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Can Photovoice foster the development of social support?

Can Photovoice foster the development of social support? BACKGROUNDPhotovoice (PV) is a qualitative, participatory research method that utilizes photography to explore community strengths and concerns and to advocate for positive social change (Wang & Burris, 1997). Since its creation in 1997, PV has been used among a wide variety of populations (see reviews by Evans‐Agnew & Rosemberg, 2016; Hergenrather et al., 2009). This includes, but is not limited to, youth (Suffla et al., 2012), indigenous groups (Castleden et al., 2008; Goodman et al., 2019; Mark & Boulton, 2017), individuals experiencing homelessness (Pruitt et al., 2018), individuals with serious mental illness (Agner et al., 2020; Mizock et al., 2015), and women in low‐income countries (Wang et al., 1996). As a participatory methodology, PV emphasizes collaboration between researchers and communities in developing knowledge that is authentic to the experience of community members (Wallerstein & Duran, 2006). Freire's theory on empowering education and critical consciousness is one of the theoretical underpinnings of this qualitative method (Freire, 1970). Freire's (1970) approach to education emphasized that the learner and the teacher are co‐creators of knowledge. When applied to research, and incorporated with social change theory, Friere's theories highlight the dual purposes of participatory research. The first is to create individual and community‐level change, and the second is to carry out methods that are empowering during the process (Carlson et al., 2006; Wallerstein & Bernstein, 1988; Wallerstein & Sanchez‐Merki, 1994). When this is realized, the method of investigation becomes an intervention in itself.This is one of the fundamental distinctions between conventional research (that which treats participants mainly as sources of information) and participatory research (that which treats participants as co‐creators of knowledge) (Agner, 2021; Baum et al., 2006). As such, PV has three main aims: (1) to engage participants meaningfully in research so the process itself is beneficial, (2) to gather compelling data that aims to answer a research question, and (3) to develop shared knowledge and content that can be used for advocacy and social change.Here, we focus primarily on the first aim. Studies analyzing PV as an intervention or process are scarce despite widespread claims that PV is an empowering research method (Budig et al., 2018; Carlson et al., 2006; Catalani & Minkler, 2010; Hergenrather et al., 2009; Suffla et al., 2012; Wilkin & Liamputtong, 2010). Past research on the PV process has found mixed results. Some have raised critiques of PV methodology and ethical issues. Several qualitative reviews found that PV research was not always as participatory as presumed (Dassah et al., 2017; Evans‐Agnew & Rosemberg, 2016; Hergenrather et al., 2009). A scoping review by Dassah et al. (2017) examined PV studies conducted with people with physical disabilities. They found that only one study out of 20 strictly adhered to participatory action research in all aspects of the research process. Furthermore, a conceptual article by Wang and Redwood‐Jones (2001) argued that PV raises a number of ethical concerns, including invasion into one's private space, public disclosure of embarrassing facts, participants being placed in a false light, and the use of an individual's likeness for commercial benefit.However, other studies have cited positive results of the PV process. Carlson et al. (2006) found that PV facilitated a social process that moved participants from passive adaptation to higher levels of critical consciousness, empowering participants to recognize that they can be a part of creating a better future. However, more research on the PV process is needed to examine its benefits to participants and its relationship to empowerment.Photovoice, social support, and empowermentOne of the primary ways PV may contribute to empowerment is through the strengthening of social bonds. This builds upon Neal's (2014) relational view of power and empowerment. Neal draws upon social capital theory and suggests that increased social support and meaningful connections within a given environment are tantamount to empowerment. This also aligns with a material view of empowerment which suggests that social support is essential to empowerment because it requires access to individuals, knowledge, and resources to accomplish specific goals.To understand the link between PV process, social connection, and empowerment, we can also return to Freire's (1970) work. According to Freire, viewing and understanding problems as a collective, moving from the concrete factors that impact health (such as food insecurity) to the abstract factors that impact health (e.g., power, colonization, discrimination) can be crucial in the development of class consciousness, understanding current situations and alternative realities, and ultimately empowerment. Friere highlighted the importance of collective understanding and decoding of the world to gain power and to change the realities we live in. For this reason, during PV, participants begin with the concrete (photos of their daily realities) and return to analyze the photos collectively alongside the researchers and as a group, to identify the many‐layered meanings, themes and subthemes, and opportunities for action. Thus, the social support and connection facilitated in this process can be key to empowerment.Early in PV research, Wang (2003) identified that this collective process of capturing images, analyzing the world, drawing conclusions, and taking collective actions to improve health, may result in increased social support and connection among participants, particularly those who shared similar experiences. However, few studies have empirically examined whether social support has been enhanced in the PV process. Those who addressed the potential for PV to impact social connection found confirmatory results. A literature review by Catalani and Minkler (2010) found that highly participatory PV projects were associated with long‐lasting relationships between the community and research partners, engagement in action and advocacy, increased understanding of community needs and assets, and promotion of individual empowerment. Castleden et al. (2008) found that PV created opportunities for relationship‐building and community interaction that fostered trust between researchers and participants from First Nations in Western Canada. This suggests that participants do not always need to have the same background to deepen social connections during the PV process. Similarly, Foster‐Fishman et al. (2005) found that PV led to enhanced networks through the formation and deepening of relationships among participants and a sense of belonging to their community.Taken together, these studies illustrate the potential of PV to impact social connection and support, but more research is needed, ideally with diverse populations, to analyze how and whether engaging in the PV process develops social support (Castleden et al., 2008; Catalani & Minkler, 2010; Foster‐Fishman et al., 2005; Wang, 2003). To our knowledge, no study has exclusively analyzed the mutual exchange of social support that occurred between participants during the sessions, and no past research has examined the benefits of the PV process when used with people with serious mental illness (PWSMI). This is important to note because PWSMI may be at increased risk of isolation (Marrone & Golowka, 1999), have greater difficulty forming relationships due to stigma (El‐Badri & Mellsop, 2007), and therefore may benefit substantially from participatory, qualitative methods that develop support and a sense of community. This research aims to fill these gaps by answering the question: Can engagement in PV foster the development of social support among PWSMI?Mental health ClubhousesOur study was conducted through a longstanding community‐based research partnership with mental health Clubhouses. Clubhouses are highly effective, voluntary, member‐run day programs that support PWSMI through the establishment of meaningful roles in the community (Carolan et al., 2011). Clubhouses are organized by units, such as the kitchen or clerical units, and structured by a work‐ordered day. Clubhouses have been described as an empowering setting (Mowbray et al., 2006), as members are engaged in all aspects of Clubhouse functioning and are not differentiated from the staff in dress, are able to access all areas of the Clubhouse freely, and are included in decision‐making meetings. Clubhouses promote recovery, not through the individual treatment of mental illness, but through establishing a sense of mattering, connection, and community (Agner, 2020; Conrad‐Garrisi & Pernice‐Duca, 2013; Herman et al., 2005).METHODSTranscripts from a multiyear, multisite PV study at mental health Clubhouses in Hawai'i were retrospectively analyzed using House's (1981) classic theory of social support. We chose House's framework for our analysis because it includes four subtypes that have conceptual clarity, are expressed uniquely, serve different functions, and have been associated with a wide variety of meaningful outcomes. These subtypes are emotional, informational, instrumental, and appraisal support. Instrumental support is tangible aid and service and has been associated with lower levels of loneliness and higher levels of happiness (Morelli et al., 2015). Emotional support includes expressions of empathy, love, trust, and caring, and has been associated with decreased odds of depressive and psychotic‐like symptoms (Smyth et al., 2015), lower levels of loneliness, perceived stress, and anxiety, and higher levels of happiness (Morelli et al., 2015). Informational support is advice, suggestion, and information. Appraisal is information that is useful for self‐evaluation. Thoits (2011) theorized that both informational and appraisal support increases one's sense of control, which then leads to problem‐ and emotion‐focused coping efforts that reduce stress.The purpose of the original PV sessions was to better understand how wellness was defined and cultivated within Clubhouse settings. The original PV process is outlined below but can be found in full, along with the results of the study on wellness, in Agner et al. (2020). Ethics approval was granted through the University of Hawaiʻi Institutional Review Board. Each of the participants went through a comprehensive written and oral informed consent process, and participants had the option to use their own names or pseudonyms.ParticipantsThirty‐seven Clubhouse members and six staff in five Clubhouses on O'ahu and Kauai'i islands participated in the PV process over 2 years. Staff members were able to participate because Clubhouses aim to decrease the division between members and staff, thus promoting a collaborative working environment between them. Overall, participants were highly diverse. The average age was 51.6. Sixteen participants were female and 27 were male. Participant demographics were collected in a structured interview format, with open‐ended rather than forced‐choice responses, and no participants reported a minority gender identity. The top five most common racial backgrounds were Asian (62.9%), Caucasian (34.3%), Native Hawaiian (20%), Hispanic/Latino (11.4%), and Other Pacific Islander (8.6%), with 21% reporting multiracial backgrounds. Schizophrenia and schizoaffective disorder were the most common diagnoses (77%) reported by participants. Chronic physical conditions were also widely reported (75%). The average length of time attending the Clubhouse was nine years for members and 12 years for staff. In terms of employment, the majority of participants (77%) were not gainfully employed. In addition to this, only 33% of participants lived independently. The other participants had some type of support in their living environment either through family (21%), a group home (17%), a care home (25%), or transitional housing (4%).Photovoice sessionsPV sessions for the original study were organized following the procedures described by Wang and Burris (1997) and informed by several others who have used PV and adapted it for different populations (e.g., Castleden et al., 2008; Hergenrather et al., 2009). The first session was a group brainstorming session and introduction to the process, wherein members decided on a prompt. Table 1 provides an overview of prompts chosen by each Clubhouse as well as how those prompts were divided by session (Table 1). The second session involved teaching members how to use digital cameras. Sessions thereafter involved sharing photographs from each question and analyzing each photograph as a group. The researchers took turns facilitating sessions, although members and Clubhouse staff often helped with facilitation. Sessions were audio‐recorded and later transcribed. The final session was a project closing and celebration. Participants returned their cameras and provided informal feedback. During these feedback sessions, members were asked if they had any constructive advice for the researchers, what parts of the process they found difficult, and how it could be improved, as well as what they enjoyed or appreciated. It was during these feedback sessions that members initially described feeling closer to other participants and researchers through the process. This promoted our initial interest in the development of social support through the PV process.1TableFrequency of themes by Clubhouse and photo promptSocial support themeClubhouseSessionPhoto promptAppraisalEmotionalInformationalInstrumentalKo'olau Clubhouse1Past11002Past (continued)00003Present60004Future10000Waipahu Aloha Clubhouse1Happiness42012How to make others happy20003What cheers you up0110Diamond Head Clubhouse1Meaning and purpose130512Meaning and purpose (continued)15530Hale O Honolulu Clubhouse1What supports you?41112How do you support others?114203What support do you still need?11633Friendship House1The healing power of work114202The healing power of work (continued)12301Note: Numbers under each theme correspond to the average number of times that theme was coded per session between two raters.Data analysisEach session from the original PV was analyzed using the framework method, a strategy for qualitative analysis that involves both inductive and deductive coding (Gale et al., 2013). The deductive analysis utilized House's (1981) four subtypes of social support. The inductive analysis allowed unique subthemes to emerge within the predetermined subtypes. These subthemes were informed by the first two phases of analysis and were interpreted iteratively through a process of memoing and charting. Charting involved placing subthemes into a matrix, based on the framework chosen for analysis. The goal was not to identically replicate or reproduce the original framework but to identify relationships between themes and to allow new insights on the framework to emerge. This allowed us to: (1) identify whether each of the types of social support was present, and (2) develop subthemes within each aspect of the framework to illustrate its unique application to PV. Our focus was primarily on the interactions during the sessions.TrustworthinessThe quality of the secondary data analysis was considered using Korstjens and Moser's (2018) criteria, which include credibility, transferability, dependability, confirmability, and reflexivity. Credibility, the qualitative equivalent to internal validity, was supported by the fact that the lead researchers in this study have had a long‐standing relationship with Clubhouses in Hawai'i. These relationships allow for ongoing dialog with participants to ensure that findings are true to their experiences. The original idea to examine social support as a PV outcome came from member feedback, and findings were checked with Clubhouse members before submission. Credibility was also supported by the fact that the researchers who did the textual analysis were also present at the meetings and had a sense of the tone and relational quality between participants, and observed interactions between participants throughout the process. The ability to understand local norms and ways of speaking was enhanced by several members of the research team being born and raised in Hawai'i, which is culturally unique.Confirmability, the degree to which findings are supported by multiple researchers, was supported by our coding and analysis process. All interviews were coded in NVivo 12 by at least two researchers. Researchers worked collectively in group meetings, read through and discussed transcripts, and came to a consensus on any discrepancies in coding. Transferability was supported by the research being conducted in four Clubhouses, across two islands, without notable differences based on the setting. This suggests that the findings are not unique to a particular dynamic within a single Clubhouse. However, as noted in the limitations section, transferability may be limited to other settings and should be replicated with different populations. Dependability, the extent to which the results can be audited, and decision‐making replicated, was enhanced by multiple coders utilizing NVivo to track coding and decision‐making in addition to note‐taking during team meetings.RESULTSEach of the four main social support themes is presented individually, followed by the subthemes. To see the number of times each of the main themes was coded per session, please see Table 1. Emotional support subthemes included encouragement and empathic response to adversity, identification of shared experience, and connection through humor. Informational support subthemes included advice on how to manage symptoms and promote wellness, and navigate employment. Instrumental support subthemes were the opportunity for creativity and learning through digital photography and supporting members who had challenges taking the photos. Lastly, appraisal subthemes included group praise for photos and insights and positive self‐appraisal for engaging in the process.Emotional (expressions of empathy, love, trust, and caring)Encouragement and empathic response to adversityDuring the PV process, members primarily engaged in emotional support when one member described a challenge or adversity happening in life. For example, Hubz, a member of Hale O Honolulu Clubhouse, shared his experience of hardship and how Clubhouse changed his life:I was thinking to myself, ‘What am I doing? How am I gonna live?’… I have nowhere to go… fortunately my life changed when I got into this program. They told me I could start working a regular job as soon as I am good and ready.In response, another member, Lito, expressed his encouragement and care by telling him “I'm proud of you brother!” These displays of affection and support were often in response to another member sharing about their lives, and others were unprompted messages of encouragement to the group. For example, Nancy, a member of Koʻolau Clubhouse, shared a photo of a budding plant growing out of a decaying tree, symbolizing the growth that arises out of hardship. She conveyed the message, “Yes, there is decay amidst the new life…but we also have to go through those challenges to be strong, and to be who we want to be today.” Uplifting statements frequently occurred between members during the process and they also came from staff. Linda, a staff member at Hale O Honolulu, praised a member, Loren, for his perseverance and success with his job. She encouraged other members by saying,Maybe it didn't work out the first time. Maybe it didn't work out the second time, but look at the third time. You know, lasting this long. Everything is progress, you know? Progression. Everybody is in a different place in your life and it's okay to get that support. I think that's the biggest thing. Because you can look at other people and say ‘I want to be there.’Identifying shared experienceAnother subtheme of emotional support emerged by members sharing positive and negative past experiences that others could relate to. For example, members connected over poor past responses to their isolation and lack of activity at home. Alexia described being forced to attend substance use classes even though she did not use drugs, just so she would have something to do during the day. Reflecting on the experience and her transition to Clubhouse, Alexia shared, “It was miserable [going to the substance use classes]…but I fit in here, and I think that's a good thing.” Another member (Shelby) offered support saying:I can relate. Before coming to Clubhouse, I was having difficulties getting out of my house… I was just isolated all day, all the time. Since I've been at Clubhouse, I've been making friends, and we've been friends since I've been here.In this exchange, it is clear how PV provided an opportunity for Alexia and Shelby to share empathic responses to challenges they had experienced in the past and to articulate a similar story of overcoming isolation and finding a place to go during the day that fostered a connection. Members stated in feedback sessions that this sharing led to a greater understanding of one another. Furthermore, members were able to connect through their shared experiences with mental health‐related stigma and grief. For example, during a discussion on the misconceptions that surround mental illness, the research team asked members if they had a message they wanted to share regarding mental illness and Clubhouses. Karen responded by saying:I just wanted to say that it's not mental illness, it's just being different and not being accepted by others. The only difference between them and us is that we've got a diagnosis and they don't… Being different isn't wrong.Sounds of agreement echoed across the group, and members nodded. Verbally and nonverbally, members consistently recognized and acknowledged similar experiences with mental health stigma. In another instance, Los photographed a tree that symbolizes Clubhouse members who had passed away. Other members expressed their shared emotions about the photo and what it represents as well. Sharon said, “The tree represents the people that passed away. So, to remember them sometimes we go to the tree and take time to say a prayer.” In this example, PV provided an opportunity to connect through their shared experience with loss and grief.Connection through humorEarly in the transcription process, it became clear that humor was one of the main pathways through which PV provided opportunities for emotional connection. Members playfully teased staff. Staff teased each other. And both members and staff laughed at puns and jokes made throughout the process. In one instance, Cinch, a member of Friendship House, chose a humorous bumper sticker for her photo: “Mo bettah you make born time.” She explained that in Hawaiian, make (pronounced mak‐eh) means dead, and that her father used to say this when someone was being naughty because it loosely translates to “you would be better off not being born.” This made everyone laugh because the bumper sticker did not match her photo, which depicted her appreciation for Iris, a staff member she knew for 10 years. Joy, a member of the research team, asked her “But I am curious, is that why you chose this, to make everybody laugh? Or is there a different reason?” She replied, “To make everybody laugh. I made Iris bust up laughing!” Everyone laughed. This interaction is reflective of the warm nature of Clubhouses in Hawaiʻi, but also illustrates how PV can foster emotional connection through humor, which occurred frequently in our sessions.Informational (advice, suggestions, and information)Advice on how to manage symptoms and promote wellnessAs this PV was done with mental health Clubhouses, a major form of informational support included advice on how to manage symptoms and promote wellness. For example, Vernon, a member of Diamond Head Clubhouse, shared multiple photos of the room he went to to recover from delusions or paranoia. This story of his “safe space” developed into a conversation with others about where they went to seek refuge and find peace. One member, Robree, shared that she went to the Clubhouse parties to feel peace and support, and another member described that he was looking to increase his education and find more stability in life. This evolved into a conversation about how to manage symptoms. Vernon said, “I've learned that movement is a friend… there is no way [paranoia] will alleviate without my initiating something.” It also resulted in sharing information on how to relax and manage emotions, Joseph said:People mention that here, how they are coping and managing, how they fight or flight… but really if you wanna settle down, and you wanna understand what it is to have a quiet comfortable moment… that is more or less going over all the things you accomplished.In another instance, Shelby advised others on how to deal with negative emotions, using her own experience. Shelby described, “It's actually helpful when you open up more because you get most of your feelings out. Cause it's not good to hold your feelings in. Cause it just bundles and you explode… From holding everything in.” Although this was not the original focus of the session, which was Meaning and Purpose, the PV conversation evolved with Shelby sharing information on how she improved her own mental health.PV also opened up conversations between the research team, members, and staff, which provided natural opportunities to foster informational support related to wellness that wouldn't have occurred otherwise. Kurt, a member of Friendship House, took a picture of a treadmill and talked about how he wanted to engage in more exercise to be healthier. A research team member joined in the discussion, sharing information about the relationship between mental illness and physical health. She mentioned that people with mental illness are twice as likely to have cardiovascular illness and to pass away from that prematurely due to a combination of less physical activity, medication side effects, higher stress of life events, and discrimination.Debbie, a staff member, responded with surprise by saying, “It really hit me when you said that… people with mental illness have twice the rate [of cardiovascular disease].” She expressed how this information can be helpful for improving the Clubhouse, and this led to a conversation about the importance of exercise and the ways in which the Clubhouse can incorporate more wellness activities. Debbie said, “We can definitely do our part here at the Clubhouse with healthy food choices and really sticking to our wellness activity.” These conversations between members, staff, and the research team illustrate how PV can provide opportunities for informational support to enhance wellness.Support for navigating employmentMembers, staff, and the research team also exchanged information related to Clubhouse employment programs. Hoku, a member of Friendship house, shared his experience receiving support from the Clubhouse for finding a job through the transitional employment program with members and staff. This led to a conversation about the different forms of employment programs offered by the Clubhouse. Linda, a staff member of Hale O Honolulu Clubhouse, took a picture of a member who started a new job, to show how she supported him through the transitional employment program. She explained:So, I have to go in and learn the job with him, cover if he's absent… [supporting members is] a big part of our program to ease transitional employment… It's another step into their recovery so they can get back into independent living.While the photos were initially taken to answer the prompt, “How do you support others?” Analyzing the photos collectively prompted a group discussion about transitional employment that was informational as well. As members and staff shared their experiences, they also shared information about the steps to engage in transitional employment and supported employment, and how to access those opportunities.Instrumental (tangible aid and service)Opportunity for creativity and learning through digital photographySeveral members discussed that engagement in the PV process supported them tangibly because of the opportunity it provided to learn how to use digital cameras, to engage in a creative process, and to express themselves. Maile described, “I just really enjoy this opportunity with you guys… Take pictures. Pictures branch out to art, and that's good for your head I think.” Another member described the value of having more artistic practice in his life saying, “Music, dance, the arts, it conjures up memories. The memory it conjures up is happiness.” He also shared that seeing the photos others took gave him opportunities for pleasure. While looking at a photo Maile took of palm trees Vernon commented, “It brings you back to a peaceful spot.”Some members were surprised at the photos they took and found the process revealing as well. This relates to past research that has found PV can have similar positive benefits to narrative therapy, wherein self‐discovery occurs, and new understanding develops through the process as it unfolds (Mizock et al., 2015). One member, Nancy, shared, “I was really surprised by the pictures I took. It was really revealing to me that I wanted everything to be perfect, but there are bumps and forks in the road.” Nancy had photographed a triptych of leaves and flowers, reflecting on her Past, Present, and Future. The photo she chose to represent her future had flowers around a tree, but also a broken stick. As she described it, the photo illustrated hope, but also difficulty and loss. While this is distinct from tangible support in the way of providing goods and services, it illustrates how photography and the PV process provided a tangible vehicle for self‐reflection.Additionally, at each Clubhouse, we witnessed members and staff tangibly supporting other members by taking photos. Several members had concurrent physical disabilities that made it hard for them to use the camera at times. One member was legally blind, but still wanted to participate, and thus she narrated to researchers, other members, or staff exactly what she wanted to have captured in the photo. Members who had trouble with the small screens or had limited dexterity to use the buttons sought out support from other members and researchers to capture their photos. Throughout the process, there were several obstacles to using the cameras or sharing the photos that were overcome collectively.Appraisal (information that is useful for self‐evaluation)Group appraisal: Praise for photos and insightsAppraisal is a type of social support that occurs when others provide information we can use for self‐evaluation. This stems from the fact that we define ourselves in relation to others and how they respond to us. PV provided frequent, small, but seemingly meaningful opportunities for positive appraisal. After a member shared their photo, other members often provided praise for their photos and the insights they shared during the discussion. For example, Hoang, a member of Koʻolau Clubhouse, took a photo of a painting he made of a turtle, and he shared his aspiration to pursue painting. Other members praised his artwork and talent. Nancy, another member, said, “I think you're really gifted. I mean that's incredible. It's amazing that you would sit down for a whole thing and do from start to finish.” Another member, Robert then added, “I think you should sell art.” In another instance, when Vernon shared where his safe space was, instead of focusing on his symptoms and the fact that he was having paranoia, Mark, a staff member, normalized his experience and complimented his choice. Mark said, “I really like what you said about having a spot to find your peace. Everybody needs that little spot.” Other members highlighted talents that emerged through the photos. They either remarked that the photos were high quality or that they captured something poignant or accurate. One member commented on another member's photo of his mother:It's just like how we live here in Hawai'i. She's wearing a tank top, and she looks like native from here…You know like people, like photographers, take pictures of people from Tibet? Like a National Geographic? I don't know, it's a picture that can go into a National Geographic picture of how people live in Hawai'i.Although these comments were about the photos, they often extended directly to the personality, role, or talent of the photographer. In another instance, Roebree, a member of Diamond Head Clubhouse, took a photo of orchids. She described that caring for orchids at her home and for her family gave her a sense of meaning and purpose. Another member commented:I love the color of the orchids, and as far as how healthy the leaves are, makes it a beautiful picture… The way you take care of the pots and all that, the medium to grow, and the fence in the back…It shows how much care and love you provide for the orchids and the flowers they produce.This PV exchange prompted one member to make positive character reflections about another member's role, her intentions, and her success at caring for the orchids.Positive self‐appraisal for engaging in the processFor some members, committing to the several‐week process, showing up with their photos, and engaging with others was a commitment that they were proud to engage in that seemed to affect their self‐appraisal. For example, when asked how her photo represented a sense of Meaning or Purpose, a member said, “Just being a responsible person, coming through with the Photovoice… It makes me feel happy that I can share. I knew I wanted to do this, and it makes me happy that I accomplished it.” Furthermore, when asked about what the PV process was like, one member from Friendship House, David, said, “I feel like I did an honest, honorable process of following your request.” While these were self‐appraisal comments, they were still relational with the research team and may have prompted a sense of support through connection with the research group.DISCUSSIONThis study adds to the literature on the outcomes and benefits of the PV process. Instances of all four types of social support (emotional, informational, instrumental, and appraisal support) were qualitatively analyzed in the process of PV. Findings provide preliminary empirical evidence that engagement with PV has the potential to foster social support among participants, as well as among participants and researchers. This builds upon previous scholarship arguing PV could or did lead to meaningful and supportive connections (Budig et al., 2018; Castleden et al., 2008; Suffla et al., 2012; Wang, 2003), which we hope is a starting point for further and deeper exploration of this topic. The implications of increased social support are profound. Social support has been linked to lower levels of loneliness, perceived stress, and anxiety (Morelli et al., 2015), and better mental and physical health (Hakulinen et al., 2016). Increased social support has also been found to reduce the odds of depressive and psychotic‐like symptoms (Smyth et al., 2015), making it particularly impactful for individuals with severe and persistent mental illness who may be at an increased risk of isolation (Marrone & Golowka, 1999).In addition to the benefits of social support alone, our findings lend support to the numerous studies which have claimed that PV is an empowering research method (Budig et al., 2018; Carlson et al., 2006; Hergenrather et al., 2009; Suffla et al., 2012; Wilkin & Liamputtong, 2010). As mentioned in the introduction, empowerment is a construct with multiple dimensions. According to Teti et al. (2013), changes in self‐perception, specifically enhanced self‐esteem and self‐confidence, can contribute to an internalized sense of empowerment. These changes in self‐perception may be developed through positive appraisal, which was the most prevalent form of social support within our sample. This aligns with past research that found PV led to a transformation in self‐perception due to the recognition that participants received from others (Budig et al., 2018). For theorists who take a more collective view of empowerment, such as, PV may foster social connectedness, which is a form of collective empowerment.Additionally, PV opened up the opportunity for members to be involved with advocacy through the collective construction of themes. Members and staff remarked how PV provided an opportunity to challenge narratives about the lives of individuals with serious mental illness, particularly focusing on positive aspects of their lives and personalities. Notably, the prompt chosen by each of the Clubhouse was positive in tone. During feedback sessions, members shared advocacy ideas such as photography exhibits, social media, and creating a “member stories book.” The book, Picturing Recovery in Hawaiʻi's Mental Health Clubhouses, was developed and shared with the Hawaii State Legislature and various organizations on Mental Health Awareness Day. In the future, we hope that other scholars further examine the impacts of this method, using various dimensions of social support as well as empowerment.Limitations and opportunities for future studiesSome of the strengths of this work also point to its limitations, which provide ample opportunities to grow and expand this line of methodological inquiry. First, this study was conducted in a unique setting. Mental health Clubhouses are community mental health centers that provide support for PWSMI. Members are able to build meaningful social support networks with other members and staff through participation in the Clubhouse. For this reason, many (but not all) of the participants of this study were acquainted with each other before the PV project. Not all PV studies are conducted in this type of socially connected setting.PV in a setting where participants are distrustful of one another may provide a challenge or limit some of the positive exchanges that occurred, which may be predicated on a willingness to share intimate details about one's life. It remains unclear whether PV can foster connection or shared understanding among individuals with vastly different or contentious viewpoints. While some themes in our study were not identified frequently (such as instrumental support) that seemed to be related to the construct itself (tangible aid is typically material or physical rather than conversational) rather than disconfirmation of our overarching question.This begs the question, what does the opposite of social support look like? Derision? Insults? Silencing? We witnessed a single instance of a member being asked not to share his photo by a staff person. He had taken a photo of his work as a bouncer at a strip club, and the staff thought the content might not be appropriate for the session. The research team asked the staff person to allow it, with permission from the group (i.e., if it was not offensive to the other members). By that point, the member no longer wanted to share the photo and left the session, seemingly upset. He debriefed with the research team and staff later, and was able to share his intentions, but he no longer engaged in the process. However, there were many other instances where members shared potentially divisive or upsetting stories that were typically met with empathy and supportive comments. Future research should examine the relationship between PV outcomes and content. Are the results the same if the PV focuses on a politically or socially divisive topic? If PV fosters identification of shared experiences, can it provide an opportunity to overcome barriers or division, or build trust among estranged groups? For example, Castleden et al. (2008) found that PV fostered relationships and trust between researchers and First Nations participants in Western Canada.Anecdotally, our research team also experienced newfound trust and social connection during our own internal PV project. We completed a pilot PV with the research team to prepare for the first study both logistically and to experience some of the emic perspectives of participants (e.g., potential vulnerabilities, challenges, etc.), which we recommend to other researchers employing this method with a new team. The research assistants chose the PV topic: fears of failure. The research team members barely knew each other at the start of the project. By the end, we were more prepared logistically, but more importantly, we had developed a bond and mutual trust as a team, having identified some of our shared experiences despite differences in age, educational attainment, role on the team, and various other aspects of identity.On a related note, the present study did not examine differences in perceived social support across different social identities. Social inequalities faced by marginalized communities may impact one's experiences of social support and result in disparate outcomes. For example, a recent study by Zhai and Du (2022) examined disparities in perceived social support among marginalized communities facing socioeconomic disadvantages that were exacerbated by the coronavirus disease 2019 pandemic. They found significant disparities in perceived social support among racial and ethnic minorities, sexual minorities, and persons with disabilities. Given that similar disparities may manifest in PV sessions, future research should take an intersectional approach by examining differences in perceived social support among diverse sociodemographic groups.Finally, our analysis examined exchanges that occurred naturally during in‐person sessions. It is unclear whether the same benefits would be experienced in a virtual format, and whether participants would rate their perceived social support differently pre‐and‐post PV sessions. While some members shared an increased sense of connectedness during the feedback sessions, future research should examine this quantitatively, ideally with social network methods. Pre–post tests could indicate whether members experience increased connections and depth of relationship and whether those trends relate to aspects of psychological wellness or empowerment. Ideally, this work would measure various dimensions of support and connection, multiple dimensions of empowerment, and collective measures of trust and a sense of community.CONCLUSIONThis work seeks to provide a novel, empirical approach to understanding whether engagement in PV may be beneficial to participants. Based on our findings, PV has the potential to foster mutual social support among PWSMI, which other researchers have highlighted is foundational for empowerment (Neal, 2014). Members exchanged emotional support by providing encouragement, empathic responses to adversity, and statements of appreciation, as well as by connecting through shared experience and humor. Members exchanged informational support for managing symptoms and promoting wellness. Members received instrumental support, including opportunities for advocacy, creativity, and learning, and supporting each other tangibly in participating in the process. 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Humanities and Social Sciences Communications, 9(1), 143. https://doi.org/10.1057/s41599-022-01163-y http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Community Psychology Wiley

Can Photovoice foster the development of social support?

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© 2023 Society for Community Research and Action
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0091-0562
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Abstract

BACKGROUNDPhotovoice (PV) is a qualitative, participatory research method that utilizes photography to explore community strengths and concerns and to advocate for positive social change (Wang & Burris, 1997). Since its creation in 1997, PV has been used among a wide variety of populations (see reviews by Evans‐Agnew & Rosemberg, 2016; Hergenrather et al., 2009). This includes, but is not limited to, youth (Suffla et al., 2012), indigenous groups (Castleden et al., 2008; Goodman et al., 2019; Mark & Boulton, 2017), individuals experiencing homelessness (Pruitt et al., 2018), individuals with serious mental illness (Agner et al., 2020; Mizock et al., 2015), and women in low‐income countries (Wang et al., 1996). As a participatory methodology, PV emphasizes collaboration between researchers and communities in developing knowledge that is authentic to the experience of community members (Wallerstein & Duran, 2006). Freire's theory on empowering education and critical consciousness is one of the theoretical underpinnings of this qualitative method (Freire, 1970). Freire's (1970) approach to education emphasized that the learner and the teacher are co‐creators of knowledge. When applied to research, and incorporated with social change theory, Friere's theories highlight the dual purposes of participatory research. The first is to create individual and community‐level change, and the second is to carry out methods that are empowering during the process (Carlson et al., 2006; Wallerstein & Bernstein, 1988; Wallerstein & Sanchez‐Merki, 1994). When this is realized, the method of investigation becomes an intervention in itself.This is one of the fundamental distinctions between conventional research (that which treats participants mainly as sources of information) and participatory research (that which treats participants as co‐creators of knowledge) (Agner, 2021; Baum et al., 2006). As such, PV has three main aims: (1) to engage participants meaningfully in research so the process itself is beneficial, (2) to gather compelling data that aims to answer a research question, and (3) to develop shared knowledge and content that can be used for advocacy and social change.Here, we focus primarily on the first aim. Studies analyzing PV as an intervention or process are scarce despite widespread claims that PV is an empowering research method (Budig et al., 2018; Carlson et al., 2006; Catalani & Minkler, 2010; Hergenrather et al., 2009; Suffla et al., 2012; Wilkin & Liamputtong, 2010). Past research on the PV process has found mixed results. Some have raised critiques of PV methodology and ethical issues. Several qualitative reviews found that PV research was not always as participatory as presumed (Dassah et al., 2017; Evans‐Agnew & Rosemberg, 2016; Hergenrather et al., 2009). A scoping review by Dassah et al. (2017) examined PV studies conducted with people with physical disabilities. They found that only one study out of 20 strictly adhered to participatory action research in all aspects of the research process. Furthermore, a conceptual article by Wang and Redwood‐Jones (2001) argued that PV raises a number of ethical concerns, including invasion into one's private space, public disclosure of embarrassing facts, participants being placed in a false light, and the use of an individual's likeness for commercial benefit.However, other studies have cited positive results of the PV process. Carlson et al. (2006) found that PV facilitated a social process that moved participants from passive adaptation to higher levels of critical consciousness, empowering participants to recognize that they can be a part of creating a better future. However, more research on the PV process is needed to examine its benefits to participants and its relationship to empowerment.Photovoice, social support, and empowermentOne of the primary ways PV may contribute to empowerment is through the strengthening of social bonds. This builds upon Neal's (2014) relational view of power and empowerment. Neal draws upon social capital theory and suggests that increased social support and meaningful connections within a given environment are tantamount to empowerment. This also aligns with a material view of empowerment which suggests that social support is essential to empowerment because it requires access to individuals, knowledge, and resources to accomplish specific goals.To understand the link between PV process, social connection, and empowerment, we can also return to Freire's (1970) work. According to Freire, viewing and understanding problems as a collective, moving from the concrete factors that impact health (such as food insecurity) to the abstract factors that impact health (e.g., power, colonization, discrimination) can be crucial in the development of class consciousness, understanding current situations and alternative realities, and ultimately empowerment. Friere highlighted the importance of collective understanding and decoding of the world to gain power and to change the realities we live in. For this reason, during PV, participants begin with the concrete (photos of their daily realities) and return to analyze the photos collectively alongside the researchers and as a group, to identify the many‐layered meanings, themes and subthemes, and opportunities for action. Thus, the social support and connection facilitated in this process can be key to empowerment.Early in PV research, Wang (2003) identified that this collective process of capturing images, analyzing the world, drawing conclusions, and taking collective actions to improve health, may result in increased social support and connection among participants, particularly those who shared similar experiences. However, few studies have empirically examined whether social support has been enhanced in the PV process. Those who addressed the potential for PV to impact social connection found confirmatory results. A literature review by Catalani and Minkler (2010) found that highly participatory PV projects were associated with long‐lasting relationships between the community and research partners, engagement in action and advocacy, increased understanding of community needs and assets, and promotion of individual empowerment. Castleden et al. (2008) found that PV created opportunities for relationship‐building and community interaction that fostered trust between researchers and participants from First Nations in Western Canada. This suggests that participants do not always need to have the same background to deepen social connections during the PV process. Similarly, Foster‐Fishman et al. (2005) found that PV led to enhanced networks through the formation and deepening of relationships among participants and a sense of belonging to their community.Taken together, these studies illustrate the potential of PV to impact social connection and support, but more research is needed, ideally with diverse populations, to analyze how and whether engaging in the PV process develops social support (Castleden et al., 2008; Catalani & Minkler, 2010; Foster‐Fishman et al., 2005; Wang, 2003). To our knowledge, no study has exclusively analyzed the mutual exchange of social support that occurred between participants during the sessions, and no past research has examined the benefits of the PV process when used with people with serious mental illness (PWSMI). This is important to note because PWSMI may be at increased risk of isolation (Marrone & Golowka, 1999), have greater difficulty forming relationships due to stigma (El‐Badri & Mellsop, 2007), and therefore may benefit substantially from participatory, qualitative methods that develop support and a sense of community. This research aims to fill these gaps by answering the question: Can engagement in PV foster the development of social support among PWSMI?Mental health ClubhousesOur study was conducted through a longstanding community‐based research partnership with mental health Clubhouses. Clubhouses are highly effective, voluntary, member‐run day programs that support PWSMI through the establishment of meaningful roles in the community (Carolan et al., 2011). Clubhouses are organized by units, such as the kitchen or clerical units, and structured by a work‐ordered day. Clubhouses have been described as an empowering setting (Mowbray et al., 2006), as members are engaged in all aspects of Clubhouse functioning and are not differentiated from the staff in dress, are able to access all areas of the Clubhouse freely, and are included in decision‐making meetings. Clubhouses promote recovery, not through the individual treatment of mental illness, but through establishing a sense of mattering, connection, and community (Agner, 2020; Conrad‐Garrisi & Pernice‐Duca, 2013; Herman et al., 2005).METHODSTranscripts from a multiyear, multisite PV study at mental health Clubhouses in Hawai'i were retrospectively analyzed using House's (1981) classic theory of social support. We chose House's framework for our analysis because it includes four subtypes that have conceptual clarity, are expressed uniquely, serve different functions, and have been associated with a wide variety of meaningful outcomes. These subtypes are emotional, informational, instrumental, and appraisal support. Instrumental support is tangible aid and service and has been associated with lower levels of loneliness and higher levels of happiness (Morelli et al., 2015). Emotional support includes expressions of empathy, love, trust, and caring, and has been associated with decreased odds of depressive and psychotic‐like symptoms (Smyth et al., 2015), lower levels of loneliness, perceived stress, and anxiety, and higher levels of happiness (Morelli et al., 2015). Informational support is advice, suggestion, and information. Appraisal is information that is useful for self‐evaluation. Thoits (2011) theorized that both informational and appraisal support increases one's sense of control, which then leads to problem‐ and emotion‐focused coping efforts that reduce stress.The purpose of the original PV sessions was to better understand how wellness was defined and cultivated within Clubhouse settings. The original PV process is outlined below but can be found in full, along with the results of the study on wellness, in Agner et al. (2020). Ethics approval was granted through the University of Hawaiʻi Institutional Review Board. Each of the participants went through a comprehensive written and oral informed consent process, and participants had the option to use their own names or pseudonyms.ParticipantsThirty‐seven Clubhouse members and six staff in five Clubhouses on O'ahu and Kauai'i islands participated in the PV process over 2 years. Staff members were able to participate because Clubhouses aim to decrease the division between members and staff, thus promoting a collaborative working environment between them. Overall, participants were highly diverse. The average age was 51.6. Sixteen participants were female and 27 were male. Participant demographics were collected in a structured interview format, with open‐ended rather than forced‐choice responses, and no participants reported a minority gender identity. The top five most common racial backgrounds were Asian (62.9%), Caucasian (34.3%), Native Hawaiian (20%), Hispanic/Latino (11.4%), and Other Pacific Islander (8.6%), with 21% reporting multiracial backgrounds. Schizophrenia and schizoaffective disorder were the most common diagnoses (77%) reported by participants. Chronic physical conditions were also widely reported (75%). The average length of time attending the Clubhouse was nine years for members and 12 years for staff. In terms of employment, the majority of participants (77%) were not gainfully employed. In addition to this, only 33% of participants lived independently. The other participants had some type of support in their living environment either through family (21%), a group home (17%), a care home (25%), or transitional housing (4%).Photovoice sessionsPV sessions for the original study were organized following the procedures described by Wang and Burris (1997) and informed by several others who have used PV and adapted it for different populations (e.g., Castleden et al., 2008; Hergenrather et al., 2009). The first session was a group brainstorming session and introduction to the process, wherein members decided on a prompt. Table 1 provides an overview of prompts chosen by each Clubhouse as well as how those prompts were divided by session (Table 1). The second session involved teaching members how to use digital cameras. Sessions thereafter involved sharing photographs from each question and analyzing each photograph as a group. The researchers took turns facilitating sessions, although members and Clubhouse staff often helped with facilitation. Sessions were audio‐recorded and later transcribed. The final session was a project closing and celebration. Participants returned their cameras and provided informal feedback. During these feedback sessions, members were asked if they had any constructive advice for the researchers, what parts of the process they found difficult, and how it could be improved, as well as what they enjoyed or appreciated. It was during these feedback sessions that members initially described feeling closer to other participants and researchers through the process. This promoted our initial interest in the development of social support through the PV process.1TableFrequency of themes by Clubhouse and photo promptSocial support themeClubhouseSessionPhoto promptAppraisalEmotionalInformationalInstrumentalKo'olau Clubhouse1Past11002Past (continued)00003Present60004Future10000Waipahu Aloha Clubhouse1Happiness42012How to make others happy20003What cheers you up0110Diamond Head Clubhouse1Meaning and purpose130512Meaning and purpose (continued)15530Hale O Honolulu Clubhouse1What supports you?41112How do you support others?114203What support do you still need?11633Friendship House1The healing power of work114202The healing power of work (continued)12301Note: Numbers under each theme correspond to the average number of times that theme was coded per session between two raters.Data analysisEach session from the original PV was analyzed using the framework method, a strategy for qualitative analysis that involves both inductive and deductive coding (Gale et al., 2013). The deductive analysis utilized House's (1981) four subtypes of social support. The inductive analysis allowed unique subthemes to emerge within the predetermined subtypes. These subthemes were informed by the first two phases of analysis and were interpreted iteratively through a process of memoing and charting. Charting involved placing subthemes into a matrix, based on the framework chosen for analysis. The goal was not to identically replicate or reproduce the original framework but to identify relationships between themes and to allow new insights on the framework to emerge. This allowed us to: (1) identify whether each of the types of social support was present, and (2) develop subthemes within each aspect of the framework to illustrate its unique application to PV. Our focus was primarily on the interactions during the sessions.TrustworthinessThe quality of the secondary data analysis was considered using Korstjens and Moser's (2018) criteria, which include credibility, transferability, dependability, confirmability, and reflexivity. Credibility, the qualitative equivalent to internal validity, was supported by the fact that the lead researchers in this study have had a long‐standing relationship with Clubhouses in Hawai'i. These relationships allow for ongoing dialog with participants to ensure that findings are true to their experiences. The original idea to examine social support as a PV outcome came from member feedback, and findings were checked with Clubhouse members before submission. Credibility was also supported by the fact that the researchers who did the textual analysis were also present at the meetings and had a sense of the tone and relational quality between participants, and observed interactions between participants throughout the process. The ability to understand local norms and ways of speaking was enhanced by several members of the research team being born and raised in Hawai'i, which is culturally unique.Confirmability, the degree to which findings are supported by multiple researchers, was supported by our coding and analysis process. All interviews were coded in NVivo 12 by at least two researchers. Researchers worked collectively in group meetings, read through and discussed transcripts, and came to a consensus on any discrepancies in coding. Transferability was supported by the research being conducted in four Clubhouses, across two islands, without notable differences based on the setting. This suggests that the findings are not unique to a particular dynamic within a single Clubhouse. However, as noted in the limitations section, transferability may be limited to other settings and should be replicated with different populations. Dependability, the extent to which the results can be audited, and decision‐making replicated, was enhanced by multiple coders utilizing NVivo to track coding and decision‐making in addition to note‐taking during team meetings.RESULTSEach of the four main social support themes is presented individually, followed by the subthemes. To see the number of times each of the main themes was coded per session, please see Table 1. Emotional support subthemes included encouragement and empathic response to adversity, identification of shared experience, and connection through humor. Informational support subthemes included advice on how to manage symptoms and promote wellness, and navigate employment. Instrumental support subthemes were the opportunity for creativity and learning through digital photography and supporting members who had challenges taking the photos. Lastly, appraisal subthemes included group praise for photos and insights and positive self‐appraisal for engaging in the process.Emotional (expressions of empathy, love, trust, and caring)Encouragement and empathic response to adversityDuring the PV process, members primarily engaged in emotional support when one member described a challenge or adversity happening in life. For example, Hubz, a member of Hale O Honolulu Clubhouse, shared his experience of hardship and how Clubhouse changed his life:I was thinking to myself, ‘What am I doing? How am I gonna live?’… I have nowhere to go… fortunately my life changed when I got into this program. They told me I could start working a regular job as soon as I am good and ready.In response, another member, Lito, expressed his encouragement and care by telling him “I'm proud of you brother!” These displays of affection and support were often in response to another member sharing about their lives, and others were unprompted messages of encouragement to the group. For example, Nancy, a member of Koʻolau Clubhouse, shared a photo of a budding plant growing out of a decaying tree, symbolizing the growth that arises out of hardship. She conveyed the message, “Yes, there is decay amidst the new life…but we also have to go through those challenges to be strong, and to be who we want to be today.” Uplifting statements frequently occurred between members during the process and they also came from staff. Linda, a staff member at Hale O Honolulu, praised a member, Loren, for his perseverance and success with his job. She encouraged other members by saying,Maybe it didn't work out the first time. Maybe it didn't work out the second time, but look at the third time. You know, lasting this long. Everything is progress, you know? Progression. Everybody is in a different place in your life and it's okay to get that support. I think that's the biggest thing. Because you can look at other people and say ‘I want to be there.’Identifying shared experienceAnother subtheme of emotional support emerged by members sharing positive and negative past experiences that others could relate to. For example, members connected over poor past responses to their isolation and lack of activity at home. Alexia described being forced to attend substance use classes even though she did not use drugs, just so she would have something to do during the day. Reflecting on the experience and her transition to Clubhouse, Alexia shared, “It was miserable [going to the substance use classes]…but I fit in here, and I think that's a good thing.” Another member (Shelby) offered support saying:I can relate. Before coming to Clubhouse, I was having difficulties getting out of my house… I was just isolated all day, all the time. Since I've been at Clubhouse, I've been making friends, and we've been friends since I've been here.In this exchange, it is clear how PV provided an opportunity for Alexia and Shelby to share empathic responses to challenges they had experienced in the past and to articulate a similar story of overcoming isolation and finding a place to go during the day that fostered a connection. Members stated in feedback sessions that this sharing led to a greater understanding of one another. Furthermore, members were able to connect through their shared experiences with mental health‐related stigma and grief. For example, during a discussion on the misconceptions that surround mental illness, the research team asked members if they had a message they wanted to share regarding mental illness and Clubhouses. Karen responded by saying:I just wanted to say that it's not mental illness, it's just being different and not being accepted by others. The only difference between them and us is that we've got a diagnosis and they don't… Being different isn't wrong.Sounds of agreement echoed across the group, and members nodded. Verbally and nonverbally, members consistently recognized and acknowledged similar experiences with mental health stigma. In another instance, Los photographed a tree that symbolizes Clubhouse members who had passed away. Other members expressed their shared emotions about the photo and what it represents as well. Sharon said, “The tree represents the people that passed away. So, to remember them sometimes we go to the tree and take time to say a prayer.” In this example, PV provided an opportunity to connect through their shared experience with loss and grief.Connection through humorEarly in the transcription process, it became clear that humor was one of the main pathways through which PV provided opportunities for emotional connection. Members playfully teased staff. Staff teased each other. And both members and staff laughed at puns and jokes made throughout the process. In one instance, Cinch, a member of Friendship House, chose a humorous bumper sticker for her photo: “Mo bettah you make born time.” She explained that in Hawaiian, make (pronounced mak‐eh) means dead, and that her father used to say this when someone was being naughty because it loosely translates to “you would be better off not being born.” This made everyone laugh because the bumper sticker did not match her photo, which depicted her appreciation for Iris, a staff member she knew for 10 years. Joy, a member of the research team, asked her “But I am curious, is that why you chose this, to make everybody laugh? Or is there a different reason?” She replied, “To make everybody laugh. I made Iris bust up laughing!” Everyone laughed. This interaction is reflective of the warm nature of Clubhouses in Hawaiʻi, but also illustrates how PV can foster emotional connection through humor, which occurred frequently in our sessions.Informational (advice, suggestions, and information)Advice on how to manage symptoms and promote wellnessAs this PV was done with mental health Clubhouses, a major form of informational support included advice on how to manage symptoms and promote wellness. For example, Vernon, a member of Diamond Head Clubhouse, shared multiple photos of the room he went to to recover from delusions or paranoia. This story of his “safe space” developed into a conversation with others about where they went to seek refuge and find peace. One member, Robree, shared that she went to the Clubhouse parties to feel peace and support, and another member described that he was looking to increase his education and find more stability in life. This evolved into a conversation about how to manage symptoms. Vernon said, “I've learned that movement is a friend… there is no way [paranoia] will alleviate without my initiating something.” It also resulted in sharing information on how to relax and manage emotions, Joseph said:People mention that here, how they are coping and managing, how they fight or flight… but really if you wanna settle down, and you wanna understand what it is to have a quiet comfortable moment… that is more or less going over all the things you accomplished.In another instance, Shelby advised others on how to deal with negative emotions, using her own experience. Shelby described, “It's actually helpful when you open up more because you get most of your feelings out. Cause it's not good to hold your feelings in. Cause it just bundles and you explode… From holding everything in.” Although this was not the original focus of the session, which was Meaning and Purpose, the PV conversation evolved with Shelby sharing information on how she improved her own mental health.PV also opened up conversations between the research team, members, and staff, which provided natural opportunities to foster informational support related to wellness that wouldn't have occurred otherwise. Kurt, a member of Friendship House, took a picture of a treadmill and talked about how he wanted to engage in more exercise to be healthier. A research team member joined in the discussion, sharing information about the relationship between mental illness and physical health. She mentioned that people with mental illness are twice as likely to have cardiovascular illness and to pass away from that prematurely due to a combination of less physical activity, medication side effects, higher stress of life events, and discrimination.Debbie, a staff member, responded with surprise by saying, “It really hit me when you said that… people with mental illness have twice the rate [of cardiovascular disease].” She expressed how this information can be helpful for improving the Clubhouse, and this led to a conversation about the importance of exercise and the ways in which the Clubhouse can incorporate more wellness activities. Debbie said, “We can definitely do our part here at the Clubhouse with healthy food choices and really sticking to our wellness activity.” These conversations between members, staff, and the research team illustrate how PV can provide opportunities for informational support to enhance wellness.Support for navigating employmentMembers, staff, and the research team also exchanged information related to Clubhouse employment programs. Hoku, a member of Friendship house, shared his experience receiving support from the Clubhouse for finding a job through the transitional employment program with members and staff. This led to a conversation about the different forms of employment programs offered by the Clubhouse. Linda, a staff member of Hale O Honolulu Clubhouse, took a picture of a member who started a new job, to show how she supported him through the transitional employment program. She explained:So, I have to go in and learn the job with him, cover if he's absent… [supporting members is] a big part of our program to ease transitional employment… It's another step into their recovery so they can get back into independent living.While the photos were initially taken to answer the prompt, “How do you support others?” Analyzing the photos collectively prompted a group discussion about transitional employment that was informational as well. As members and staff shared their experiences, they also shared information about the steps to engage in transitional employment and supported employment, and how to access those opportunities.Instrumental (tangible aid and service)Opportunity for creativity and learning through digital photographySeveral members discussed that engagement in the PV process supported them tangibly because of the opportunity it provided to learn how to use digital cameras, to engage in a creative process, and to express themselves. Maile described, “I just really enjoy this opportunity with you guys… Take pictures. Pictures branch out to art, and that's good for your head I think.” Another member described the value of having more artistic practice in his life saying, “Music, dance, the arts, it conjures up memories. The memory it conjures up is happiness.” He also shared that seeing the photos others took gave him opportunities for pleasure. While looking at a photo Maile took of palm trees Vernon commented, “It brings you back to a peaceful spot.”Some members were surprised at the photos they took and found the process revealing as well. This relates to past research that has found PV can have similar positive benefits to narrative therapy, wherein self‐discovery occurs, and new understanding develops through the process as it unfolds (Mizock et al., 2015). One member, Nancy, shared, “I was really surprised by the pictures I took. It was really revealing to me that I wanted everything to be perfect, but there are bumps and forks in the road.” Nancy had photographed a triptych of leaves and flowers, reflecting on her Past, Present, and Future. The photo she chose to represent her future had flowers around a tree, but also a broken stick. As she described it, the photo illustrated hope, but also difficulty and loss. While this is distinct from tangible support in the way of providing goods and services, it illustrates how photography and the PV process provided a tangible vehicle for self‐reflection.Additionally, at each Clubhouse, we witnessed members and staff tangibly supporting other members by taking photos. Several members had concurrent physical disabilities that made it hard for them to use the camera at times. One member was legally blind, but still wanted to participate, and thus she narrated to researchers, other members, or staff exactly what she wanted to have captured in the photo. Members who had trouble with the small screens or had limited dexterity to use the buttons sought out support from other members and researchers to capture their photos. Throughout the process, there were several obstacles to using the cameras or sharing the photos that were overcome collectively.Appraisal (information that is useful for self‐evaluation)Group appraisal: Praise for photos and insightsAppraisal is a type of social support that occurs when others provide information we can use for self‐evaluation. This stems from the fact that we define ourselves in relation to others and how they respond to us. PV provided frequent, small, but seemingly meaningful opportunities for positive appraisal. After a member shared their photo, other members often provided praise for their photos and the insights they shared during the discussion. For example, Hoang, a member of Koʻolau Clubhouse, took a photo of a painting he made of a turtle, and he shared his aspiration to pursue painting. Other members praised his artwork and talent. Nancy, another member, said, “I think you're really gifted. I mean that's incredible. It's amazing that you would sit down for a whole thing and do from start to finish.” Another member, Robert then added, “I think you should sell art.” In another instance, when Vernon shared where his safe space was, instead of focusing on his symptoms and the fact that he was having paranoia, Mark, a staff member, normalized his experience and complimented his choice. Mark said, “I really like what you said about having a spot to find your peace. Everybody needs that little spot.” Other members highlighted talents that emerged through the photos. They either remarked that the photos were high quality or that they captured something poignant or accurate. One member commented on another member's photo of his mother:It's just like how we live here in Hawai'i. She's wearing a tank top, and she looks like native from here…You know like people, like photographers, take pictures of people from Tibet? Like a National Geographic? I don't know, it's a picture that can go into a National Geographic picture of how people live in Hawai'i.Although these comments were about the photos, they often extended directly to the personality, role, or talent of the photographer. In another instance, Roebree, a member of Diamond Head Clubhouse, took a photo of orchids. She described that caring for orchids at her home and for her family gave her a sense of meaning and purpose. Another member commented:I love the color of the orchids, and as far as how healthy the leaves are, makes it a beautiful picture… The way you take care of the pots and all that, the medium to grow, and the fence in the back…It shows how much care and love you provide for the orchids and the flowers they produce.This PV exchange prompted one member to make positive character reflections about another member's role, her intentions, and her success at caring for the orchids.Positive self‐appraisal for engaging in the processFor some members, committing to the several‐week process, showing up with their photos, and engaging with others was a commitment that they were proud to engage in that seemed to affect their self‐appraisal. For example, when asked how her photo represented a sense of Meaning or Purpose, a member said, “Just being a responsible person, coming through with the Photovoice… It makes me feel happy that I can share. I knew I wanted to do this, and it makes me happy that I accomplished it.” Furthermore, when asked about what the PV process was like, one member from Friendship House, David, said, “I feel like I did an honest, honorable process of following your request.” While these were self‐appraisal comments, they were still relational with the research team and may have prompted a sense of support through connection with the research group.DISCUSSIONThis study adds to the literature on the outcomes and benefits of the PV process. Instances of all four types of social support (emotional, informational, instrumental, and appraisal support) were qualitatively analyzed in the process of PV. Findings provide preliminary empirical evidence that engagement with PV has the potential to foster social support among participants, as well as among participants and researchers. This builds upon previous scholarship arguing PV could or did lead to meaningful and supportive connections (Budig et al., 2018; Castleden et al., 2008; Suffla et al., 2012; Wang, 2003), which we hope is a starting point for further and deeper exploration of this topic. The implications of increased social support are profound. Social support has been linked to lower levels of loneliness, perceived stress, and anxiety (Morelli et al., 2015), and better mental and physical health (Hakulinen et al., 2016). Increased social support has also been found to reduce the odds of depressive and psychotic‐like symptoms (Smyth et al., 2015), making it particularly impactful for individuals with severe and persistent mental illness who may be at an increased risk of isolation (Marrone & Golowka, 1999).In addition to the benefits of social support alone, our findings lend support to the numerous studies which have claimed that PV is an empowering research method (Budig et al., 2018; Carlson et al., 2006; Hergenrather et al., 2009; Suffla et al., 2012; Wilkin & Liamputtong, 2010). As mentioned in the introduction, empowerment is a construct with multiple dimensions. According to Teti et al. (2013), changes in self‐perception, specifically enhanced self‐esteem and self‐confidence, can contribute to an internalized sense of empowerment. These changes in self‐perception may be developed through positive appraisal, which was the most prevalent form of social support within our sample. This aligns with past research that found PV led to a transformation in self‐perception due to the recognition that participants received from others (Budig et al., 2018). For theorists who take a more collective view of empowerment, such as, PV may foster social connectedness, which is a form of collective empowerment.Additionally, PV opened up the opportunity for members to be involved with advocacy through the collective construction of themes. Members and staff remarked how PV provided an opportunity to challenge narratives about the lives of individuals with serious mental illness, particularly focusing on positive aspects of their lives and personalities. Notably, the prompt chosen by each of the Clubhouse was positive in tone. During feedback sessions, members shared advocacy ideas such as photography exhibits, social media, and creating a “member stories book.” The book, Picturing Recovery in Hawaiʻi's Mental Health Clubhouses, was developed and shared with the Hawaii State Legislature and various organizations on Mental Health Awareness Day. In the future, we hope that other scholars further examine the impacts of this method, using various dimensions of social support as well as empowerment.Limitations and opportunities for future studiesSome of the strengths of this work also point to its limitations, which provide ample opportunities to grow and expand this line of methodological inquiry. First, this study was conducted in a unique setting. Mental health Clubhouses are community mental health centers that provide support for PWSMI. Members are able to build meaningful social support networks with other members and staff through participation in the Clubhouse. For this reason, many (but not all) of the participants of this study were acquainted with each other before the PV project. Not all PV studies are conducted in this type of socially connected setting.PV in a setting where participants are distrustful of one another may provide a challenge or limit some of the positive exchanges that occurred, which may be predicated on a willingness to share intimate details about one's life. It remains unclear whether PV can foster connection or shared understanding among individuals with vastly different or contentious viewpoints. While some themes in our study were not identified frequently (such as instrumental support) that seemed to be related to the construct itself (tangible aid is typically material or physical rather than conversational) rather than disconfirmation of our overarching question.This begs the question, what does the opposite of social support look like? Derision? Insults? Silencing? We witnessed a single instance of a member being asked not to share his photo by a staff person. He had taken a photo of his work as a bouncer at a strip club, and the staff thought the content might not be appropriate for the session. The research team asked the staff person to allow it, with permission from the group (i.e., if it was not offensive to the other members). By that point, the member no longer wanted to share the photo and left the session, seemingly upset. He debriefed with the research team and staff later, and was able to share his intentions, but he no longer engaged in the process. However, there were many other instances where members shared potentially divisive or upsetting stories that were typically met with empathy and supportive comments. Future research should examine the relationship between PV outcomes and content. Are the results the same if the PV focuses on a politically or socially divisive topic? If PV fosters identification of shared experiences, can it provide an opportunity to overcome barriers or division, or build trust among estranged groups? For example, Castleden et al. (2008) found that PV fostered relationships and trust between researchers and First Nations participants in Western Canada.Anecdotally, our research team also experienced newfound trust and social connection during our own internal PV project. We completed a pilot PV with the research team to prepare for the first study both logistically and to experience some of the emic perspectives of participants (e.g., potential vulnerabilities, challenges, etc.), which we recommend to other researchers employing this method with a new team. The research assistants chose the PV topic: fears of failure. The research team members barely knew each other at the start of the project. By the end, we were more prepared logistically, but more importantly, we had developed a bond and mutual trust as a team, having identified some of our shared experiences despite differences in age, educational attainment, role on the team, and various other aspects of identity.On a related note, the present study did not examine differences in perceived social support across different social identities. Social inequalities faced by marginalized communities may impact one's experiences of social support and result in disparate outcomes. For example, a recent study by Zhai and Du (2022) examined disparities in perceived social support among marginalized communities facing socioeconomic disadvantages that were exacerbated by the coronavirus disease 2019 pandemic. They found significant disparities in perceived social support among racial and ethnic minorities, sexual minorities, and persons with disabilities. Given that similar disparities may manifest in PV sessions, future research should take an intersectional approach by examining differences in perceived social support among diverse sociodemographic groups.Finally, our analysis examined exchanges that occurred naturally during in‐person sessions. It is unclear whether the same benefits would be experienced in a virtual format, and whether participants would rate their perceived social support differently pre‐and‐post PV sessions. While some members shared an increased sense of connectedness during the feedback sessions, future research should examine this quantitatively, ideally with social network methods. Pre–post tests could indicate whether members experience increased connections and depth of relationship and whether those trends relate to aspects of psychological wellness or empowerment. Ideally, this work would measure various dimensions of support and connection, multiple dimensions of empowerment, and collective measures of trust and a sense of community.CONCLUSIONThis work seeks to provide a novel, empirical approach to understanding whether engagement in PV may be beneficial to participants. Based on our findings, PV has the potential to foster mutual social support among PWSMI, which other researchers have highlighted is foundational for empowerment (Neal, 2014). Members exchanged emotional support by providing encouragement, empathic responses to adversity, and statements of appreciation, as well as by connecting through shared experience and humor. Members exchanged informational support for managing symptoms and promoting wellness. Members received instrumental support, including opportunities for advocacy, creativity, and learning, and supporting each other tangibly in participating in the process. 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Journal

American Journal of Community Psychology – Wiley

Published: Jun 1, 2023

Keywords: community‐based participatory action research; empowerment; photo‐based methods; Photovoice; qualitative research; social support

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