photo therapy: theory & practice

Art P.vrc/rorhu~p~, Vol. 6 pp. 41-46. Pergamon Press, 1979. Printed in the U.S.A.

PHOTO THERAPY: THEORY & PRACTICE*

DOUG SEWART

Counseling Associates Sycamore, IL

Judging from attendance at convention pro- grams and responses to magazine and journal ar- ticles, one of the most sought-after new uses of photography is photo therapy-the use of photography in a therapeutic setting, under the direction df a trained therapist, to reduce or relieve painful psychological symptoms, and as a method of facilitating psychological growth and change. This paper is admittedly an interim effort to provide many interested counselors; photog- raphers, and others in the helping professions with basic information about photo therapy, until such time as more complete theoretical and practical information can be compiled and dis- tributed.

BACKGROUND

Photography itself was first made public by Louis Daguerre in 1839, but the first record we have of it being used in conjunction with psy- chology was in the 1850s when English physician Dr. Hugh Diamond used it to record the patients in a mental hospital and then realized there was therapeutic value in showing the patients the results. His paper “On the Application of Photog- raphy to the Physiognomic and Mental Phenomena of Insanity” was read before the Royal Society in 1856.

The first major public recognition of photo therapy, .however, was with the publication of Dr. Robert Akeret’s book, Photo Ana/_ssis in 1973. I am certain that other therapists had been using family albums and snapshots for some time, but his book crystallized the process and’ gave impetus to wider usage of’the medium in therapy.

The first conference/convention presentations began in 1975 at the International Photography Center in New York. Ralph Levinson and I gave some of the first national/regional convention presentations in 1976-77.

The social milieu in which photo therapy has been conceived is, of course, the Age of Me- dia, with Marshall McLuhan (1964) its first major exponent, followed shortly by Alvin Toffler (1970). In 1923 L. Maholy-Nagy said “The illit- erate of the future will be ignorant of the use of camera and pen alike.” Photo therapy is simply utilizing the current “literature.” There is no one author or guiding genius behind photo therapy. As McLuhan explained the Electric Age, things do not move linearly, but simultaneously-and photo therapy is growing more like Topsy than like psychoanalysis, as befits the age in which it was spawned.

The core of organized photo therapy activity currently appears to be in Chicago, centering around the program originated by Brian Zakem at the Day Center of Ravenswood Hospital Community Mental Health Center.

THEORETICAL CONSIDERATIONS

A theory is generally a verbal construct at- tempting to explain a known phenomenon or series of phenomena, and is usually stated in fac- tual form, although it is actually conjecture. A good theory allows for the making of hypotheses. From these hypotheses research can be designed that will test the theory. If the theory holds up under such hypothesis testing, it eventually be- comes a law. Photo therapy fits most of the re- quirements for a good theory and can also be

*Requests for reprints should be sent to Doug Stewart, Counseling Associates, BOX 121, Sycamore, Illinois 60178. Please enclose stamped, self-addressed envelope.

0~90921791010041-06$02.00/O Copyright c 1979 Pergamon Press Ltd.

42 DOUG STEWART

considered as a treatment mode. That is. since photo therapy is only now beginning to have theoretical constructs articulated, some of the philosophical foundations have been more im- plicit than explicit; i.e., if you did not believe Man functioned this way, you would not be likely to use photo therapy in the first place. The obvious need for photo therapy, a need we are at- tempting to redress, is for such articulated theories, from which can be drawn testable hypotheses. Most of the theoretical constructs are riding piggyback on the older art therapy work, although photo therapy is different from other art forms in some very significant ways. The following theoretical stances, therefore, are those from which the current practitioners of photo therapy would seem to be working, as seen, admittedly, from my own point of view.

I think that a comprehensive counseling theory should cover the following major components:

1. Definition 2. Philosophy 3. Definition of anxiety/neurosis-the pre-

senting problem 4. Treatment goals 5. Counseling techniques-the applications 6. Advantages and disadvantages 7. Client populations

The seven major components of photo therapy therefore are as follows: 1. Drfinition. Photo therapy may be defined as

“the use of photography or photographic materials, under the guidance of a trained therapist, to reduce or relieve painful psychological symptoms and to facilitate psychological growth and therapeutic change.” I am sure the rest of this presentation could ex- pand solely on the definition, but in general I am indicating that while just taking photographs might be considered therapeutic by the photographer, it is not “therapy.” Dis- tressing symptoms usually should lead one to seek the services of a professional therapist. Photo therapy in its broad sense also refers to the use of video and motion pictures but this paper is concerned primarily with still photography. However, many of the constructs of photo therapy also apply to film and video.

2. Philosoplr~ uttd Nltttrrr oj’ Mtrn. Photo therapy sees Man as inherently creative, with

a natural proclivity for self-growth. self- actualization, and self-healing. His basic needs are reality contact (grounding) and per- ceiving himself as being capable of both loving and being loved, i.e., of both sensing and causing deep emotions.

Photo therapy believes that Man inherently uses both halves of the brain. but that one half is usually repressed in a highly linear. “ra- tional” society such as ours. Photo therapy also contends that virtually all human experiences-and therefore memories-are intricately related to visual phenomena, and it is impossible to deal thoroughly with one without referring to the other.

3. Atzsiery rrntl Nrrrrosis. These are basically caused by doubt: that I am capable of loving and being loved, of coping (reality contact). of surviving-all of which may be summed up in the self-concept. A neurosis may be considered a fixated anxiety, and photo therapy believes that many of the causes of anxiety can be found in childhood, most often in the relationship with family and/or “significant others.”

4. The Trrrrhtlrtlt Gotrls in photo therapy therefore generally center around the client’s awareness of self, and in what ways that self-concept can subsequently be improved. We feel that without integrated gains in self- concept, other gains will be short-lived.

5. Therupv Techtliyrrrs. a. Prci,jrcri\vr-using any photograph in

which the client or therapist has an interest, as discussion-generating or as material for interpretation. The photograph may be from a magazine, newspaper, or any other source.

b. Frrttlily crlhrrtw-one of the most frequently used sources, it often gets at early childhood experiences and relationships which the client is otherwise unable to recall, generally because they have been repressed.

c. Pho~ogrtrphs of the client-these enable the client to begin to explore feelings about self and relationships with objects and people other than family.

d. Photocgrtrph.v by the clirttr--a method in which the client indicates things of value, interest, or concern. When under the

PHOTO THERAPY 43

therapist’s supervision, this activity also allows the therapist to observe the client’s interactions with both his social and objective environment.

e. Photogr-uphs c1.f the client by the clic)nt (self-portraits)-although the most dif- ficult for most clients, this approach leads directly to feelings about self-the es- sence of photo therapy.

6. Advnntuges and Distld~wntuges. Briefly, the main adwntuges of photo therapy are: a. It is an intriguing media in its own right,

“hooking” the client, which makes an easy transitional relationship to the therapist, leads to a confidence-building skill, and produces a tangible artifact.

b. It extends the client’s visual awareness, a logical step to self-awareness.

c. It produces a documentary, tangible record of the therapeutic process, available as a constant reference point.

The chief disudvuntuges of photo therapy are : a. As with all media, it requires a capital in-

vestment by someone-and there are times when the equipment just won’t work.

b. It requires therapists who are as visually sophisticated (aware) as they hope the client will become. (Not from an “art” standpoint, I hasten to add, but in the sense of “heightened awareness.“)

7. Client Populations. Photo therapy has been and is being used with a wide variety of clients. It has proven very successful with low or non-verbal clients, as well as exces- sively verbal ones. It is being used with psychotic patients and virtually every form of counseling problem, from marriage and family distress to acute depression.

GENERAL APPLICATIONS

There are many reasons for using photography in therapy. (I hesitate to say “as an adjunct to therapy,” as the implication then is that they are somehow two separate functions. I conceive of “therapy” as a complex composite of skills, atti- tudes, and relationships, of which photography can be an integral component.) Following are ten basic reasons for using photo therapy:

1. Virtually all human experience other than that in -total darkness or with eyes tightly closed has “bonded” with it a visual component. In therapy it often seems that whereas the client may have successfully repressed the verbal component of painful memory experiences with adequate verbal defenses (this is, after all, largely a verbally-rewarded culture), the visual aspects of the memory or experience lie largely undefended. A photograph, therefore, can often trigger a flood of recalled material that had been previously successfully blocked. Photography produces a tangible artifact, and in the case of still photography-unlike film and videcF_it is also non-linear; that is, photographic prints can be sequentially ma- nipulated in their order of perception. Photography is a powerful reality check, stronger than the other visual media (paint- ing, drawing, etc.). Since the gap between our own perceptions and the perceptions of others plays such a major role in many counseling presenting problems, such a reality check has broad uses in therapy.

4. The use of photography with clients leads to their acquiring a finite skill. This skill can be used (a) after the conclusion of therapy, as career (rarely), hobby, further self-growth, or any other purpose the client may choose: (b) as an asset to the client’s self-confidence, and hence to the self-concept; (c) as an easy bridge to making and retaining social contacts-which was often the original presenting problem.

5. Photography is a seductive media, and the client is easily hooked, at which time the photographic habit and program may make for an easier transition to a therapeutic relationship between counselor and client, as well as help bridge over rough spots in the counseling process.

6. The client’s use of visual imagery apparently utilizes the other half of the brain from the usual verbal therapies, giving the client a better balance of awarenesses and analysis. In the process, it improves the client’s visual sensitivity, a positive step in the direction of heightened self-awareness.

7. Photography can be used in both group and individual settings, in either a passive or an

44 DOUG STEWART

active mode. One can either take photographs, be photographed, or respond to photographs, depending upon the therapeutic needs. There is also an easy transition from one mode to the other-especially with Polaroid or video-and from individual to group and back again. With a leader who is well-trained, photography can be used in a group much like psychodrama-with the additional plus that it produces artifacts that document both the process and the progress.

8. Photography can be either highly verbal or non-verbal, depending upon whether it is being used in the active (making photographs) or passive (responding) mode. As a non- verbal activity, it can be used with low verbal clients (both as a confidence and relationship-building activity, and to elicit increased verbalizations) and with highly verbal clients, as an aid to attention-focusing.

9. The use of photography is generally a very low-risk approach, as (a) most clients have previously been both photographer and subject; (b) it appears far less risky than talking initially about self and feelings; and (c) un- trained lay persons do not realize how much of themselves they reveal in their photographs, or their response to them (hopefully, by the time that they do, a trusting reiation- ship will have been established with the therapist).

10. The contemporary video and “instant” still materials provide visual feedback in literally seconds. This is especially helpful with young children, whose memories and attention span are short.

SPECIFIC TECHNIQUES

Once again, briefly, the five ways in which photo therapy is most often used, followed by some specific examples for each:

1. Material for projectives 2. Family album 3. Photos of client, by others 4. Photos by client 5. Self-portraits

A. Projecti\~c~s. It often occurs that the counselor feels the client is repressing or blocking material in a given sensitive area. In such a case, either the client or the therapist can

bring in photographs to which client responses may bring forth material that will re- sult in the freeing-up of the blockage. A photograph is, of course. far more specific than an ink blot. Since photographs are useful in some cases, but less so in others, the deci’- sion to use photography is one the therapist must make.

B. Fumi!\’ rrlhrru7. There are times when either client or therapist suspects that certain material pertinent to family relationships is being blocked. A family album can be most helpful in (a) releasing blocked material: (b) correct- ing memory distortions of childhood events. appearances, or relationships; (c) determining the age at which certain traumatic events may have occurred.

C. Cliet~t us subject. It often occurs that the client does not really know how others per- ceive him/her, distorts that perception, or is not consciously aware of the discrepancy. At this point the introduction of photographs taken of the client by others-especially “significant others”- can be beneficial, both as a reality check and as an incentive to get the client to talk about perceptions, relationships, and the image of self.

D. Photogtaphs h_v the client. The client-as- photographer technique may be used in a number of ways, chief among them being ( 1) under observation by the therapist in a group setting, and (2) as an indicator of the client’s valuing process. 1. While the client is photographing in or

with a group, the therapist can observe the degree to which the client is direc- tive/passive, patient/frustrated, creative/ safe, self-centered/other-centered. trusting! suspicious, photographer/subject, and many other aspects of interpersonal trans- actions that give the therapist additional information to use in the therapeutic process.

2. One method which has proven helpful in determining the client’s valuing process is to have the client fantasize that “because of the silver shortage, this is the last roll of film available. Take anything you wish, but this is all there is.” The resulting images tell both client and therapist a great deal about the client’s values and areas of

PHOTO THERAPY

E.

emotional investment-or avoidance. (In one case, this method was a major break- through, as a living-at-home student had only a picture of the exterior of the house, but no parents. It became obvious where the problems were, but it was material the client had successfully blocked verbally for several weeks.) Having the client photograph the therapist can often help equalize the relationship, as well as open up transference and counter-transference issues, should that be desirable.

Selfportruits. As you can imagine, this is the area where there is both the greatest therapeutic material, but also the greatest emotional risk for the client. My own series of Photo Therapy Workshops is based largely on the self-portrait, and the creative therapist will find many productive variations in this area.

For example, when a client and I are working with problems of self-concept and/or distortions and uncertainties as to how the client is perceived by others, I will sometimes suggest that the client make the following self-portraits: (1) “How I think I’m seen by others”; (2) “How I see myself’: (3) “How I want to be seen by myself.” (These images can often be done in a passport photo ma- chine.) The resultant photos can usually trigger a great deal of relevant material. Addi- tional self-portrait suggestions that can be made, depending upon the therapeutic needs, are (1) “dress-up” (you in your favorite cos- tume, clothes, period of your life, etc.), (2) “dreams,” in which the client recreates a dream and photographs it, (3) “equivalent,” in which the client photographs some object which he/she feels can stand as a symbol or metaphor for them.

UNIQUE CONTRIBUTIONS AND CAUTIONS

There are several aspects of photo therapy which I feel are advantages over other therapy modes: 1. It results in an art$uct. The implications of

this are still being expanded by practitioners, but it clearly gives client and therapist an object which:

a.

b.

C.

d.

documents both the process and progress of therapy, as well as acting as a perma- nent reference point; being sequentially non-linear, it is much easier to extract data from than tape re- cordings, notes, film or video; can be combined with other art media, sent physically or electronically to virtually any point in the world, or transferred chemically to other objects; can easily be made use of in “homework assignments,” as it is cheap, portable and visual (photographic prints) by both clients and others from whom the client may desire feedback.

2. Photography uses both a familiar vocabulary

3.

4.

and equipment that most everyone has available. With commercial processing and with Polaroid and Kodak instant materials often being a viable alternative, no on-site lab is necessary. Photography is a confidence-building act; you generally get better at it the more you do it. This often acts as an effective emotional counter balance as the client gets deeper into therapy and the emotional going gets tougher; i.e., the “hook” of photography will help hold the client in therapy. Again, photography-in all its forms-is a very powerful reality grounding media, prob- ably the strongest that the therapist has available.

Photo Therap? contraindicated. There are, of course, some situations in which the use of photo therapy would not be advisable. More may surface as it receives wider recognition and use: 1.

2.

3.

Depending upon the nature of the psychosis or phobia, there are clients who should not work in the darkroom, especially if they are easily hallucinating. Self-portraits are not recommended for those. clients whose ego strength is so low or distorted that such a reality confrontation would be more damaging than helpful. Assignments to photograph in subject areas with which the client is having great difficulty (parents, for example) is not always helpful. It is a decision the therapist must make with care. I personally prefer to work out all such “assignments” with the client, so that some degree of psychic comfort in backing off, if

DOUG STEWART 46

4. necessary, can be maintained. Most photo-chemistry is not lethal, but care must still be exercised with both chemistry and equipment if clients are self-destructive.

Generally speaking, these seem to be the major limitations, although specific situations may call forth their own cautions.

A CASE HISTORY

I have had a number of “successful” client outcomes using photo therapy, but the one I would like to relate here seems significant because the outcome surprised both the client and myself, and I learned a great deal from the case.

The client was “Rachael,” a middle-aged widow who was experiencing difficulties with anxiety, manifesting itself in excessive smoking, drinking, difficulty in sleeping and concentration. She scored below the 50th percentile on all five sub-scores of the Tennessee Self-concept Scale, and also scored low in the area of the face on my Body Image Rating Scale. The counseling discussion therefore centered on her self-concept, especially as to her physical appearance, since though she was an attractive woman, she felt her face was so unattractive that she couldn’t stand to look at it in the mirror.

My usual method in a case such as this is to have the client take a series of self-portraits- first of head and shoulders-and discuss their objective appearance in the photograph, as con- trasted with their self-image. (The photograph serves as a primary visual reality check-it is “self-confronting.“) However, in this case, it was to no avail, as her distorted self-perception continued. I was ready to try something else when, as part of the “homework” of just living with the photographs of herself between sessions, the client asked herself two very meaning- ful questions:

a. “Was there ever a time or a way in which my face got me in trouble?”

b. “Was there ever a time when I felt as good about my face as I srill do about the rest of my body?”

The answers were most significant to the progress of the therapy:

a.

b.

“Yes. My father was very cruel and strict. and when my expression to!d him how I felt about him, he would beat me-my face betrayed me.” “Yes. When I was very young, my ‘boy- friend’ followed me home from school. My father found out and beat me. He also forbade me to have any more boyfriends. I reasoned that from then on ‘being pretty’ would oniy get me into trouble.”

With these insights, triggered by the self- portraits, the ensuing discussions resulted in a much greater understanding by the client of the parental relationship-most of which she had blocked in earlier sessions-a greater acceptance of her physical features, and, as we put some of these insights into practice, an improved self- concept and a great reduction in her anxiety and its symptoms.

CONCLUSION

This brief paper has only touched the surface of the rapidly-emerging field of photo therapy. With the progressive studies in the areas of both photography and the application of contemporary counseling theories, it is inevitable that some aspect of photo therapy will be found helpful in a myriad of mental health situations. It may never take its place as a unified discipline alongside Gestalt, TA, RET, Primal, or Reality Therapy-by its inherent eclectic nature it is more likely to infiltrate than replace-but if McLuhan was a true prophet, it may someday be in wider use than any of them.

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Weyden. M,\HOI 1 -NA(;~ . M. I 1966) P/rot~,,~~c~l,/t(,~.r ou P/~~~to:~trplr~.

Nathan Lyon\. ed. Englewood Cliffs, N.J.: Prentice-Hall. M~LuuN. MAHSHAI.~. (1964) C/,cc/c,,..\ttr,~cli,r,~ IIcc!i[r. New

York: McGraw-Hill. TOI-FI FH. AI VIN (1970) F-utrrrc, S/IOC~~. New York: Bantam

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photo therapy: theory & practice

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