Introduction
Smartphones have revolutionised the way we take and use photographs. The addition of cameras to mobile phones has resulted in a photography boom: whilst the number of photographs stored on smartphones at any one time may vary, a recent survey suggests that 40% of adults in the UK have more than 1000 images (CartridgePeople.com, 2020). These images are being used to communicate and share experiences and a number of applications (for example, WhatsApp and Snapchat) have been developed to facilitate and enhance this process. Despite the prevalence of this form of non-verbal communication in everyday life, it has received little attention in the therapy literature.
Laurent (Reference Laurent2017) explored the motivations of professional photographers and reported that photographs are a ‘universal language’. Photographers described using photographs to communicate experiences, to convey ideas and perspectives, and to deliberately elicit emotions in the viewer. There is a long-established link between images and emotions (Lang, Reference Lang1979; Öhman and Mineka, Reference Öhman and Mineka2001) and memory (Holmes et al., Reference Holmes, Blackwell, Burnett Hayes, Renner and Raes2016; Stopa and Jenkins, Reference Stopa and Jenkins2007). These strong connections to experience and emotion have been influential in the development of specific research methods using photography. In Photovoice research, participants bring photographs pertinent to the focus of the research to discuss in a group, whereas Photo-elicitation involves interviews supplemented by photographs, usually brought by the participants. Researchers value these techniques not only for enriching data collection, but for strengthening the relationship between researchers and participants (Pain, Reference Pain2012). Recent evidence also suggests valuable benefits to research participants (Milasan et al., Reference Milasan, Bingley and Fisher2022).
If photographs enhance communication, enrich data collection and strengthen relationships in interviews, it is a reasonable assumption that they could support a more detailed account of client experience in therapy too. Cognitive behaviour therapy (CBT) approaches, including dialectical behaviour therapy (DBT; Linehan, Reference Linehan1993), use written records to aid recall and develop connections between experiences outside the therapy room and therapeutic discussions (Kennerley et al., Reference Kennerley, Kirk and Westbrook2016). It seems likely that photographs could serve a similar purpose, with a heightened potential to connect closely to emotions.
People with complex emotional needs sometimes experience overwhelming emotions during group treatments, but also value the sense of belonging they provide (Sheridan Rains et al., Reference Sheridan Rains, Echave, Rees, Scott, Lever Taylor, Broeckelmann, Steare, Barnett, Cooper, Jeynes, Russell, Oram, Rowe and Johnson2021). Using photographs in this setting could enhance engagement by providing an opportunity for enhanced connection with others (group members and facilitators) via shared, non-verbal experiences. Participants using photocards (pre-printed images) in therapy reported benefits that included enabling connection with memories and an enhanced ability to express, share and reflect on their emotional experiences (Loewenthal et al., Reference Loewenthal, Avdi, Chauhan, Saita, Natri, Righi, Tompea, Giordmaina and Issari2017). Whilst some psychological therapies have been designed around the use of photography (see Saita and Tramontano, Reference Saita and Tramontano2018), the current study was influenced by anecdotal feedback from Photovoice research participants that sharing photographs in focus groups had enabled them to speak more easily about their experiences and make stronger connections with fellow participants. Anecdotal reports also indicate that service users sometimes show their therapist photographs in sessions unprompted. This is not a new phenomenon; Prins (Reference Prins2013) suggested that for some clients sharing photographs had added value as a means of communication. As this appears to be a naturally occurring phenomenon, it warrants further exploration.
The potential benefits of using photographs in therapy, such as enhanced therapeutic connection (Prins, Reference Prins2013), expression (Halkola, Reference Halkola2009) and communication (Weiser, Reference Weiser2004) may be particularly relevant in a group for people with complex emotional needs. Whilst the use of photography within psychotherapy has a long history and leads to good outcomes (e.g. Cosden and Reynolds, Reference Cosden and Reynolds1982; Tourigny and Naydenova, Reference Tourigny and Naydenova2020), it is not much discussed in CBT practice or research. To our knowledge, no published research has explored either the impact or experience of introducing photographs as an element of homework tasks. Therefore, the current study sought to explore clients’ experience of using photographs within a DBT-informed emotional coping skills group, where photographs were utilised as a method of homework recording and feedback.
Method
Design
The study used a cross-sectional design with semi-structured interviews as the primary data collection method. Additional data consisted of the photographs themselves (used to support the interviews, analysis and write-up) and written group-evaluation measures. The photographs were not subject to full analysis, despite the increased recognition of the value of visual methods in interpretative phenomenological analysis (IPA) (Burton et al., Reference Burton, Hughes and Dempsey2017), as the images had been constrained by the therapeutic task and group setting.
The interview schedule was developed using the guidelines in Smith et al. (Reference Smith, Flowers and Larkin2009). Questions explored participants’ initial reactions to the task, their usual expectations of taking and sharing photographs, and their experiences of sharing photographs in the group. The participants’ photographs were used within the interviews to support recollection of their experiences and allowed further exploration of the meaning of their photographs.
The group evaluation questionnaires consisted of open and closed questions about satisfaction with the group, as well as the use of photographs specifically.
Setting and sample
The emotional coping skills group was an 8-week programme informed by DBT techniques and the group intervention outlined in Clarke (Reference Clarke2012). The therapeutic aims were to develop understanding and skills in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Attendees were asked to practise skills at home and were provided with a homework sheet to record this in a written format. They were also asked to take a photograph that represented their skills practice or experience of using the skill each week. A brief outline of the session topics and homework set is provided in Table 1. To help engagement with this task, in the first group session they were shown example photographs, such as a flower that had been used for mindful observation by a facilitator. Most attendees chose to take photographs using their mobile phone, with only one using a digital camera. Photographs were emailed or brought to the facilitators prior to the session and displayed during the feedback component.
Session topic and homework setting
The group guidelines included a stipulation to not share photographs that included other people, for confidentiality and consent purposes. Attendees were asked to avoid sharing images of unhelpful coping strategies or events that may be distressing for others (e.g. images of self-harm). Other than this, the photograph element of the instructions was intentionally non-prescriptive to avoid suggesting what the images ‘should’ capture and to allow attendees to bring any photograph they thought was relevant. The photographs shared often represented the doing of the task itself or an indication of how this felt.
Participants for the study were recruited from the group attendees. Group attendance was not contingent on participation in the research, so recruitment began towards the end of the programme. The group ran twice; there were 10 attendees in total, of whom seven completed the programme. Six of these service users attended at least half of the sessions, which was an inclusion criterion, and five were recruited to the study. Smith et al. (Reference Smith, Flowers and Larkin2009) suggest between three and six participants generate sufficient data to be interpreted in depth.
Participants
All participants were white, female, working-age adults. Two participants were in part-time employment or education; three were not in employment. The group ran within a community mental health service for severe and complex mental health difficulties; participants had been referred to the group due to difficulties with emotional instability. Pseudonyms are used to maintain confidentiality. Pen portraits of the participants are described in Table 2. None of the participants reported having previous experience of using photographs as a feature of therapy. Participants consented for their photographs to be reproduced for the purpose of the research, three requested that specific photographs were not published in the write-up of the research.
Pen portraits
Procedure
Interviews took place at the service base. Each participant had consented for the interviewer (J.B.) to bring printed copies of the photographs they had taken (i.e. interviews only used participants’ own photographs). Interview duration ranged from 46 to 59 minutes, and were audio-recorded and transcribed.
IPA described by Smith et al. (Reference Smith, Flowers and Larkin2009) requires consideration of what is said, not said, and the use of tone to conceptualise meaning. IPA is underpinned by the theory of hermeneutics, relating to how we interpret information and the idea that researchers’ own knowledge and experiences influence analysis. The hermeneutic approach encourages the researcher to engage in self-reflection throughout the process (Laverty, Reference Laverty2003). Of particular relevance, the interviewer co-facilitated the group and therefore held her own perspective of the photographs’ meanings and how they had been discussed. She kept a reflective diary and regularly attended research supervision to acknowledge and consider the influence of her own perspectives and expectations. Throughout the research process Yardley’s quality criteria (Yardley, Reference Yardley2000) were used. Transcribing interviews, and reading and re-reading transcripts helped develop familiarity with the data, including the non-speech cues such as laughter, tone or hesitancy. The photographs were referred to alongside the verbal accounts to reflect on the described experience. Analysis began by interpreting data at an individual level. Smith et al. (Reference Smith, Flowers and Larkin2009) recommends observing individual themes alongside each other, looking for connections or differences in the experiences across cases. Theme development was aided by the photographs, and some are presented here to support description. Theme names were revised and refined during the development of a theme map (presented in Fig. 1) to ensure the titles reflected the meaning.
Theme map.
Results
The group evaluation measure provided information about the participants’ experience of using photographs in the group and is presented here for context (Table 3). Overall, the participants were positive about the use of photographs within the group, with all clients indicating that they were ‘quite’ or ‘very’ useful. Interestingly, all participants stated that they would recommend using photographs in future groups; Shelly stated that they ‘might help break the difficulty of explaining situations and problems’, suggesting that photographs offer added value in terms of communication.
Group evaluation feedback
During the interviews, participants reflected on how they had chosen the subjects of their photographs to represent their experiences, the personal meaning they held, and their experiences of sharing these within the group. Analysis identified nine subthemes which were categorised into three main themes: Theme 1: What is in a Photograph? Expectations and Engagement; Theme 2: Images and Emotions; and Theme 3: Therapeutic Connections. Figure 1 demonstrates the subthemes that make up each main theme, and these are indicated within quotes.
Theme 1: What is in a Photograph? Expectations and Engagement
Participants described an expectation that they ‘had’ to engage in the photograph task despite some initial hesitations around this. They expressed that being asked to do so by psychological therapists influenced a belief that it would be a useful process.
‘I didn’t say no ‘cause I thought well if it’s part of [the] group then that’s what needs to be done but I wasn’t very keen. [I didn’t say no because] … there’s no point coming to a group if you’re not gonna take part and not do what’s gonna help ya’ (Liz)
Four of the five participants used smartphones to take photographs, which meant that images could be captured spontaneously. Shelly was the only participant to use a digital camera, and this resulted in her sharing mostly ‘staged photographs’ (see Fig. 2).
Shelly’s staged photograph.
The initial hesitations were influenced by anxiety around how exposing sharing the images could feel. Participants spoke about the personal nature of photographs and their choices around how they might be shared with others, or kept for their own reflections. The expectation of sharing photographs in the group felt different from usual.
‘When I’ve taken a picture it’s [pauses] it’s for me. It’s not to post on Facebook … they’re personal to me’ (Liz)
Participants discussed how they had experienced photographs being taken and shared in their daily lives and how those they had taken for the group differed, which is explored further in Theme 2: Images and Emotions. They described an expectation that a photograph is ‘supposed’ to capture something positive, or something that you would like others to see. Participants identified that the content of the photographs taken for the group were therefore chosen specifically for the purpose of the task.
‘They’re not photos that you’d share with people, are they? They were for sharing with the group’ (Alex)
Having identified this, participants also noted that the meaning of the photographs would not make much sense outside the group context. Shelly described the photographs as ‘a bit weird, but I know they were related to the bits of the course that we did’. Chloe also described ‘taking weird pictures’ (see Fig. 3, which captures a day out with a friend) in relation to finding a suitable subject whilst avoiding showing other people in her images. Participants reported an expectation that photographs often capture people, therefore the guidelines elicited challenges, particularly when the homework topic featured relationships. Some participants expressed they would have preferred to include people in their photographs ‘rather than having to take a picture of an object and kind of weirdly link it’ (Chloe). Participants described feeling limited or unsure about what to take photographs of and Shelly expressed feeling restricted by the rules: ‘I’m thinking well, what can I take? [chuckles a little]’.
Chloe’s ‘weird picture’.
Group membership impacted how much participants felt able to engage with the tasks: Shelly spoke about being relieved about the small size of the group and would have struggled with a larger number of people, and Lauren reported feeling comfortable that her group were all female. The impact of the dynamics and sharing in a group setting may have been anxiety-provoking for some participants, for example Liz worried about criticism from her peers. Participants described a strong fear of getting it wrong, by doing something differently from other attendees, or by taking the ‘wrong’ kind of photograph, as this would be more apparent during the feedback than if using verbal feedback alone.
Theme 2: Images and Emotions
Participants expressed that photographs typically capture happy experiences and positive life events and are used for reminiscence or to share experiences with others. Liz described photographs as ‘[they are] supposed to be … something you can put on your wall’. Lauren shared the image displayed in Fig. 4 in the group as a representation of a personal achievement, as well as being ‘a beautiful place’. She explained, ‘taking photos to portray something positive is something we’re generally more used to, it’s more normal’ (Lauren), suggesting that images that elicit a difficult emotional response are less usual.
Lauren’s ‘beautiful place’
This seemed to be influenced by the idea that images have the power to elicit emotional reactions. Participants felt connected to the photographs and described emotional responses to both taking pictures and viewing their own and others’ photographs in the group. Alex recalled connecting with an image that was shared by another participant (see Fig. 5): ‘[They had] been for a walk on a canal. I could see – I’ve walked on that canal; I can understand their point. Even just looking at the photo, it was relaxing even though you’re not even there’ (Alex).
Chloe’s canal walk.
Lauren described the immersive nature of some photographs and the emotions that come with viewing them: ‘I remember one of the ladies she took a photo of a wood pigeon. It’s just something we can all relate to. You can practically hear it like “whoo”. Some of ‘em they stick in your head don’t they. … Because you get a feeling with it’.
Participants discussed how the photographs expressed something different from verbal explanations, providing a richness of information to support viewers’ understanding of the photographer that added value. They described this as particularly helpful when they found experiences difficult to explain. Lauren said, ‘I guess I don’t feel like I can explain things as well as I’d like to’ and suggested that the viewer may develop a better understanding by being able to ‘see it for themselves’.
In contrast, participants also observed that distressing or difficult experiences were difficult to capture in a photograph, due to the complex nature of the associated thoughts and emotions. Lauren explained that the photograph could appear trivial, as it was impossible to convey the context or history which contributed to overwhelming emotions:
‘It would have to be something symbolic and I couldn’t get a good example to show you what I meant, like the cats waking you up at six in the morning, digging their litter tray. Or just daft things, I couldn’t quite [pause] a photo just wouldn’t justify it, because it’s just a cat digging, that’s not the whole, explosion going off in your mind. I didn’t feel that I could take a photo of something that justified how I were really feeling’.
Theme 3: Therapeutic Connections
All participants identified gaining therapeutic benefit from the photographs. They described them as a method through which they could share elements of their lives with others, facilitating the development of relationships, connection, and understanding within the group.
Participants spoke about the photographs serving as prompts that led them to say more about their experience than they might have done without the image. Alex suggested that using the photograph ‘makes it easier to start explaining something’. Some participants explained that sharing photographs in the group meant that they felt less intimidated when speaking because the other participants focused their attention on the image, rather than on them directly. At times, the photographs supported participants to share something more personal than they would have chosen to convey through verbal feedback alone:
‘[The photographs were] a bit more personal than the written tasks. It kinda gives a bit more of a glimpse into your life. I didn’t really share much on the written things, [the photographs] just encouraged you to say more and [to] explain things that are a bit more personal rather than [the] more general thing which I wrote on the homework’ (Chloe)
However, this also resulted in some participants expressing concerns about sharing their photographs due to a fear of being negatively judged, criticised or laughed at in the group: ‘You’re showing people some part of your life through a photograph! That might mean nothing at all to them but has some significance to me and I suppose [pauses] I, I think that people might laugh at me’ (Shelly).
Liz shared a similar concern about how her life could be criticised or judged, particularly if it was something she felt self-critical about: ‘I wouldn’t want to show people that’.
Participants described that their images conveyed something personal, but that some also contained hidden meaning or symbolism, which they chose not to share in the group setting. Shelly described an image that was particularly important to her, a photograph of an artistic print in her home that depicted a ‘tree on fire’. She described her photograph as a metaphorical representation of the difficult nature of her emotions and her struggle to express them. She had chosen not to share this level of detail in the group:
‘It’s a way of trying to describe to people how I feel, everything churned up underneath and bits are trying to escape. The red is what’s inside me head or inside me body; the mental problems and stuff are all there and they can’t get out, even though they’re trying to … But I didn’t say that in class, I didn’t want people to know’ (Shelly)
Alex spoke about using colour and shape in her mandala photograph (Fig. 6) to represent herself, emotions, and thoughts: ‘the different colours mean stuff to me, even if the people don’t know what they are’ and that she felt safer to share the photograph in the group knowing that this meaning was hidden.
Alex’s ‘just a mandala’.
The photographic element seemed to have an impact on how participants connected with the homework tasks and encouraged reflection on their skill development. Participants described actively looking for opportunities to take photographs in order to share their skills practice with the group, suggesting that they were spending more time thinking about the task than they might have done using the written homework alone. Alex described how the photographic element of the task stayed in her mind as she looked for and found things to take photographs of. Some participants used the photograph task as motivation to try doing something differently, and to develop their coping strategies in order to have something to show in the group. For others, the photographs helped them to recognise the practice they had been doing. Shelly spoke about noticing that she was using the emotion regulation skills she had developed without necessarily thinking of these as a ‘skill’ and that ‘[the photographs] were helpful in the way they made you see things in a different light and what they mean to you’.
Participants spoke about the power of photographs to capture an event or experience, particularly when considering positive achievements. Participants spoke about choosing to take photographs to share experiences they were proud of in the group; for example, Chloe shared a photograph of a jigsaw she completed when she was distracting herself from urges to self-harm (Fig. 7). Lauren described the importance of being able to evidence an experience, and being able to ‘see it how I saw it’ when she looks back on photographs: ‘it’s more real. You believe it’s real cos it’s a true photo. You know that it happened, that it existed. You know that it was real’.
Chloe’s jigsaw.
Discussion
The aim of the study was to explore how participants in a DBT-informed emotional coping skills group experienced using photographs to record and feed back on homework tasks involving skills practice. The findings suggest that photographs can be a useful addition to written homework-recording and offer added value in terms of sharing experiences within a therapeutic group setting. Despite some initial uncertainty about the use of photographs, all participants stated that they would recommend using photographs in future groups. Whilst participants expressed a preference for capturing images with a positive valence, they described taking and sharing photographs that represented a variety of experiences and clearly connected to the therapy process.
All participants shared beliefs that photographs capture pleasant events and experiences, and initially expressed apprehension about how they could be implemented in psychological therapy. Edmondson et al. (Reference Edmondson, Brennan and House2018) also report that participants found it unfamiliar to take photographs that represented difficult experiences. In the present research, while participants expected to talk about difficult experiences in the group, they were unsure about taking and sharing photographs that represented those difficulties. This seemed to relate to both their assumptions regarding what photographs should represent and vulnerability fears regarding showing non-positive photographs. Three of the five participants expressed specific concerns that their photographs might be laughed at or criticised. Self-disclosure is a challenging yet important process in psychological therapy, and it is natural for participants to experience vulnerability fears at the start of a group intervention (Farber, Reference Farber2003; Kleiven et al., Reference Kleiven, Hjeltnes, Råbu and Moltu2020). It is unclear whether the current participants were particularly fearful of others’ responses, but this would make sense in terms of some of their difficulties as emotional instability typically develops as a result of an early environment characterised by invalidation (Linehan, Reference Linehan1993).
Despite their initial concerns, participants found photographs helpful for communicating with the group. Some observed that when it was difficult to verbally convey experiences, the photographs allowed others to ‘see it for themselves’ (Lauren). This seems likely to help clients feel validated and understood, which is important in all therapy processes and has been reported in other studies using photographs in therapy (Loewenthal et al., Reference Loewenthal, Avdi, Chauhan, Saita, Natri, Righi, Tompea, Giordmaina and Issari2017). Although there were examples of the photographs’ true meanings not being shared in the group setting, the participants discussed these during the interviews, supporting the idea that homework photographs could enhance therapeutic connection in individual CBT.
Of relevance to the current participants, Sheridan Rains et al. (Reference Sheridan Rains, Echave, Rees, Scott, Lever Taylor, Broeckelmann, Steare, Barnett, Cooper, Jeynes, Russell, Oram, Rowe and Johnson2021) noted that when service users with complex emotional needs feel understood and listened to, they are more able to be open and honest about their experiences, which is likely to lead to more effective treatment. Participants identified that photographs could improve communication, connection to others’ experiences and found themselves encouraged to open up when discussing the photographic element of their homework. This was particularly helpful in DBT-informed therapy in order to understand specific context and the links in the chain that contributed to their emotional responses and behaviours. Given the potential challenges of building rapport with and between clients who typically experience interpersonal difficulties alongside emotional instability, photographs may be a useful tool to enhance communication, improve validation and strengthen therapeutic relationships in DBT-informed group settings.
While the photographs supported most participants in sharing and connecting with their experiences, the extent of this was limited. One participant described how a photograph was unable to capture the complexity of an experience, particularly in relation to emotions that feel overwhelming. In contrast, Shinebourne and Smith (Reference Shinebourne and Smith2011) report that images may allow clients to express feelings that are too painful to verbalise. There are likely to be differences in how much an image captures a complex emotional event, and in how much of the meaning and underlying emotion service users will share. In a longer intervention, it seems likely that the way clients use photographs would evolve over time, as they became more familiar with the method and experiment with different ways of capturing their experiences. Interestingly, some participants found the photographs a useful prop to expressing themselves and opening up, as the group’s attention was drawn away from the speaker, which has been noted as a benefit of using photographs in other therapies (Tourigny and Naydenova, Reference Tourigny and Naydenova2020).
Participants found that photographs enabled a better connection with emotions or elaboration of experiences than the written homework feedback, whilst the verbal explanation helped convey context. Given the importance in DBT of understanding the specific context in which a person experienced emotional dysregulation, photographs may provide a helpful reminder as well as promoting a sense of shared understanding. The photographs supported participants to share personal experiences, providing ‘a glimpse into their lives’ (Chloe), which served to create a richer, shared experience. This valuable connection to personal meaning and emotional experience has been noted in previous photo-therapy literature (Weiser, Reference Weiser2004; Tourigny and Naydenova, Reference Tourigny and Naydenova2020). The ability to connect to emotions in the therapy setting is an important element of effective therapy (Lane et al., Reference Lane, Ryan, Nadel and Greenberg2015), so using photographs to enhance this connection could have benefits for both group and individual psychotherapy. In the group setting, shared emotional responses to images are likely to build relationships and potentially lead to transformational experiences.
The photographic task provided participants with an opportunity to share their experiences in a way that they could control, for example by leaving some elements of their images unspoken. The sharing of photographs appeared to add therapeutic benefit, by prompting participants to complete the skills practice, enabling the recording and recall of their achievements and providing an opportunity to test out the accuracy of their assumptions about others’ responses.
Clinical implications
The current findings support the idea that using images in psychological therapy improves connection to emotions and can also help build therapeutic relationships. The results suggest a variety of potential benefits to using photographs within therapy from the clients’ perspective, as well as some specific recommendations. If used in a similar setting, a more detailed exploration of the group’s usual experience of photographs, with discussion of how those taken for the group will differ, may reduce anxiety. It is useful to clarify the purpose of the photographs to support service users to record and share experiences; perhaps using a metaphor such as taking photographs for a newspaper, to encourage capturing events as they happen. The photographs were particularly useful in tasks where participants felt able to capture something ‘relevant’, such as in a mindfulness observation task or when using distraction techniques. The photograph content seemed more difficult to choose when the homework task was abstract, such as a representation of experiencing emotions. Our participants particularly struggled with the instruction not to include identifiable people in their pictures. This could be modified in other settings and/or examples could be provided of how to symbolically include a person (e.g. photographing something that represented the person, like their shoes, or an ‘anonymous’ aspect of their appearance). However, care should be taken not to become too prescriptive with this in order to encourage creativity and spontaneity, endeavouring for some rules within the group without impeding the task.
Some practice in the group setting itself could help develop confidence in taking photographs. Participants expressed that they would have liked to see more examples before they engaged in the first task. Sharing more examples could provide an opportunity to alleviate or discuss concerns about the task, as well as collaboratively discussing the group’s ideas around what would or would not be appropriate to share. This collaborative agreement about how to approach the task could help build a safe environment prior to the first anxiety-provoking sharing of photographs.
In either group or individual therapy, a potential development would be to capitalise on the participants’ preference for positive images and to use photographs to record evidence for positive data logs of the type used in CBT (Padesky, Reference Padesky1994). The use of positive photographs has been considered to be therapeutically beneficial (Gibson, Reference Gibson2018). Photographs could also capture behavioural experiments and progress made towards therapy goals, which would apply across a range of therapeutic approaches. Photographs submitted by the public are being used to elicit self-soothing in ongoing research (Project Soothe; www.projectsoothe.com) and could be used in compassion-based approaches. Smartphone-based positive-photography interventions have benefits for well-being (Chen et al., Reference Chen, Mark and Ali2016) and could be a useful tool to elicit positive emotions in clinical settings. This potential needs to be balanced with the reality of work in busy clinical settings. We experienced some technical difficulties sharing the photographs within a group setting (we initially attempted to print out the photographs but had problems with connections to the printer), therefore, we recommend additional testing of processes otherwise valuable therapeutic time may be lost. Clearly, within individual therapy these processes are more straightforward as images can be viewed together on the screen.
Limitations and future research
The design of the study was influenced by the clinical setting where it was carried out. We were unable to test whether using photographs had a measurable impact on either alliance or the efficacy of the treatment, so further research is needed to establish this. Some potential participants dropped out of the group, and one chose not to participate in the research, meaning that the final participants represent half of those who started and may be those most positive about the experience. The participants were all white, working-age females, which limits the generalisability to other demographics. Further work is needed to explore how the addition of photographs is experienced with a more diverse group of participants and in other types of groups or therapy settings.
The dual roles of the first author as group facilitator and interviewer appears both a strength and a limitation. Some participants expressed anxiety about the research interview and may have only felt able to contribute to the research as they had a pre-existing relationship with the interviewer. However, it also may have hindered participants’ expressions of negative responses to the photograph task. Just as clients tend to hide their negative reactions from their therapist (Farber, Reference Farber2003), it is possible that participants felt limited in expressing any negativity.
The clinical setting of the study raises some questions for further research. There may be benefits to evaluating the impact of photographs as homework tasks in other group programmes and within individual therapy. It is unclear how much participants’ experience of using photographs related to their mental health difficulties (for example, their fears of being rejected) and the type of group they were attending. It would be of particular interest to test the suggestion in the current participants’ experiences and therapist’s observations (Prins, Reference Prins2013), that the sharing of photographs leads to improved therapeutic alliance.
The current focus on clients’ experience of taking and sharing photographs does not allow us to address whether photographs are a better tool than written formats for homework engagement and recording. It seemed in this context to elicit good engagement with the skills-based practice and to relate well to the therapeutic tasks, but we were unable in this study to establish whether it provided additional opportunities for ‘corrective experiences’ (Eubanks and Goldfried, Reference Eubanks and Goldfried2019). Although the CBT literature demonstrates considerable research focus on the importance of homework tasks (Kazantzis et al., Reference Kazantzis, Whittington, Zelencich, Kyrios, Norton and Hofmann2016), the use of smartphone photography to strengthen engagement with homework would benefit from further exploration.
Conclusion
The accessibility of taking and sharing photographs using smartphones leads to consideration regarding whether therapists can make use of photographs in regular practice. We sought to use photographs as a means of documenting and sharing service users’ experiences of skills practice, in a DBT-informed emotion coping skills group.
The current findings suggest the addition of photographs as a homework task provided valuable connection to client experiences and supported them to express themselves in ways that added value to verbal feedback. Participants’ accounts suggest that the photographs strengthened emotional connections between their experiences and discussion in the group and helped build safe, understanding relationships with the facilitators and each other. Whilst this is a small study, in the specific setting of an emotional skills coping group, this type of task seems appropriate for both group and individual therapy settings, therefore we would encourage clinicians to engage in collaborative discussions about how best to use this form of documentation and expression.
Key practice points
-
(1) The taking and sharing of photographs had a number of therapeutic benefits, including supporting understanding and connection within the group.
-
(2) The taking of photographs encouraged people to hold in mind the homework tasks and engaged them in thinking about ways of representing this.
-
(3) Photographs can help people share experiences that are difficult to describe verbally.
-
(4) Participants tended to use photographs to capture positive rather than negative experiences, and reported challenges to sharing photographs, such as feeling vulnerable.
-
(5) We would encourage therapists to engage in a collaborative discussion with clients regarding how to best use this form of documentation and expression.
Data availability statement
The data that support the findings of this study are available from the corresponding author, J.B., upon reasonable request.
Acknowledgements
Thank you to the Research and Development Team at South-West Yorkshire Partnership NHS Foundation Trust; the University of Leeds; Dr Simon Pini and Dr Alison Winch for their advice and support in this research project; Isabel Clarke for sharing her Woodhaven manual with us.
Author contributions
Jamie Barrow: Investigation (equal), Writing – original draft (equal), Writing – review & editing (equal); Ciara Masterson: Investigation (supporting), Supervision (equal), Writing – review & editing (supporting); Rachel Lee: Investigation (supporting), Supervision (supporting), Writing – review & editing (supporting).
Financial support
This research received no specific grant from any finding agency, commercial or not-for-profit sectors
Competing interests
The authors declare none.
Ethical standards
This research was reviewed and approved by the South-West Frenchay Research Ethics Committee (REC ref. 19/SW/0109) and the Health Research Authority. All participants gave informed consent to participate in the study and for the data to be used in publications and presentations. The authors abided by the Ethical Principles and Code of Conduct of the BABCP and BPS.
Open access
Comments
No Comments have been published for this article.