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The ORIGINAL Experience ARTICLES of Living With Chronic Mental Illness: A Photovoice Study Blackwell Malden, Perspectives PPC

XXX 0031-5990 USA Publishing in Psychiatric Inc Care

The Experience of Living With Chronic Mental Illness: A Photovoice Study

Noreen C. Thompson, RN, MSN, APRN-BC, Edward E. Hunter, PhD, Lorraine Murray, RN, MS, BC, ATR, Lisa Ninci, RN, BSN, BA, BC, Elaine M. Rolfs, RN, BSN, BA, and Leonie Pallikkathayil, RN, DNS, ARNP

PURPOSE.

This study aims to explore if

photovoice methodology can be used to enhance the level of empathy professionals feel when meeting a patient who carries a psychiatric diagnosis in any setting.
DESIGN AND METHODS.

This study used a

qualitative descriptive design. Seven adult patients were interviewed for 1 hr regarding photos that were taken to represent what it has been like to live with their chronic illness.
FINDINGS.

Noreen C. Thompson, RN, MSN, APRN-BC, is Psychiatric Consultation Liaison Nurse, Department of Nursing; Edward E. Hunter, PhD, is Associate Professor, Department of Psychiatry; Lorraine Murray, RN, MS, BC, ATR, Psychiatric Unit Educator, Department of Nursing (retired); Lisa Ninci, RN, BSN, BA, BC, is Psychiatric Unit Staff Nurse, Department of Nursing; Elaine M. Rolfs, RN, BSN, BA, is a graduate student in the School of Nursing; and Leonie Pallikkathayil, RN, DNS, ARNP, is Associate Professor, School of Nursing, University of Kansas Medical Center, Kansas City, Kansas.

his study was inspired by the Melva Jo Hendrix T Lecture, during the 2004 meeting of the International Society of Psychiatric Nurses. Dr. Susan McCabe presented the address that explained her use of cameras and photovoice in one outpatient setting. Dr. McCabe wanted to discover the meaning of having mental illness and used a creative and nonthreatening way to have conversations with persons who were suffering with chronic mental illness about their lived experience. The first author returned from that conference with a desire to replicate Dr. McCabes work, hoping to present the findings locally and nationally. The main objective of the current study was to explore if the photovoice methodology could be used to enhance the level of empathy professionals feel when meeting a patient who carries a psychiatric diagnosis in any setting. It seems ironic that we speak of the stigma of mental illness, and yet, health professionals are often biased as well. In her experience, the first author often had noticed that professional staff did not listen as well as they could to patients when they discovered these patients had concurrent psychiatric diagnoses. This often led to poor communication between professional healthcare staff and their patients. Therefore, it seemed meritorious to provide patients with a forum to tell their lived experience through photographs. We also asked them to tell the professionals what was lacking or advantageous in the patients day-to-day interactions with them.
Perspectives in Psychiatric Care Vol. 44, No. 1, January, 2008

Four major themes emerged: (a) feeling

misunderstood and invisible in the world; (b) attempting to gain control and be safe through various actions and activities; (c) making an ongoing effort to repair injured self-esteem; and (d) using various coping skills.
PRACTICE IMPLICATIONS.

Patients in this study

enjoyed the process of taking photos to help tell their story, and they were able to capture meaningful images that communicated their lived experience of dealing with a mental illness.
Search terms: Camera, chronic mental illness,

empathy, photovoice, psychiatric patients

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Often, psychiatric professionals think they know what their patients experience, but the literature points to a lack of understanding. Empathy is cited as an important component of the nursepatient relationship (Reynolds & Scott, 1999), but if we dont fully understand the lived experience of our patients, can we really be effectively empathic? A review of the empirical literature on nurse patient communication revealed that nurses tend to offer advice and provide information but pay little attention to the subjective experiences of their patients (Gallop, Lancee, & Garfinkel, 1990). One nursing study probed the psychiatric patient experience and also reinforced the need for professionals to understand the lived experience of having psychiatric illness in order to fully empathize with the patients (Muller & Poggenpoel, 1996). Empathy is a concept deeply rooted in and central to professional nursing. A brief review of the CINAHL database reveals over 1,000 articles that mention empathy (Walker & Alligood, 2001). Empathy assists the individual in restoring self-esteem, and empathy is built through the therapistpatient interpersonal process. Empathy allows the individual to integrate and rebuild aspects of the self to correct his or her identified problems (Kohut, 1971). Use of Photography in Research Photography has been used in research for decades. Hagedorn (1994) used photography with parents and families of children with chronic illness. In one of Hagedorns studies, parents were given cameras and asked to take pictures that symbolized the experience of caring for the child. Another study focused on chronically ill children who were asked to take pictures to represent what it was like to live with their illness (Dr. Ann K. Cobb, University of Kansas School of Nursing, personal communication, September 1999). Photovoice The photovoice concept was developed by Wang and Burris in 1994. Photovoice allows us to gain the
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possibility of perceiving the world from the viewpoint of people who are leading lives that are different from those traditionally in control of the means for imaging the world (Wang & Burris, p. 172). This approach values the knowledge put forth by those who have actually lived with mental illness. It entrusts cameras to the hands of people to enable them to act as recorders of their own story or lived experience (Fleury, 2002). Photovoice is also a participatory health promotion strategy in which people use cameras to document their health and work realities (Wang, 1999; Wang & Redwood-Jones, 2001). Photovoice has three goals ( Wang & Pies, 2004). First, it enables people to record their communitys strengths and problems. Second, it promotes dialogue about important issues through the use of photographs. Finally, it can be used to engage policy-makers. Lucy Flint-Gohlke, Curator of the Davis Museum and Cultural Center, Wellesley College, has stated Photo-voice enlarges the perimeters of health from the strictly medical to the psychological, economic and social conditions of a given community (Wang & Burris, 1994, p. 173). Research Study The Purpose The goal of this study was for professionals to gain insight into the inner world of their patients or clients, but the study may facilitate future photovoice projects aimed at policy change as well. The purpose of this pilot study was to identify what it is like for chronic mentally ill adults to live with their illness. This study was approved by the institutional review board. Setting and Sample This study was conducted at a Midwestern teaching hospitals psychiatric outpatient clinic. A purposeful sampling was done to select information-rich cases for in-depth study (Marshall & Rossman, 1999). Participants were recruited from a group of outpatients from the
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The Experience of Living With Chronic Mental Illness: A Photovoice Study

caseload of one of the authors. The selection criteria for inclusion were the following: that the participant was 18 years or older, had a psychiatric diagnosis, had been in psychiatric treatment for more than 2 years, and, in the judgment of the therapist, was able to participate and follow the data collection method. Thirteen potential participants consented to participate and accepted cameras, but only seven followed through and returned them. The participants of this study included two men and five women, ranging in age from 38 to 51 years, with primary diagnoses of bipolar disorder, depressive disorder, or anxiety disorder. Methods This study used a qualitative descriptive method. Because the intent of the study was to learn about the subjective experience of individuals, the qualitative method was appropriate to get the insider view (Agar, 1996; Denzin & Lincoln, 1994; Marshall & Rossman, 1999). The data collection took place from January 2005 to May 2006. One of the authors, the outpatient therapist, explained the study to potential participants and obtained informed consent. Participant rights were explained, and participants were told that not participating would have no adverse effect on their care. The therapist then gave each participant a disposable camera and a postage-paid, addressed, padded envelope in which to return the camera. The participants were told to take pictures to represent what it was like for them to live with chronic mental illness. They were told not to take pictures of people. Seven cameras were returned. The returned cameras had 1027 photos each to develop. The principal investigator of the study met with each participant who returned the camera. She interviewed the participants individually for about an hour to understand the meaning of the pictures. Each participant was asked to select four pictures and explain the meaning for them. The principal investigator discovered during the interviews that rigidly limiting the participants to only four
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photos would have stifled the interview process. Three participants wanted to discuss all of their photos. On average, participants discussed five photographs; the range was from two to nine. The interviews were taped and transcribed. The participants were given a copy of their photos and $10 for their time investment.

Each participant was asked to select four pictures and explain the meaning for them.

Data Analysis The research team included two clinical nurse specialists, one psychologist, a psychiatric nurse in the role of research intern, a psychiatric nurse practitioner student, and a psychiatric nursing faculty member who was experienced in qualitative research methods. The research intern nurse transcribed the interview tapes. In order for all team members to have an understanding of qualitative method and content analysis, all reviewed Coffey and Atkinson (1996), Making Sense of Qualitative Data. The team discussed various methods described in the Coffey and Atkinson book. The team often reaffirmed the intent of this study, which was to learn the lived experience of the participants and, therefore, use the participants words as much as possible. The team agreed on the levels of coding as verbatim, codes, categories, individual story, and overarching themes. All except the psychologist independently completed content analysis of the data. The team met after four interviews were coded and then again after seven interviews were coded. Each member read and re-read the interview transcripts to get a sense of the whole. Special focus was given to the explanations of each photograph. We highlighted meaningful segments, either phrases or sentences, and
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gave a code on the margin. Codes were later collapsed into categories and finally to themes, individually and collectively. We summarized each participants story and then concluded the overarching themes. Team members kept each other true to this structure of coding. Although personal styles varied, the team members reached similar conclusions on each participants story and overarching themes. Credibility of the Method Bracketing is a concept in qualitative method where researchers try not to be influenced by their bias. Self-awareness is of utmost importance. During team discussions of coding, bias surfaced in the form of previous knowledge of a client, strong positive emotional response to a participant, and, in one case, a negative response, but team members were quick to point this out, or, in some cases, the researcher recognized it without prompting from team members. Discussing the coding in team meetings helped keep all members honest and self-aware. After each team discussion of the data analysis, the principal investigator wrote a summary of the discussion, decisions made, and collective agreement of codings. Each team member reviewed these summaries and added to their completeness. After the individual data analysis and team discussions, one clinical specialist member of the team listened to each interview tape to ensure the accuracy and completeness of the transcriptions. Most importantly, the listening of the tapes helped to determine if our analysis was true to the subjects tone and intent of the personal meaning. Results The salient story for each participant is written first; then, the overarching themes are discussed. The subjects first names have been changed, but the age, gender, and diagnosis remain true in the reporting of the results.
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Figure 1. Annette: I Am Not Seen.

Individual Stories Annette Annette is a 49-year-old Caucasian woman who had been diagnosed with generalized anxiety disorder and obsessivecompulsive disorder. She has a history of abuse and betrayal, resulting in a strong need for safety. She withdraws into her bedroom for 14 hr each day in order to feel safe. She described feeling invisible, faceless, and misunderstood. Its like I am there, and I try to come out, and I am asked a question, and I try to answer it. Its just like it is passed over me, and the person starts talking to someone else. I am not seen (see Figure 1). Annette expresses a need to be acknowledged; however, her frequent withdrawal from others might suggest ambivalence regarding being seen. Annette questions why she has mental illness without finding a satisfactory answer. The tone of her interview indicates that she feels alone, grim, and has a very unhappy existence. She is focused on the past and the present. She would like healthcare providers to know that she is more than a diagnosis, and she wants them to see her as an individual. I wish the rest of the world could see that seeking help for mental
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The Experience of Living With Chronic Mental Illness: A Photovoice Study

health is not a bad thing or something to joke about or judge me. She expressed positive regard for her current therapist and uses positive coping skills, such as humor. If I can make a joke about whats wrong with me, it makes me feel lighter. She shared a photo of a tee shirt she wears that has The voices arent real but they have some good ideas written on the front. You cant be negative all the time, you know. She uses negative coping skills, such as withdrawal, and experiences dissociation when she feels threatened. In my family nobody really identifies with my problem. It isnt talked about, and that is hard.

Figure 2. Bob: In My Computer I Keep a Journal . . .

I wish the rest of the world could see that seeking help for mental health is not a bad thing or something to joke about or judge me.
to one of my church families (see Figure 2). His therapist learned that Bob had devised this emotional self-monitoring diary while reading the interview transcript. Bob is focused on the present. He would like healthcare providers to know that medications work differently for different people and to be aware of how different medications interact. Carla Bob is a 42-year-old Caucasian man who had been diagnosed with depression and obsessivecompulsive disorder. He values his self-identity as a responsible contributor and uses healthy coping skills, such as tracking his symptoms and forming honest, supportive relationships. The tone of his interview indicates adaptation to limitations, functioning from personal strengths rather than weaknesses, and a strong connection with people. And I am appreciative of the deacons giving me this responsibility to fix things around the church and help them in other ways. In my computer, I keep a journal on a disc and I have designed a scale from zero to ten. Nine to ten is a good day. Eight to seven is average and so on. I try to update it periodically. I write in there like I am talking
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Bob

Carla is a 48-year-old Caucasian woman who had been diagnosed with bipolar affective disorder. She struggles with fear and the need for safety. In her past, she was in abusive situations where she did not have control, but now she has gained control over some situations in her life. These are the things people have used on me physically to control me (see Figure 3). She wanted to show me all the tools of abuse so I would understand why she suffers with depression. Carla wants to be her authentic self rather than what she feels others want her to be. One example was a photograph of four glasses: four were the same, and one was unique. She described her experience as follows:
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Figure 3. Carla: These Are the Things People Have Used on Me Physically to Control Me.

Figure 4. Carla: . . . I Would Be Trying to Be Like Another Person, and It Became Confusing and Very Unhappy; and So I Decided to Be Myself.

I kept trying to fit in, but one day I realized that if I remain this glass and quit trying to be one of these, then thats OK; because as long as I keep trying to pretend to be one of these, I am not being my authentic self. This is my sister-in-law, my friend, and my neighbors, and I would try to do what they wanted me to do; but then the next week, I would be trying to be like another person, and it became confusing and very unhappy; and so I decided to be myself (see Figure 4). Carla demonstrates successful coping by managing some obsessive traits that were bothersome. Religious faith is important to her and is a source of strength. The tone of her interview indicates ambivalence; she is gaining mastery and self-efficacy, and yet she suffers with sadness. She is focused on the past and the present. Carla is unable to forgive her father who was the original abuser. She would like healthcare providers to know that children need more mental health intervention so that they will have fewer problems when they are older.
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Dave Dave is a 42-year-old Caucasian man who had been diagnosed with autism and depression. He is a very concrete thinker, and he focuses mainly on things he likes, such as somewhere to go and staying busy. Dave wants a job so that he will have more money. He has a lady friend that he values. The tone of his interview indicates good feelings and a focus on the present. His past support was his grandmother. He would like healthcare providers to help him meet his immediate goals. If only Dr. X could help me find a job. Eileen Eileen is a 29-year-old Caucasian woman who had been diagnosed with posttraumatic stress disorder and depression. She has experienced extreme trauma, including rape, and things in her environment frequently remind her of that traumatic experience.
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The Experience of Living With Chronic Mental Illness: A Photovoice Study

Figure 5. Eileen: She Substitutes Tattoos and Piercings for Past Cutting Behaviors

Francine Francine is a 51-year-old Caucasian woman who has a borderline IQ and suffers with depression. She is frustrated by everyday problems. She needs people to respond to her needs and is frustrated when they do not. She feels no one really listens to her. A mitigating factor is that she is mentally challenged, according to her own report. The tone of her interview indicates unhappiness; however, she enjoys playing games on the computer. She is focused on the recent past and on the present. She would like healthcare providers to know that they need to listen to their patients because a lot of them dont. Gina Gina is a 45-year-old African American woman who had been diagnosed with bipolar disorder. She would like to be independent, but instead she must rely on other people. She has difficulty maintaining relationships because of her mental illness, and she also has difficulty completing tasks. She took a few photos of the sky. She finds peace and comfort in the sky, quietness, and thoughts of God. When I feel alone, I look up at the sky, and I talk to God. Thats a calming thing for me. Once I heard a deep voice speak to me, and I just knew that God was up there. Now I know I cant hear Gods voice, but back then, I did. She asks why she has mental illness. There is an interplay between her medical and mental illness that the team members could not decipher, but her lived experience is of great physical pain, suffering, dependence, and resignation to a life filled with inconvenience and being misunderstood. The tone of her interview is conflictual, indicating both hopefulness and helplessness. She would like healthcare providers to know that she wants respect as a human being and not to dismiss her concerns when they discover that she has a mental illness. I hate to tell them (doctors and nurses in the emergency room) what I am on. Then they ask, Why are you on that medicine? Then
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She has a need to take back control and to have mastery over her life and feel normal. The need to feel safe is paramount, and Eileen copes by relying on her dog to increase her skill at recognizing when she is safe. She also keeps items in every room of her home (e.g., a screwdriver, hammer, cell phone, knife) to be used for self-protection. Eileen suffers guilt over her compromised performance of the parenting role. She relies on her family for support, and she is empathetic of the burden this places on them. She uses creative writing as a positive coping skill, and she substitutes tattoos and piercings for past cutting behaviors (see Figure 5). The tone of her interview indicates hopefulness, and she is actively engaged in therapy. Eileen is focused on the past, present, and future. She would like healthcare providers to know that she needs them to explain things in a way that she can understand and that enhance her receptiveness. She related a time when she was so depressed and thinking of a way to commit suicide, but when this friend called she changed her mind. Describing that friend she stated, there is always caring in her voice.
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I fess up. When I say bipolar, you see the whole face change. Identified Themes Need to Be Valued The main theme was that participants frequently experienced being misunderstood and invisible. They wanted to be heard, valued, treated as important, understood, joked with, and generally to be seen as individuals rather than to be seen simply as a mentally ill person.

Need for Self-Esteem The third major theme was the ongoing effort each participant employed to help them repair injured self-esteem. Participants faced challenges ranging from common to extreme and unusual. Regardless of the intensity of the problem, participants were frequently overwhelmed and frustrated. Another response was quiet, sad resignation. Often participants had to fight for the things they needed. The participants conveyed a feeling of life being full of obstacles, and that survival was similar to fighting an uphill battle. Improvements in mental health occurred, but they were often incremental and required a lot of personal investment and energy. Two of the participants mentioned that each time they faced something challenging in therapy, their symptoms worsened. Use of Varied Coping Skills The fourth theme was that participants varied in their use of coping skills. Chosen skills were generally positive, which may be attributed to the fact that these participants were functioning at a level high enough to participate in this study. Other coping strategies were negative, to the extent that at one point the team questioned whether a participants diagnosis was used to explain or excuse negative coping skills. Strategies for coping varied widely with little commonality among participants. One coping factor that was mentioned with some frequency was a faith in God. Need for Support The need for support, both physical and emotional, was common. The participants needed someone to talk to as well as someone to offer them assistance (e.g., in the form of transportation). The benefits of having a supportive relationship with a therapist were mentioned repeatedly. Participants reported that lack of support was a significant hindrance and a source of frustration. They wanted assistance, understanding,
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The main theme was that participants frequently experienced being misunderstood and invisible.

Need for Control, Safety, and Mastery The second theme was the need for control, safety, and mastery, both physical and emotional. A history of abuse was very common among this group of participants, perhaps because they were recruited from a clinic known for working with clients with psychogenic seizures. In fact, four of the five female participants mentioned having these nonepileptic seizures, although neither of the males described these seizures. This experience of having been abused amplified participants feelings of being unsafe, and they responded with an increased need for safety. This need for safety manifested in positive as well as negative coping strategies, affecting the participants choices and behaviors.
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The Experience of Living With Chronic Mental Illness: A Photovoice Study

and respect from family members, friends, and support staff. Why Me? Several of the participants questioned why they had a mental illness. The Why me? question reflects the lack of a belief system that explains illness and the meaning of it in ones life. Even when they were able to attribute it to an event in their past, there was a sense of unfairness, anger, and regret. Interestingly, none of the participants specifically attributed their mental illness to a genetic predisposition. Need for Activity A few of the participants mentioned, directly or indirectly, a desire to stay busy. The two males both filled their schedules as much as possible, and Eileen mentioned that when shes home alone, sometimes the writing is the only thing I could do. Gina stayed busy because most of my life is spent here at the hospital. Discussion Several interesting features of using photographs were noted. For example, the photographs revealed information about participants at two different points in time. One was the time that they took the photograph, and the other was the time that they discussed the photograph. Francine, for example, was frustrated with her personal attendant while she took the photographs, but at the time of her interview, she had moved on to other issues, and said, Its been so long, I am having trouble remembering why I took these pictures. Another feature was that many photographs were of things already present and assembled in the participants environment, but a few participants manufactured scenes to photograph. For example, Annette drew a question mark, and photographed it
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to ask Why? Carla gathered things that people have used on me physically to control me. Eileen took photographs of items she had stashed around the house or carried on walks to be used for self-defense. There may be some significance to why or which participants chose to photograph manufactured versus unmanufactured scenes. Many of the individual themes and overarching themes were not surprising, although actually looking at the photographs while hearing or reading the participants thoughts was an emotional experience at times. In fact, Wang and Burris, the two individuals who designed the photovoice method, coauthored an article with Ping (1996) in which they named empathy as a valuable outcome. They wrote, Anthropology is ultimately carried out to increase our empathy. As our project demonstrates, photo novella creates the opportunity for village women to promote outsiders empathyrather than paternalism, condescension or idealismtoward their lives. Documenting their health and work realities on their own terms, these village women can educate health policymakers, researchers, and other professionals about what is best about their lives and what needs to change (p. 1399). That stated, as team members, we noticed that our emotional reactions could color our analyses. This was true for the team member who met with and interviewed each participant, and it was true for the rest of the team members who relied on the written transcripts. When we felt strong connections or disconnections, we instinctively began to develop biases about individual participants. One team member identified this as our own transference process, whether positive or negative. Using the bracketing concept discussed earlier, we worked to overcome our transferences through self-awareness and with the help of group discussion. Empathy that manifested in transference made it hard to listen objectively. When we projected our own selves into the interview, we gained empathy, but we became less attuned to what the participant was telling us. Another team member pointed out that as
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professionals interacting with clients, we have the power to influence how they feel about themselves. Our empathy and our transference are likely to affect their self-esteem. In short, we need to remain aware of our own projections into the professionalclient interaction, and we need to remember that the client wants to be seen and heard as an honest-to-goodness individual person of value, not as a shiny diagnosis that reflects the image of the person they are interacting with. If bias crept in during the objective research process despite hypervigilance to bracketing our biases, it was an indication that we as professionals and researchers must be on guard constantly and have structures in place to provide checks and balances. Our team process helped us to overcome our momentary lapse to bias. Lessons Learned for Future Photovoice Studies For future studies, we would explore having the consent include the ability to take photos of people. We excluded people to keep it simple, but it limited the participants disclosure of how the most important people in their lives interact with them. Perhaps deciding how the photos will not be used (e.g., used for the data collection but not for posters, publications, or presentations) could have been written into the consent form. We would use a more inclusive process of recruiting subjects in future studies, such as advertising the study in the waiting room of the outpatient clinic in hopes of having a more diverse ethnic and age demographic. The major limitation of this study was limited funding. This research was accomplished through the support of the Hospitals Department of Nursing. The department paid for a staff nurse to act as a research intern. The intern was paid for 144 hr over 18 months and was responsible for the transcription of all the interviews. In addition, she attended all team meetings and contributed to the data analysis. The research team paid for the cameras, printing of the photos, and the participants stipends.
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In the future, with a funded study, we would send out postcard reminders and include a data manager. This study demonstrates that research is possible with little funding within the hospital setting when you have the support of the Chief Nurse Executive and Faculty. Our Nursing Research Council expects that the interns will present the research or evidencebased project at a nursing conference. Our intern will be attending the American Psychiatric Nurses Associations conference in October 2007 to present our poster. This example of multidisciplinary research was enjoyable for the participants as well as the researchers. Our hospital received Magnet accreditation in 2006. Conclusions One of the unexpected benefits we discovered was the way that the participants viewed their assignment. They seemed to see it as a value-rich assignment, which actually enhanced their sense of being valued by others. Our results support that there is a need for further research in methods used to educate and support the patients supportive circle. There is also a need for continued societal education about mental illness. Patients in our study described being invisible not only to health professionals but to their own family members. That is an additional cause of the patients suffering; yet it must be acknowledged that the family members are also under considerable stress and, therefore, may find it difficult to be empathetic even with added support and education. We hope that there will be other researchers and clinicians who will further explore the use of cameras and/or photovoice in their work with the psychiatric patient population.
Author contact: nthomps2@kumc.edu, with a copy to the Editor: mary@artwindows.com References
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The Experience of Living With Chronic Mental Illness: A Photovoice Study

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Reynolds, W. J., & Scott, B. (1999). Empathy: A crucial component of the helping relationship. Journal of Psychiatric Mental Health Nursing, 6(5), 363370. Walker, K. M., & Alligood, M. R. (2001). Empathy from a nursing perspective: Moving beyond borrowed theory. Archives of Psychiatric Nursing, 15(3), 140147. Wang, C. (1999). Photovoice: A participatory action research strategy applied to womens health. Journal of Womens Health, 8(2), 185192. Wang, C., & Burris, M. A. (1994). Empowerment through photo-novella: Portraits of participation. Health Education Quarterly, 21(2), 171 186. Wang, C., & Pies, C. (2004). Family, maternal and child health through photovoice. Maternal and Child Health Journal, 8(2), 95102. Wang, C., & Redwood-Jones, Y. (2001). Photovoice ethics: Perspectives from the Flint photovoice study. Health Education and Behavior, 28(5), 560572. Wang, C., Burris, M. A., & Ping, X. Y. (1996). Chinese village women as visual anthropologists: A participatory approach to reaching policy makers. Social Science Medicine, 42(10), 13911400.

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