Photostories: An innovative approach to helping people cope

In our current featured ANS article, author Jan Sitvast , RN, MA, PhD presents the results of a study exploring the effectiveness of the photo story method on self-motivation in self-management.  The article is titled “Self-management and Representation of Reality in Photo Stories.”  Dr. Sitvast has generously shared additional information about the photo-instrument, which follows his video presentation below.  Visit the ANS web site to download your copy of this interesting article at no cost while it is featured!

The Photo-instrument

Psychiatric patients often are inhibited to express their feelings and thoughts. They sometimes experience their surroundings as threatening. They can feel alienated from their surroundings because of derealisation and depersonalisation. Negative experiences and anxiety about the future can destabilise their confidence and self-appraisal.

When patients are institutionalised for a long time this also will have effects on the way they look upon their selfs. Moreover patients and clients run the risc of their individuality only being acknowledged as being ill and needing help. The communication between the patient and his environment tend to be continously coloured by symptoms and problems. Looking for a nursing intervention to offset the disadvantages of these communicationpatterns centring upon a discours of disease and disorder we found in the medium of photography a suitable aid to apply in health settings.

The Photo-instrument is a manual or protocol for implementing a set of interventions with the medium of photography. It describes the stages that are needed to have patients or clients make photos of their lifeworld. There are 12 groupmeetings. At the start the participating patients get a disposable camera and an assignment that tells them what to photograph.

After the participants have taken their pictures they are invited to express their feelings and thoughts relating to the pictures. This is done in a very structured way and is extended over a number of sessions. In the end the participants select a small number of photos for an exposition. Photo and text are then combined.

In this way photography is a means to orient and direct our care more to patients demands and attune/tune in to their experiencing their lifeworld. At the same time it fulfills the need for developing activities in the field of leisure and provides opportunities for taking up new roles.

The Photo-instrument responds to the call for more ethics in care. There is a need for ‘narrative practices’. Renowned nurses and nursing scientists stress the importance of the patient narrative and the significance of the lifeworld paradigm.

More concrete, what are the contributions of the Photo-instrument to dimensions of nursing and caring ? We distinguish the following aspects or dimensions:

Observation – Using the photo-instrument nurses can collect information on the psycho-social consequences of illnesses and disorders for living one’s daily life. It’s an intermediary observation technique and shows how patients cope with their illness outside the hospital setting.

Support -This information is the result of a dialogue of participants with the interviewing nurse. Important to notice is that the participants are owners of their photos and decide for themselves which photos are selected for further discussion. Their expressed opinions and feelings may well be elicited by the nurse but are not subject to any modification for explicit therapeutic purposes. The expressed opinions and feelings are validated in their own right, that is their sayings are accepted and acknowledged as valuable per se. And that strengthens the participants confidence.

Empowerment  – There is an element of empowerment when for once nurses don’t respond in a councilling way from a position of knowing better and having greater expertise. Now it’s up to our patients to inform us about their lifeworld. In taking upon them to photograph their world and showing us the results in an exhibition they become providers and producers of information, amusement and tangible results. The photo-instrument realizes an active involvement in the project. There are many new roles the participants can involve themselves in: writing texts for brochures and announcements, deliver a speech at the opening of the exposition, taking care of the catering of visitors, etc.

Nursing – Nursing is about activating and stimulating health and healthy behaviour. It also aims at minimalizing or reducing and taking away the negative consequences of illnesses and disorders. This supposes that nurses help patients to deal with the meaning of being ill, recovering or remaining handicapped. Taking pictures can assist the nurse in this task. Photos have one unique quality, that is they freeze time and place in an image. To get a hold on their existence and be able to cope patients need to halt their lives for one moment, to suspend the daily routine in order to have an opportunity to reflect. Offering this opportunity the photo-instrument helps integrating crises, illnesses and other life-events in the wider context of the patients’lifeworld. Moreover, making Photos implies certain awareness of the surroundings and settings you live in. The choices you have to make when selecting the places and people you want to make pictures of , highten your self-awareness. The interview questions in the sessions of the photo-instrument help people to verbalize their choices and reflect on them where they have to decide what to communicatie to spectators who come to the exhibition.

Social Skills – There is still another contribution to nursing and that’s its capacity to train social skills. Making pictures stimulates communication among people. Someone making a picture always attracts attention and is an invitation for conversation. Sharing photos you can show connects people. Organising an photo-exhibition offers opportunities to practice social skills and does an appeal to latent talents while limitations and handicaps can be reckoned with and compensated.

Conclusion – The photo-instrument has been developed in a multi-centred trial with different patient groups, in different settings, elderly patients as well as young people, institutionalised patients as well as ambulatory treated patients. There is a printed version now, available with Publishers Kavanah (in Dutch) or with the author (English version).

How to do it: A short introduction of the manual of the Photo-instrument.

The instrument contains a series of instructions how to go about in a project of between 6/7 meetings up to 12 meetings (depending on the capacities and limitations of the clients).

First meeting: explanation of the project: the participants recieve a snap-shot camera and an assignment to make pictures. During the meeting there is an opportunity to practise the use of the camera.

Second meeting: Either the participants have taken pictures in between the first and the second meeting or this meeting is devoted to making pictures. Experiences with taking pictures are exchanged. The snap-shot cameras are handed in and will be taken to the photography-shop for developing and printing.

Third meeting: The photos are returned to the participants and the group shares the collective admiring of the pictures. The instruction that follows are: go through your photos and group them together. Then everyone gets a large-sized sheet of photo-carton and is asked to glue the photos on to the sheet in the groups that have been selected. The next step is the request to think of a caption for every group of photos on the sheet and to write this down on a memo (the small sized blocks of sheets one uses in an office to stick it on your computer to remind you of tasks still to perform). The participants stick their memo’s to their groups of photo’s. A caption can be an emotion aroused by the picture or a topographical reference or whatever they can make up to be the theme or the subject of the photos

Fourth meeting: We use the same office-memos to have the participants choose two pictures per group, namely: the most beautiful picture and the picture that represents best the chosen caption. When this has been done we start rounds of interviewing the participants on their choices. Everone gets a turn. Questions to be asked are: -why is this your finest photo ? -what can be seen on the picture ? -What does the picture mean to you ? -which other picture belongs with this picture ? -in what aspects do pictures agree or differ ? -what picture shows best what you intended to tell us ? -are there pictures you wanted to make but couldn’t and for what reasons ? There is the possibility to have individual interviews but you can organise this as question rounds during the meeting itself. The relevant things the participants tell about the photos are noted down by the therapist/nurse.

Fifth meeting: The therapist/nurse has processed the notes on the computer during the interval between the fourth and the fifth meeting. Now the notes are printed and given to the participants. Every psrticipant gets a sheet with his own lines going with the photographs. They are asked to cut the sheets in lines. They can now glue the bits of paper with the lines underneath the pictures (on the carton )where the lines refer to. It’s completely up to the participants to decide whether they skip lines or add new lines or make corrections in the prints. The participants exchange their feelings, thoughts, etc. in an evaluation round.

Sixth meeting: the assignment is now to select three pictures for an exhibition. You can discuss with them what aspects they should/may take into account, for instance are they aware of any consequences of sharing certain private feelings with a greater public ? The selected pictures will be enlarged and framed for the exhibition.

Seventh meeting: The enlargements are handed out and they frame them themselves. They pick out the lines that will go with the pictures. This meeting can be used to share the preparations for the exhibition: writing invitations, is someone willing to hold a speech, producing brochures and posters, catering. Iall these tasks can be collectively done and are part of the project.

Eigth meeting: Th exhibition itself. An extra dimension can be given by having a jury giving prizes for the finest pictures or the picture that shows best the intention of the maker. Extra is also the possibility of producing a book with the photos. The exhibition can be formally opened. May-be the participants guid the visitors along their pictures. Who does the catering ?

Ninth meeting: Evaluation with all participants.