpretive possibilities and reinforce normative assumptions about gender, sexuality, and relationships. Therefore, future vignette design should incorporate intersectional design principles, ensuring that visual and narrative representations include variations in gender expression, sexual orientation, cultural background, relationship structures, and disability-related experiences (Misra et al., 2021). Such an approach is vital for avoiding the reproduction of dominant ableist and hetero-norms and for adequately representing the compounded vulnerabilities faced by people with cognitive disabilities, who may experience overlapping forms of marginalization.

Footnotes

Acknowledgments

The authors wish to express their gratitude to all participants, including professionals, expert groups, and individuals who share their experiences, time, and knwoledge through this process.

ORCID iDs

Lisette Farias Vera

Sofie Adaszak

Marie Holmefur

Johanna Gustafsson

Ethical Considerations

Ethical approval was obtained from the Swedish Review Authority (2023-02008-01) prior to participant recruitment.

Consent to Participate

Participation was voluntary, and participants were informed of their right to withdraw from the study at any time before providing written consent. Information about the participants’ rights and the study was shared with participants through a short film, verbally, and in writing, using an easy-to-read text accompanied by pictures to support their understanding.

Consent for Publication

Submissions containing any data from an individual person (including individual details, images, or videos) must include a statement confirming that informed consent for publication was provided by the participant(s) or a legally authorized representative.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is part of the research project Dialogue, funded by the Swedish Research Council for Health, Working Life and Welfare, Grant number: STY-2022/0003.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Due to the sensitive nature of the data supporting this study, data are not available.*

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