Available online at www.sciencedirect.

com

An Ethnographic Approach to Interpreting

a Mental Illness Photovoice Exhibit
John Fleming, Jane Mahoney,
Elizabeth Carlson, and Joan Engebretson

The aim of this study was to explore the use of photovoice as an innovative
methodology for understanding aspects of the mental illness experience. Ap-
plied ethnographic methods were used to examine 15 photographs and accom-
panying narratives from a mental illness photovoice exhibit. Analysis occurred
within and across cases, resulting in individual case studies and a thematic
description of the narratives. Suffering, stigma, and loss of identity were found
at the center of this rendering of mental illness experience. The findings sug-
gest that a photovoice project offers a useful lens from which to examine experi-
ences associated with living with mental illness.
D 2009 Elsevier Inc. All rights reserved.

T HERE IS GROWING awareness in the United

States and throughout the world of the
immense burden of disability associated with
mental illness (Murray & Lopez, 1996; U.S.
Department of Health and Human Services,
2000). Reports highlight the significant disparities
that plague the availability of and access to services
in the field of mental health and underscore the
urgency to improve the delivery of care. However,
despite increased awareness at both national and
international levels, support and resources to
improve treatment of mental illness remain limited.
From the School of Nursing, The University of Texas
Health Science Center at Houston, Houston, TX, Nurse
Corps, U.S. Navy, Naval Hospital Camp Pendleton,
California, Box 555191, Camp Pendleton, CA, Menninger
Clinic, Houston, TX, and Mennonite College of Nursing,
Campus Box 5810, Normal, IL.
The views expressed in this article are those of the
authors and do not reflect the official policy or position of
the Department of the Navy, Department of Defense, or
the United States Government.
Corresponding Author: Jane Mahoney, PhD, APRN,
BC, Director of Nursing Practice and Research, Menninger
Clinic, 2801 Gessner Road, Houston, TX 77080.
E-mail addresses: john.fleming@med.navy.mil,
jmahoney@menninger.edu, elizabeth.carlson@insightbb.
com, joan.c.engebretson@uth.tmc.edu
© 2009 Elsevier Inc. All rights reserved.
0883-9417/1801-0005$34.00/0
doi:10.1016/j.apnu.2008.02.008
One explanation given for the state of mental
health care is the stigma associated with mental
illness. Stigma leads to distrust, fear, anger, and
avoidance. The stigmatization of mental illness
often serves as an excuse for inaction and is a
powerful barrier to seeking appropriate care. Fear of
stigma, and the resulting discrimination, is what
often discourages individuals and their families
from receiving the medical attention they require.
The profound degree of disability associated with
mental illness and the significant lack of mental
health resources suggest a need to identify inno-
vative methodologies designed to illuminate the
significance of the problem more fully. New
methods that have the potential to create a shift in
social views about mental illness from margin-
alization and avoidance to inclusion and social
justice are needed. Such a shift is needed to create
space for mental health policy based on humanistic
and moral principles. The purpose of this study was
to explore the use of photovoice as an innovative
methodology for understanding and communicating
aspects of the mental illness experience.
BACKGROUND
Mental illness is an equal opportunity offender,
affecting people from all walks of life, races, and

16 Archives of Psychiatric Nursing, Vol. 23, No. 1 (February), 2009: pp 16–24

AN ETHNOGRAPHIC APPROACH TO INTERPRETING A MENTAL ILLNESS PHOTOVOICE EXHIBIT
ethnicities. Chronic mental illness remains a serious
public health concern, due, in part, to inadequate
screening, recognition, and treatment in primary
care settings (Institute for Clinical Systems Im-
provement, 2004); poor compliance with treatment
regimens (U.S. Department of Health and Human
Services, 1999); inadequate funding for mental
health programs (New Freedom Commission on
Mental Health, 2003); and social stigma associated
with mental illness (Byrne, 2001). Ultimately,
access to and use of services are influenced by a
global lack of understanding about the true nature of
such a disorder.
It is essential to develop and communicate a
better understanding of the experiences of those
living with mental illness to advocate for greater
support and to engage this population more fully.
Understanding of the mental illness experience from
a new vantage point might provide nurses and other
professionals with new opportunities to engage
patients, families, and policymakers into action that
produces a more equitable standard of care for those
with mental illness. Illuminating such experiences
has impacted policy related to other marginalized
groups (Douard, 1995). Although previous studies
(Heilemann, Coffey-Love, & Frutos, 2004; Ridge &
Ziebland, 2006) have underscored the importance of
the patient perspective in mental health, no study
examining the experience through photovoice
methods is available.
Photovoice is a qualitative method of inquiry that
provides a forum for the presentation of partici-
pants' experiences through images, language, and
contexts defined by the participants themselves
(Streng et al., 2004). In addition to its aesthetic
quality, a professional artistic medium allows for
increased accessibility to the public sector. Greater
access to these public venues makes it possible to
influence policymakers in a manner that may
positively impact mental health policy; an explicit
goal of a photovoice project is to reach policy-
makers (Wang & Burris, 1997; Wang, Morrel-
Samuels, Hutchinson, Bell, & Pestronk, 2004).
As one example, an important photovoice project
took place in China, developed as part of a larger
needs assessment conducted by the Yunnan
Women's Reproductive Health and Development
Program (Wang & Burris, 1997). Although the
method did not uncover different issues previously
found with the use of other assessment methods
(surveys, focus groups, nominal group process), it
17
provided an effective and vivid way to reach
policymakers through images and stories that
exploit the emotional power of photographs. More
recently, photovoice projects have been sponsored
by communities, state agencies, private foundations,
and national funding agencies to use this method of
community-based participatory research in direct-
ing further research, funding, and program planning
(Lockett, Willis, & Edwards, 2005; Lopez, Eng,
Randall-David, & Robinson, 2005; McAllister,
Wilson, Green, & Baldwin, 2005; Moffitt & Voll-
man, 2004; Stevens, 2005; Wang et al., 2004; Wang
& Pies, 2004; Wilson, Minkler, Dasho, Wallerstein,
& Martin, 2006).
In its most basic form, photovoice refers to a
research tool in which photographs, taken either by
participants or researchers, are used as a means of
understanding human experiences. As an ethno-
graphic method of inquiry, photovoice is a fairly
recent technique that has been used successfully in
a wide variety of research settings and populations.
A great deal of work incorporating photovoice has
been done in the public health arena and collec-
tively referred to as a participatory health promo-
tion strategy (Wang & Redwood-Jones, 2001).
Although a relatively new research method,
photovoice has already been proven to be a valuable
asset for participatory inquiry (Wang et al., 2004).
Because a photograph exists as a universally
understood visual medium, photovoice as a partici-
patory co-learning process is especially suited for
culturally diverse populations, or those who are
traditionally overlooked, such as individuals with
mental illness (Collier & Collier, 1999; Prosser,
1998; Rose, 2001). In addition to photographs,
illness narratives have been used to view the life
disruption created by the chronic mental illness
experience (Bruehl, Lende, Schwartz, Sterk, &
Elifson 2006; Keady, Ashcroft-Simpson, Halligan,
& Williams, 2007; Perseius, Ekdahl, Asberg, &
Samuelsson, 2005). By combining photography and
narrative, a photovoice project seems capable of
improving the quality of research by drawing on
local knowledge, developing local theory, and
establishing a suitable environment for change
(Carlson, Engebretson, & Chamberlain, 2006).
CONCEPTUAL FRAMEWORK
Kleinman's (1980) local health care system
model underpinned this study. According to Klein-
man, the health care system of any culture can be
18
explained by three somewhat overlapping sectors:
the popular, professional, and folk sectors. The
popular sector is composed of individuals, families,
communities, and social networks. People make
health-related choices based on their health orienta-
tions formed in the popular sector that may be
verified or modified through encounters with the
professional or folk sector. The professional sector
is composed of the organized health professions of a
society. Much mental health research is oriented on
the Western biomedical professional sector. The
folk sector is composed of traditional healing
practitioners who use both sacred and secular
healing modalities.
The authors believed that understanding the
mental health experience from the popular sector
would enlighten the clinical perspective. Using this
approach, clinicians might better incorporate each
client's experience of mental illness into a mutually
negotiated treatment plan that supports patient-
centered care (Mahoney & Engebretson, 2000). The
underlying assumption of this study was grounded
in beliefs that individuals make sense of their
experiences by situating them in narrative form
(Riessman, 1993) and that photographs of experi-
ences provide a valuable emotional interconnection
to others (Van Leeuwen & Jewitt, 2001).
METHODS
This qualitative study used the applied ethno-
graphic methods of fieldwork, participant observa-
tion, and retrieval of electronic and print documents
and audio materials (LeCompte & Schensul, 1999).
A contemporary photovoice exhibit served as the
platform from which the mental illness experience
was investigated. According to the artist, this
traveling exhibit is intended to challenge stereo-
types and to depict the courage and vulnerability of
those living with chronic mental illness (Nye, 2006).
The data used from the exhibit were renderings of
the artist's observations and firsthand narrative
accounts of persons living with mental illness.
The artist was authorized by the subjects of the
exhibit to portray aspects of their lives related to
their mental illness. The renderings provided were
selected for exhibition from a larger data set of
narratives and photographs by the artist. The voices
of the subjects were transcribed into text. In his
photographs, the artist chose to frame and display
his subjects in a manner consistent with his
interpretation of their narratives and his observa-
FLEMING ET AL
tions. Thus, the renderings have been produced
through the interpretive lens of the artist in the
forms of voices, texts, and portraits to reflect
aspects of the mental illness experience.
In accordance with this study's conceptual
framework, the principal investigator (J.F.) engaged
in participant observation, reflectively situated from
both the popular and professional sectors. From the
popular perspective, the researcher participated in
the public experience of the museum exhibit of
photographs and audio narratives, along with the
artist's public Website exhibit. From the profes-
sional sector, as a mental health nurse, the same
author used qualitative research methods to decon-
struct the Fine Line photovoice exhibit, Website
audio and visual displays, and museum brochures.
This simultaneous analysis added another inter-
pretive lens and analysis that attended to the
cultural cognitive, emotional, and behavioral phe-
nomena as they were interpreted.
Setting and Sample
The Fine Line art exhibit was first examined in its
original format at a nearby museum of science and
history in the fall of 2006. The examination of
photographs and narratives occurred within three
contexts: museum art exhibit, printed brochure, and
Internet documentary. Together, these formats were
both highly accessible to the public and served as
cultural mechanisms to communicate an empathic
view of mental illness.
The original photovoice exhibit consisted of 55
portraits, each with an accompanying audio narra-
tive documenting the experiences of persons with
mental illness. A sample of 15 cases was purpose-
fully selected because they were available in all three
formats—museum exhibit, Internet exhibit, and
print documents. Limiting the sample in this manner
allowed for a rigorous analysis, as the researchers
were exposed to the photos and narratives in
different ways. As such, the researchers were
positioned to explore the meaning of the narratives
and photos through multiple approaches, promoting
increased reflexivity in the analytic phase.
Data Collection
Permission to conduct this study was obtained
from the University of Texas Health Science Center
at Houston Institutional Review Board. Written
informed consent was obtained from subjects by the
original artist in the creation of his art exhibit.
AN ETHNOGRAPHIC APPROACH TO INTERPRETING A MENTAL ILLNESS PHOTOVOICE EXHIBIT
Written permission was then obtained from the
artist to use those materials from his exhibit made
available to the public. All materials used in this
study have been available to the public in the form
of printed documents or electronic media via the
Internet. Data were collected in the form of field
notes from participants' observations of the exhibit,
the Fine Line, the exhibit brochure that contained
15 selected photographs with accompanying narra-
tives, and archived exhibit photographs and narra-
tives from the Internet.
Analysis
Each narrative was read and reread, and photo-
graphs were repeatedly scrutinized for the human,
clinical, and moral messages conveyed. Two three-
column tables were created for each case: one for
visual interpretations, and the other for narrative
interpretations. Columns were designed to categor-
ize and display interpretations by the first author
according to the human, clinical, and moral
messages embedded within. The decision to use
these categories was based on the postulation that
these categories aligned with the popular, profes-
sional, and folk sector orientations underpinning the
study. Key elements from narratives were recorded
in the first table, followed by key impressions from
the iconographic analysis of photographs in the
second table. This process continued until all 15
cases were critiqued.
An iconographic approach from visual anthro-
pology was used to analyze the photographs
(Carlson et al., 2006; Van Leeuwen & Jewitt,
2001). This approach systematically focuses the
analysis from lower to higher levels of abstraction.
The first level of analysis approaches a photograph
from the most concrete perspective—the everyday
recognition of the subject and surroundings. As
such, the analysis would record recognizable
features of the photograph—fog, dilapidated build-
ing, or a well-dressed person. The second level of
analysis focuses attention on the cultural symbolic
features of the photograph. For example, a chain
link fence is culturally recognized as a barrier and a
dilapidated building is recognized as abandoned.
The most abstract level of iconographic analysis
considers deeper patterns and, most often, requires a
deductive search of extant theory to understand and
interpret symbolic meanings.
The narrative and iconographic three-column
tables were combined, and interpretations were
19
applied within cases and then across the 15 case
summaries. Consistent with recommendations for
thematic analysis (Leininger, 1985), key elements
and impressions recorded in all tables were
examined for relatedness and clustered into pat-
terns. Each of the analyzed 15 cases resulted in a
three-page, double-spaced typed interpretive sum-
marization. Patterns were then reexamined, orga-
nized into themes, and then reexamined for
underlying symbolic messages, the most abstract
level of interpretive analysis.
During this phase, the research team met regularly
to debrief and compare within-case studies with the
original data for logic, coherence, and fittingness. In
this manner, the research team ensured the trust-
worthiness of the first phase of thematic analysis. As
the analysis continued, the research team continued
to examine the interrelatedness of terms and patterns
as well as affirm the theoretical and referential
adequacy of findings, hence increasingly providing
the analytic foundation that establishes the trust-
worthiness of the findings.
FINDINGS
The interpretive analysis of narratives and pho-
tographs resulted in two products, each of which
offers a unique insight into the mental illness
experience. The first product was a series of case
studies that integrated the human and moral
messages imbedded within the photographs and
narratives. The second product of analysis resulted
in the identification of suffering, stigma, and loss of
identify as across-case themes. For the purposes of
this article, and primarily due to length restrictions, a
single excerpt is provided in truncated form to
illustrate the contribution of iconography and a brief
narrative in communicating aspects of the mental
illness experience.
Case Study Excerpt
Case 1
The photograph shows a female subject wearing
a black veil as she stares out across a river, whose
opposite bank is quickly disappearing under a dense
fog. There is an oddly shaped tree in the back-
ground whose branches hang precariously low over
the subject, as if reaching out toward her. Just
behind the tree and at the top of a slope is a chain
link fence that is strangely out of place by the
river's edge. The ground by the river is covered
20
with thick and lush grass, with the exception of the
spot where the subject stands. The patch of earth
directly underneath the subject is barren and
appears to have been plowed over. Like several
other photographs throughout the exhibit, this
image is framed by a familiar black circle that
narrows the view of the observer.
On its opposite shore, the river's banks and
surrounding foliage are obscured by a thick fog
that appears to be rolling in toward the subject. In
this case, the weather serves as an adequate
barometer of the subject's mood. In describing
her depression, the subject compares her illness
with a horrible state of nonexistence. In many
ways, the fog closing in on her also exists
between states of form and shape. Without
enough mass or density to become rain, a fog's
mist hovers in between states where water is
mixed with air, taking on the appearance of earth-
bound clouds. Just like the fog, the subject's
mental illness is what breaks up the definitions of
her world. The horizon between sky and earth is
lost, and the edges of shapes become blurred. The
subject's world takes on an even deeper layer of
gloom as it becomes shrouded and unrecogniz-
able. Interestingly enough, the subject even
describes her life at one point in her narrative
as a great deal like fog.
The chain link fence at the top of the slope is a
physical obstacle that has been constructed to keep
persons in or out of a certain space. The fence may
be seen as representative of the barriers to health-
seeking behaviors experienced by persons with
mental illness. As the ultimate representation of
the stigma of mental illness, the fence in this
photograph blocks the subject's path to a higher
place and impedes her ability to move forward.
Within her narrative, the subject speaks of one of
the main differences between mental illness and
physical illness. Unlike a sore, break, or cut,
mental illness is not seen on the outside. To the
subject, mental illness is often “bizarre and
ridiculous; something that is reacted to.”
The dark and evocative photograph is set against
a narrative background that bears witness to a tragic
illness experience. The subject's desire for a “fair
balance” as described in her narrative reflects the
nature of her bipolar disorder. The subject exists in
a state somewhere between the depths of depression
and the bizarre world of her mania. These
experiences have collectively defined the subject's
FLEMING ET AL
world and left her at the edge of a void, searching
for hope.
Themes
The integration of thematic analysis and icono-
graphic analysis across all cases revealed suffering
and stigma as the two themes fundamental to the
mental illness experience as represented by this
photovoice exhibit. At the center of these two
experiences, a collective loss of identity was firmly
established as the universal and unifying theme.
One of the most frequently reoccurring elements
identified through this project was the negative
experience of being defined by a mental illness
rather than a genuine sense of self. Loss of identity
was found to encompass both the internally
navigated experiences of suffering and the exter-
nally navigated experiences of stigma. Patterns of
stigma included categories of “caged,” “shadowed,”
“derailed,” “detached,” and “afraid.” Patterns of
suffering included categories of “tragedy,” “sad-
ness,” “sickness,” “darkness,” and “pain” (Figure 1).
Suffering
The photographs and narrative accounts collec-
tively present suffering as an internally navigated
experience endured by persons with chronic mental
illness. Suffering is defined as an emotional
phenomenon of extreme discomfort, a uniquely
devastating experience that causes a fragmentation
in the integrity of sense of self as a whole. Multiple
accounts of depression, anxiety, irritability, and fear
are found throughout the data. Collectively, these
accounts portray the experiences of anguish and
distress associated with the emotional state of
Fig 1. Mental illness experience themes and patterns.
AN ETHNOGRAPHIC APPROACH TO INTERPRETING A MENTAL ILLNESS PHOTOVOICE EXHIBIT
suffering. As a threat to the integrity of the person
as a whole, suffering is capable of stripping an
individual's central purpose in life.
Categories of suffering were defined as “tra-
gedy,” “sadness,” “sickness,” “darkness,” and
“pain.” One subject vividly described her experi-
ence as being in a “dark cave” that is both “devoid
of feeling” and “devoid of light.” Another spoke of
her panic attacks as “like a storm in your brain.” Her
severe episodes of fear are “like thunder” that
“comes out of nowhere.” The experience of
suffering is so intense that the subject is unable to
recover until she physically secures herself to a
solid object that is permanently fixed to the ground.
Human tragedy was evident on the lines of
subjects' faces as it was within their spoken words.
The shadows in many photographs are powerful
metaphors that express the darkness and despair
associated with the sickness of severe depression.
The darkness and lack of definition in the backdrop
of one photo suggest an uncertainty about the
subject's future and an ambiguity about his past.
The subject's experience with sadness and grief has
left him in what he describes as a “dark place” that
does not easily make sense.
In addition to the thematic representations of
suffering in the narrative data, there are also
unique examples found in the photographs. In one
case, there is a condemned building directly
behind the subject that suggests how she views
her illness. The building appears to have lost its
function some time ago. Many of the doors and
windows have been boarded up and show no sign
of life. When examined by itself, the structure
takes on a visible degree of sadness. Collectively,
the lonely building and dark surroundings exude
the negative qualities associated with human
suffering. In another example, adding the elements
of darkness and apprehension, the shadows of
several menacing trees appear to surround and
engulf another woman such that she is almost
completely shrouded in gloom.
The artist's deliberate use of black-and-white
film resulted in an aesthetically striking representa-
tion of emotional pain. The subjects visually appear
to suffer from the absence of color and light. The
gritty and realistic qualities of the photographs
succeed in expressing a deeply poignant message
where human words often fail. When examined
alongside each photograph, the narrative accounts
present suffering as an internally navigated experi-
21
ence endured by persons with chronic mental
illness. The darkness speaks of pain, loneliness,
and despair.
Stigma
In this photovoice exhibit, the shared experiences
of stigma began with a fundamental acknowl-
edgment of being different from the rest of society.
It is this perception of difference that distances the
subjects from the world around them and from their
own sense of self. This contributes to the further
deterioration of self-identity as the subjects struggle
with societal acceptance and self-acceptance. In this
study, subjects experienced stigma as a powerful
discrediting force that negatively impacts their
social and personal identities.
Categories of stigma were defined as “caged,”
“shadowed,” “derailed,” “detached,” and “afraid.”
The photos typically portray a central image framed
by a black circle. On first inspection, the effect this
produces is a focused narrowing of the image.
Symbolically, this represents society's narrow view
of mental illness. Society's inability to view the
entire picture of mental illness is also portrayed by
the shape of one black circle in particular. The
obstructed view of the subject creates an imperfect
and irregular circle that suggests the devastating
effects of stigma. This visual metaphor reflects how
persons with mental illness are often prejudged and
only viewed within the narrow confines of their
diagnosis, as if caged.
One subject described herself in terms of
isolation and failed to identify with those around
her as she felt forced to live on the fringes of
humanity. In telling of her own experience with
stigmatization, she said she felt as though she is
viewed as “not even human.” Another subject's
visual appearance seems to suggest feeling hidden
or unseen by those around him. The ambiguity that
encompasses the subject renders him an incomplete
man who is accustomed to being defined by his
illness rather than his person.
The intentional placement of one man's hands
out in front of his face creates a shadowed
menacing appearance that is both strange and
disturbing. He appears afraid. With his pale skin
and flat expression, the subject appears more
wraithlike than human. The unrelenting depression
has overcome the subject, leaving him waxen and
suspended in time, as if caged and detached from
others by his illness.
22
The devastating effects of schizophrenia are
displayed through a painfully exquisite photograph
of a man walking among a series of shadows.
Waiting directly before the subject is a tangled
shadow of what appears to be a fence that takes on
the semblance of a spider's web. This powerful
image, when allegorically combined with the
subject's narrative, tells a raw and poignant story
of a man placed in the shadows by society as he
experiences stigmatization. Within his narrative, the
subject spoke of isolation early on in the course of
his illness. He spoke of being a “loner” and knowing
that he was somehow “different” from other people,
as if left in the shadows and detached from society.
Another man is caught mid-stride as he walks
directly in front of a shadow of a tree unseen in the
foreground. As he steps forward, the subject's right
foot dissolves into the floor beneath him. This
image suggests a man whose life has become
derailed because of his illness.
A woman described her depression as a “total
void,” an experience that leaves her feeling detached
from others. Describing how her family had reached
a point “when they didn't want anything to do” with
her; the photograph communicates an existence
thrown off center, derailed, by the subject's illness.
A man described being afraid of losing his parents
and “not having fulfilled” his dreams or his life. It
seems that his fear of being judged is what leads him
to walk among the shadows, the photograph
blending with the darkness surrounding him.
Loss of Identity
At the very center of the mental illness experience
in this photovoice exhibit is a collective loss of
identity that is the culmination of the effects of
suffering and stigma. Data from the photographs
and narratives thematically converge at this point.
For the subjects in this study, mental illness has
served to rob them of their unique sense of self.
Unlike social roles based on occupation or educa-
tion, the distinction of being mentally ill was
imposed deliberately and without welcome. The
subjects in this study experience loss of identity as
they lose the ability to define themselves and instead
take on the ascribed persona of mental illness as
defined by others.
DISCUSSION
In the Fine Line photovoice exhibit, loss of
identity emerged as the central experience of
FLEMING ET AL
chronic mental illness, a product of the dynamic
exchange between the internally navigated experi-
ence of suffering and the externally navigated
experience of stigma. As the subjects navigated
these negative emotional experiences, they simul-
taneously surrendered their unique sense of self to
an artificial persona of mental illness. Cassell
(1991) described suffering as a state of severe
distress caused by an actual or a perceived threat to
the integrity or unity of the whole person. In many
cases, the visual and narrative details merged in
such a way that the relationship between suffering
and identity loss became blurred. Of particular
relevance to this study, suffering may disrupt an
individual's ability to communicate effectively.
Younger (1995) described suffering as the result
of individuals' loss of control over their own
existence. This threat to autonomy may then
disrupt the ability to narrate individual experience.
In the absence of a clear and discernable message,
persons suffering from chronic mental illness may
be unable to tell the stories necessary for others to
better understand and empathize with their experi-
ences. In contrast, a photovoice exhibit such as
Fine Line is able to capture and communicate the
mental illness experience in a way that empathi-
cally engages the audience.
In his classic work on stigma, Goffman (1963)
contended that a stigmatized individual is a person
who is disqualified from full social acceptance. It is
this perceived notion of difference that distances
subjects from the world around them and from their
own sense of self. Not surprisingly, this study
supports Goffman's view that stigma is a powerful
discrediting social label that radically changes the
way individuals view themselves. Unfortunately,
stigma often deprives persons with chronic mental
illness of the chance to tell their stories. Com-
pounding this problem, many stories that do get told
become lost within a lack of coherence. Chronic
and severe mental illness may disrupt an indivi-
dual's ability to construct a coherent life narrative.
This may be due to troubling psychiatric symptoms
and to loss of identity.
If persons with chronic mental illness are unable
to relate to others in narrative form, they risk
becoming an even more marginalized faction of
society (Baldwin, 2005). To this end, innovative
therapeutic methods that facilitate the construction
of coherent narratives capable of reaching a broader
audience might be developed. As this study
AN ETHNOGRAPHIC APPROACH TO INTERPRETING A MENTAL ILLNESS PHOTOVOICE EXHIBIT
demonstrates, photographs are just as capable of
carrying discernable messages as the stories
generated about them. This establishes the feasi-
bility of using a photovoice methodology as both a
research method and an intervention tool (Carlson
et al., 2006; Streng et al., 2004).
This study examined original museum gallery
guides as archival documents for data collec-
tion. There has been recent interest in, and
advocacy for, the use of such documents as
key sources of primary or supplementary data
in qualitative research (Miller & Alvarado,
2005). Unlike interviews, the documents in
this study existed before the investigator sought
to use them as data. As such, the data collected
from these documents provided an authentic
and rich source of information. The findings
from this study suggest the feasibility of future
studies using a photovoice methodology in a
psychiatric population.
Providing a context for narrative is an essential
component for overcoming the loss of identity at
the center of the mental illness experience. This
study also provides evidence to support the
development of patient-centered interventions
that acknowledge the personal experiences of
those suffering from mental illness. The quality
and dynamic nature of the nurse–patient relation-
ship situate mental health nurses in an ideal
position to use the findings of this study. Nurses
are capable of providing clients with the oppor-
tunity to tell their stories and with a listening
context that acknowledges the suffering. Attend-
ing to personal stories allows nurses to serve in
the role of healer by helping clients construct a
coherent narrative.
Although the findings in this study are impor-
tant, there are some important limitations. First,
the photovoice exhibit was not constructed
between the researchers and the subjects of this
photovoice exhibit. Thus, the findings are based
on artistic renderings rather than primarily
researcher-generated data. Second, the researchers
were not privy to demographic or clinical
information regarding the subjects. Third, the
findings are limited by the apparent focus on the
negative aspects of the mental illness experience
and do not account for the resilience, strength, and
healing that are aspects of the mental illness
experience familiar to many who care for
individuals with mental illness.
23
CONCLUSIONS
The findings of this study provide evidence that
living with chronic mental illness includes a
struggle confounded by suffering, stigma, and loss
of identity. This knowledge may serve as a
foundation for the development of therapeutic
patient-centered interventions for persons with
chronic mental illness. The use of photographs
and narratives provided a context that placed the
emphasis on the individual rather than on the
illness. Greater empathetic understanding of
the mental illness experience allows mental health
nurses to provide an improved quality of care and
thereby optimize health outcomes and quality of life
for a significantly challenged client population.
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