Outlining therapeutic photography
Therapeutic photography and PhotoTherapy
Understanding notions of positive mental health
Key Aspects of therapeutic photography
In order to recognise the parameters of therapeutic photography (as practiced by PhotoVoice and others) it is important to outline the difference between therapeutic photography and PhotoTherapy. The definitions below are collated from information published by The PhotoTherapy Centre.The PhotoTherapy Centre .
PhotoTherapy - photography- in -therapy
An interrelated system of photo-based counselling techniques used by trained mental health professionals as part of their therapeutic practice with clients.
Therapeutic Photography - photography- as -therapy
Photo-based activities conducted by oneself or as part of an organised group or project where no formal / professionalised therapy is taking place. Occurring in community settings the purpose of these projects range from personal growth and insight, creative artistic statement, increased personal and social agency, as a catalyst for political or social change or community-strengthening.
PhotoVoice and participatory photography projects around the world use a form of therapeutic photography techniques to support vulnerable and marginalised groups. Facilitated by photographic and community practitioners rather than trained mental health professionals participatory photography projects employ many similar techniques – working with, talking about and creating photographs - as used within more formal PhotoTherapy work but without taking it several steps deeper into personalised and guided unconscious process work. Therapeutic photography methods use the naturally therapeutic healing qualities of photography but not within a formal counselling process as does PhotoTherapy.
It is important to note that in the workshops run by PhotoVoice with United Response, opportunities for peer support, socialising with new people, personal support and learning new skills were seen as central to their therapeutic benefit, not just the photography itself, and the course focussed on photography not therapy:
“Photography is a means to an end rather than an end itself for these groups. They are here for purpose and not because they are mentally is but because they’re taking photographs, so you’re emphasising wellbeing rather than illness.” Workshop facilitator and former service-user
Another key distinction is that PhotoVoice projects that work with therapeutic photography techniques involve participants sharing their photography with others. This is in contrast to PhotoTherapy which is a more personalised and private therapeutic process. With therapeutic photography, participants may only share their pictures with the group, family and friends or they may exhibit them for a public audience and engage in media and advocacy work – it depends on the project context and objectives.
Sharing and presenting their photography to an audience is a key element in the PhotoVoice therapeutic photography process. It is an important step in allowing people to take pride in and ownership of their images, to build confidence and to feel validated, listened to and taken seriously. The decision of what audience the photographers want to share their work with is needs to be decided in each project context. Decisions on the appropriate audiences are dependent on the project objectives and the needs, priorities and desires of the project participants.
For Further Info: See The Photo Therapy Centre website for more details on PhotoTherapy techniques
PhotoVoice projects and therapeutic photography
All PhotoVoice projects, including those that do not take place within explicit mental health contexts, utilise therapeutic photography techniques within a more general approach to participatory photographic practice. In projects where therapeutic impact is not the primary focus this aim has to be balanced alongside other objectives such as using the photographs produced to do advocacy work. Participants will all draw something different from each project or exercise and for some the therapeutic impact will be considerably more important than any other outcomes. Project organisers should monitor this carefully and nurture therapeutic impact, adjusting activities and project plans as appropriate. Despite differing focuses in all projects the mental well being of participants should be prioritised above all other objectives.
For examples of other projects where therapeutic methods and impact have been demonstrated see:
Change the Picture / Change the Picture resource / Change the Picture evaluation
“I really enjoyed taking these photos. Through photography I have looked at things more deeply, like looking into my life and seeing how to move on. Photography has been a therapy for me. I learnt how to break free of myself.”
Loria, New Londoners
Understanding notions of positive mental health
Facilitators should take some time to explore definitions of mental health and gain an understanding of what positive mental health and well being looks like. Recent working definitions recognise that all healthy people have some neurosis at certain times. Many experts are striving to move away from understanding mental health in terms of absolutes and define a healthy state of mind in terms of a person’s comfort with their own ambivalent thinking and emotional responses. This involves being able to see the positive and negative in oneself, others and in a situation simultaneously . Enabling people through therapeutic photography to express ambivalence, freeing them up to express the unexpected and incongruous feelings can help to promote positive mental health. .
Therapeutic photography involves a facilitated process of combined group and one on one work where participants are supported to use photography as a tool for healing and self-discovery. This can be profound, sensitive and delicate work. It is crucially important that it is delivered by facilitators who have a developed understanding of responsible and self-aware practice in order that the safety, mental well-being and best interests of the participants are upheld at all times.
Working with photography can open up deep emotions and buried memories that, if handled incorrectly, could have negative repercussions for people living with mental distress. During the therapeutic photography process participants may talk about traumatic experiences or reveal highly sensitive information about themselves and their experiences. Workshop facilitators may feel ill equipped to deal with some of the issues that can arise. It is key that people working with therapeutic photography recognise their own abilities and boundaries and the support they will need to conduct a project safety.
PhotoVoice facilitators do not necessarily have formal therapeutic or counselling training and many practitioners of therapeutic photography conduct projects without any formal training in mental health issues. However PhotoVoice projects working with groups with complex mental health experiences are:
- conducted within a protective framework to ensure that both facilitators and participants are properly supported.
- delivered by facilitators working in pairs who have considerable experience of participants with a wide range of needs and complexities.
- Supported by trained professionals or experienced support workers from the partner organisation.
The workshops run in partnership with United Response, PhotoVoice facilitators worked alongside United Response support workers who are trained and experienced in working with people with mental health needs, and these support workers played a critical role in the success of the project.
To work responsibly with therapeutic photography it is essential to reflect on how you can be a good facilitator without trying to be a therapist. If you are new to working in this area it is advised that you undertake reading and research around mental health issues and therapeutic photography methods and projects, consult with local mental health organisations, consider doing some training or learn about the issues by shadowing or volunteering with professionals who have experience of working in mental health settings. Much learning can also be gained from networking with others working in this area.
Qualities that therapists acquire through their training which are also importance for group facilitators include:
- developing a clear sense of personal responsibility
- understanding the concept and function of boundaries and adhering to these as rigorously as possible
- learning to be comfortable with silence
- awareness of the fact that people express themselves through means other than words, ie. Facial expressions, mannerisms etc and being observant of these
- working with the knowledge that creative work is about discovering how you feel and as part of this process feelings change
- recognising the importance of ambivalent feelings
- develop the ability for reflection
- understanding the concept of “unconditional positive regard”“unconditional positive regard”
- awareness that the role is not to solve problems, advise or to change a person's situation but to create a space where that person can express themselves freely and be heard with respect
Therapeutic photography requires a considered, sensitive and responsive approach to facilitation. To enable responsible practice, facilitators need to be self aware: have a clear sense of their role, their boundaries, make time to reflect on their experiences and be informed. They need to be constantly monitoring and assessing the impact of methods on participants and adjusting activities as moods, needs and circumstances require.
The central skill comes in enabling people to find their potential. Much of the support for this will come not solely from the facilitator but from within the group as people learn from and support each other. The workshops run in partnership with United Response included volunteer facilitators who were themselves, or had previously been, mental health service users. As well as attending training along with support staff, it is important to recognise these service-user facilitators may themselves need support from professional facilitators, including around understanding their role. Mixed ability groups, including both participants with considerable prior experience of photography and others who are complete novices, also provide opportunities for peer support.
“the best part has been the peer support and mentoring…” Facilitator
Many people with experience of mental heath issues want to be treated with the same respect as anyone else and do not particularly want to be seen as different or to have allowances made for them. Successful facilitators are those that realise this whilst at the same time understanding the need to be patient, giving people more time and understanding and finding ways to enable and support someone to achieve what they want to.
Practitioners must take time to think through the potential issues and pitfalls that may arise and what they might mean for different members of the group, individually or collectively. Planning meetings involving facilitators and project organisers and partners is a good time to run through issues that might come up and to make provisions for how they might be dealt with.
For further info see:
See PhotoVoice's Statement of Ethical Practice for more details on responsible practice
Questions to consider:
- What are your strengths and weaknesses as a facilitator?
- What measures will you take to ensure your work with therapeutic photography is conducted safely?
- Are you aware of your own motivations and agendas for doing therapeutic photography work?
- What do you think could be the key issues that might arise with the group you are working with?
Key Aspects of therapeutic photography
The key aspects outlined here touch on the key elements that are central to PhotoVoice's approach to therapeutic photography. Underlying all these principles is a notion of responsible practice and the assertion that the best interests and mental well being of participants must be prioritised above all other considerations.
Participants' needs and interests are often complex and shifting but it is essential that those participating feel safe, secure, valued and respected. Decisions about the whys and wherefores of the project must be made in consultation with and explained clearly to participants and all the project team. Active participation and engagement does not happen without support, encouragement and a nurturing and collaborative atmosphere.
Participants must never feel under any obligation to participate in the project, individual workshops or a final show. They should always be aware that they can chose to be a part of the project or not and that they can change their mind at any point. Making firm decisions can be particularly hard for people living with mental distress and no one should ever be pressurised to be involved in a project or activities they do not want to be a part of.
Gaining understanding of experiences in the group
Awareness of the impact of medication
It is helpful for the facilitator to have some background understanding about what participants’ difficulties and experience might affect the way they work in a group. Support needs to be tailored to the individual, which may include setting of small goals and gradual reduction in support. For some people, friendships within the group and connecting people with common interests may be particularly significant
Whilst many people with enduring mental illness experience periods when they are well and free of symptoms, others live with fluctuating and distressing symptoms which may affect mood, memory, concentration and their capacity to participate in a group. Some people experience unpleasant side effects associated with medication or coming off medication, which may also affect energy levels, concentration and their ability to hold a camera.
People may have good days and bad days when symptoms of their mental distress are more extreme. Mood may be affected by a wide range of factors from how people have slept, the other things they have on their minds, their journey to the workshops. Medication will affect people differently at different times.
Some people may find it difficult or be unwilling to communicate with others or to feel to participate in certain types of group or individual work. Some people might get upset and need time out with a support worker. Others might be more sensitive to people in the groups’ emotions. Some might be more easily distracted. Group discussions might need more guiding, structuring and steering into different directions at times.
Supported and safe space
Workshops need to take place in a nurturing and inclusive atmosphere. For many participants living with mental distress, arriving at a workshop and entering into a group activity will be an intimidating experience. A notion of a supported and safe space must be at the heart of the project – both in terms of a physical workshop space where everyone is comfortable but also in terms of an environment and atmosphere that is aware, collaborative respectful and supportive of people’s needs. Ground rules should be established to ensure everyone’s wishes are upheld. The workshop environment should be non-hierarchical and one in which people can talk freely without fear of confidences being betrayed. This is not always easy to achieve. Conflicts which arise between participants must be dealt with appropriately and sensitively so tensions do not fester.
It is imperative to be as flexible as possible when working with people with mental distress. Sometimes people will respond well to a more intensive level of activity, other times people will want to work at a slower pace and will need more regular breaks. Everyone will have different needs. Project staff need to be constantly monitoring and responding to participants and the environment. They must be ready to change or adjust prepared activities in the moment, thinking thorough the various scenarios that might play out before a workshop and preparing multiple activities that can be used to suit different moods.
Workshop timetabling, materials and pace
Ensure workshops are timetabled appropriately at hours that suit participants’ daily routines and other commitments. They need to be pitched at an appropriate pace, unpressurised, with breaks and to allow people to have time for tea and chat. The length of workshops might need to be re-considered and adjusted as the sessions evolve to reflect the changing needs of the group and depending on the type of exercises being used. It is also key that there are appropriate materials and equipment. Cameras need to be adapted for people with physical or mobility impairments. Some people living with mental distress have problems with tiredness and memory loss – memory sheets and recapping sessions are good to ensure technical considerations are absorbed.
Balance workshop content
Workshops need to be structured to allow time for the full range of activities within the therapeutic photography process from photography instruction, to being out taking pictures, to reviewing and discussing work. Workshop activities might range from downloading pictures taken as part of a homework assignment, a group discussion about the next assignment, going out and taking pictures, downloading, reviewing and discussing pictures taken together, writing captions for the pictures taken or putting them into scrapbooks, albums or journals. It is also important that within workshops there is a mixture of group and one on one work. Project work is central to the process – engaging in group projects within workshops and personalised projects that participants shoot in their own time, outside of workshops. Within group activities it is possible for participants to play different ‘roles’ – from observer, photographers, model to directors, and from student to peer supporter - depending on preferences, needs and moods.
Enable peer support
Therapeutic photography projects involve an element of risk for both participants and facilitators and both parties need to be aware of how to assess, handle and navigate this risk. Sometimes people may not want to participate in activities which might make them feel uncomfortable or present too much of a risk for them personally, for example photographing in the streets or showing photographs publicly might make some people very nervous. At times supporting people to take a risk and to overcome their fears can be an important step in building confidence and have valuable therapeutic impact. At other times it is important to respect people's boundaries and not to push them to engage in activities that they perceive as risky. There are no set rules to assess risk and ensure the right choices will always be made. Facilitators need to make sure they work responsibly, consulting with others involved in the project and engaging with risk in an active way by working with participants to make supported and informed choices about any risks they might take.
Participants are an important support for each other. Create opportunities to build peer support and allow moments for peer instruction, for participants to become the facilitators and teachers. For example, one member of group can remind the others of camera functions –such opportunities build confidence and pride. It is also important that workshop tasks encourage people to work together. The workshops run by PhotoVoice and United Response demonstrated that peer support and the social aspect of the project was an important part for many participants, and key to its therapeutic benefit.
Ongoing review and feedback
There needs to be an ongoing cycle of feedback and review throughout the project process. PhotoVoice sees monitoring and evaluation of projects as key in order to assess impact, gain learning and build knowledge and awareness. In addition to formal monitoring and evaluation activities there also needs to be an open dialogue built into the workshop process to ensure that problems and tensions that arise can be addressed and activities adjusted to build on successes and respond to changing needs. Being responsive is key to working with people living with mental distress who moods and needs can fluctuate and change over the course of a project.
It is important the participants know that they have ownership of the project. If they feel that there is something that is not working or that they are not enjoying it is important that it is brought up and the issue discussed with the group. It is also crucial participants retain a sense of ownership of their images and how they are used. In PhotoVoice projects participants retain copyright of their photographs and must give consent to their use. Consent should be about an active and ongoing conversation between participants and project organisers and not just a paper filling exercise although the completing and signing of consent forms is crucial. All images generated in the workshop are saved and prints and CDs given to all participants.
Showing work publicly
This can be a scary or undesirable prospect for participants and no one must feel forced or under obligation to show their photography to an audience outside of the group. A public show or exhibition for most is the culmination of their achievement through the project and is an important, inspiring, validating and sensitive time. In different projects participants will have different levels of involvement in the actual organisation and co-ordination of the event but whatever their specific role it is key that they retain a level of ownership and involvement with their images and how they are being used.
In the Mental Wealth project run by PhotoVoice and United Response, the exhibition was an important focal part of the project for all participants. However, it is important to note that the Mental Wealth project was conceived specifically to create an exhibition (as context to the then proposed Mental Health Bill) – in this case the therapeutic benefits were a secondary (and unexpected) outcome. Conversely, for the UR in the Picture project, the therapeutic benefits of the programme (and measuring these) were at the fore and whilst the exhibitions were important and undoubtedly a highlight for participants, consideration needs to be made as to the priority between a public show and say, keeping the project going, when budget planning.
Long term follow-up / provision
It is crucial to think through the question of what happens after the workshops end from the outset and as the project progresses. In PhotoVoice’s experience there are always a number of participants who will want to continue their photography and the creative therapeutic journey after the official end of the project. For some the project might just represent the beginning of a journey that they will be keen to pursue. This can be achieved in a number of ways depending on opportunities in the local area– through peer support, organising monthly follow up workshops, joining a local photography group or course, linking people up with photographic ‘mentors’, volunteers who will support them to continue their photography or linking people to local art therapy groups and services. Projects should ensure that participants will be able to have continued access to cameras after the project end. All participants should have meetings with project staff towards the end of the project to establish their ongoing interests and make appropriate provisions. People with mental health needs may require additional support to continue their project, and consideration should be given to dedicating resources to ongoing professional facilitation, or at least to helping people to stay in touch with each other to provide mutual encouragement and support. One of the risks of a short-term project is that it builds up people’s aspirations but this rapidly dissipates and people lose the gains they have achieved in terms of self-esteem and motivation once the project is completed, because they no longer have a reason to continue to take photographs. An ongoing camera club might be a way of maintaining or even building upon the gains experienced by project participants. In the UR in the Picture project, participants were able to keep their cameras, which was a tangible benefit and an encouragement for them to continue taking pictures.
Questions to consider:
- What would you say was essential to building a secure and supported workshop space? What measures can you take?
- What kinds of indicators should you look out for to decide whether to change workshop activities or pace?
- How can you build in conversations with participants to ensure you gain an understanding of their mental health experiences and needs? Who else can you talk to inform yourself on what the key issues may be for the different people you are working with?
- How would you work with individuals with specific needs who might distract your attention from the entire group?
- How can you build time into the workshop timetable for ongoing feedback and review?
- How can you ensure that participants retain ownership of their photography when their work is being used publicly?
- What kinds of risk taking do you think is healthy and to be supported? Where do your boundaries lie?
- How can you ensure participants have an informed understanding of the issues around consent and copyright?
- What kind of networks can you build to ensure there is follow up provision for participants in the project you are working on?