By Molly Wimbiscus, MD
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For many adolescents hospitalized for mood or anxiety disorders, standard psychiatric interventions delivered through the traditional medical system leave too many needs unaddressed. Moreover, behavioral health providers’ lack of access to community youth programs often leaves few, if any, ways to follow the progress of our adolescent patients after they are discharged. To try to fill some of those gaps, I recently developed the Photography Perspective Project, a novel longitudinal initiative mixing art therapy, group therapy and community-building for a small group of adolescents with recent psychiatric hospitalizations.
Targeting needs missed by standard interventions
Soon after I joined Cleveland Clinic’s Center for Behavioral Health, my encounters with adolescents in the inpatient unit made me wonder how we could better provide supportive community services to these young patients who too often end up rehospitalized despite adequate medication doses and intensive levels of psychotherapy, group therapy and dialectical behavior therapy. An interest in community mental health and my own positive experience with youth groups as a teenager prompted me to think about the possibility of a community-building program.
I hoped to address a number of unmet needs. First was the need for continuity in these adolescents’ lives. Rather than just a six- or 12-week intensive outpatient program, we needed a more longitudinal project — one that would be a fixture over many months. This would promote the parallel goals of engagement, relationship-building and mutual support, allowing the adolescents to get to know each other over time and beyond the context of their mental illness.
That’s where having an element of creative expression came in, which would be fun and give us something else to focus on. I chose photography as the vehicle because it is accessible and easy to share. Also, the adolescents would be developing a skill that might be valuable down the road and would be good for self-esteem and self-expression right away.
Photography also provided technical themes that could be used as metaphors for life experiences, such as view, depth, balance, contrast, light, shadow and perspective. Rather than dwelling on inward struggles, the project would focus on experience and self-reflection by capturing the participants’ connectedness to the world at large. This would serve the project’s goal of linking teens more closely to their physical space and urban environment.
A final goal was to have good adult supervision to provide further continuity via stable role models. This was provided by me and our several adult volunteers (primarily occupational therapists) who participated in the project’s weekly classes and monthly field trips.
Making the project happen
With $3,000 in grant funding, we proceeded with the project in mid-2010. We invited adolescents hospitalized at Cleveland Clinic for mood, anxiety or adjustment disorders during the prior six months. Eight adolescents, ages 14 to 17 and mostly from urban neighborhoods, agreed to participate. They were given a digital camera and notebook and asked to record and reflect on their personal environment.
The teens met weekly from November 2010 to July 2011 for classes covering a new photographic technique each week, took pictures (see examples on opposite page) and talked about their feelings. Photos were shared on a free private website.
The weekly classes were supplemented by monthly Saturday field trips, led by me and one of our adult volunteers, to sites of interest around Cleveland, such as gardens, urban landmarks and historic cemeteries. The trips were a great opportunity for the teens to take photos and build bonds with each other in real-world settings. The trips also underscored that the world is far bigger than the teens’ home lives and that these special places are theirs to visit whenever they need them.
At the end of the eight months, the participants presented and sold prints of their photos in a show at a local art gallery. Participants continued other ongoing treatments throughout the project.
Outcomes: Qualitative trumps quantitative
We evaluated the project’s effects in several ways. All participants underwent serial ratings on psychometric scales and clinician evaluations at the project’s start, four months into it, at project completion and a year after completion.
While some teens showed modest improvements in their scale ratings, none were statistically significant. However, the project yielded several readily observed qualitative improvements: The teens’ socialization improved notably, their peer interactions became more positive, and they grew more expressive. Many of the teens remain in touch with (and supportive of) each other and with me a year after the project ended, and they still occasionally post photos to the project website.
The teens’ reflective notebook entries consistently testified to the program’s value to their quality of life and their sense of fulfillment through self-expression (see example above).
These findings underscore the need for careful planning of appropriate qualitative research measures in future offerings of the project (no formal qualitative measures were included in the initial project assessment).
Discussion and lessons learned
Although photography therapy is a growing field, I know of no other similar longitudinal projects using photography as a therapeutic social intervention for teens suffering from mental illness.
While the Photography Perspective Project’s quantitative effects were modest, it offered a number of benefits that may distinguish it from more traditional interventions for this population. The project’s community-building effects were clear and endured after the project ended, which participants reported is valuable to them. The project also provided the teens with a tangible skill they can feel good about and may one day use in the workplace. Finally, it focused on the teens’ strengths and, unlike some outpatient programs, let them open up about their psychiatric histories on their own terms and timetables, often several months into the project.
One reason this type of project may be largely unprecedented is the challenge of obtaining insurance reimbursement. Our project was funded by a one-time grant, and we are now exploring funding options for repeating the project with new cohorts. One approach for gaining reimbursement may be to structure the program as group therapy and have it run by an occupational therapist, but such a strategy has yet to be tried.
Here is additional advice for others considering this type of project:
Make sure you have strong support from your department and institution. This is critical in light of the resource challenges typical for a project like this. Cleveland Clinic provided free transportation for some field trips, complimentary printing of the photos for the gallery show and similar forms of invaluable in-kind support.
Don’t underestimate the work involved, which amounts to 20 to 30 hours per month, plus the up-front planning time.
Fully commit to the project from the start. If the project peters out midway through, the vulnerable teen participants will be left stranded precisely when they need consistency the most. Make sure you have an adequate supply of committed adult volunteers who care about teens, mental health and photography. While photographic skill is desirable (one of our volunteers is a devoted amateur photographer), commitment to making a difference is more important.
Involve participants’ families. Future iterations of our project will include earlier family education on exactly what the project involves and ways parents can more actively support their child’s progress.
From the notebook of a Photography Perspective Project participant:
“After I got out [of the psychiatric ward], I got a phone call about this photography class. I was really happy when I found out. I was already into taking pictures there for a long time. Ever since I got in this class, I have become a more outgoing woman, and it is easier for me to make friends. When me and the other participants started this class we were all strangers to each other, now we are like family. They are everything to me. This class made my life amazing.” ~ T., 15 years old
Dr. Wimbiscus is an associate staff member in the Center for Behavioral Health and the Department of Psychiatry and Psychology specializing in child and adolescent psychiatry. Her interests include local urban education, community development and mental health, and medical humanities. She can be contacted at 216.444.8674 or firstname.lastname@example.org.