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A brief history of therapeutic photography

As early as the mid-1800s, Victorian era doctor Hugh Welch Diamond turned a camera towards his psychiatric asylum patients as a diagnostic and record keeping tool. More radically, he suggested using photographs as a form of therapy; portrait photographs represented a self that patients could attempt to reconcile with.2 While not specifically focused on photography, Adrian Hill first formally conceptualized the term “art therapy” in 1942, having served as a war artist during World War 1 and using art as therapy during his own recovery from tuberculosis in 1938.3 In some cases, photography has reached beyond being a therapy, becoming a mechanism for self-realization and self-actualization. For instance, prolific landscape photographer Ansel Adams saw the medium as a tool to realize the “deeper reality of things”, profoundly conveying “the spiritual in art”.4 Adams believed that “all should be encouraged to reveal themselves, their perceptions and emotions, and to build confidence in the creative spirit”; for him, photography was the means to build this confidence.5 Iconic street photographer Fan Ho, with his dramatic compositions of light and shadow, initially started taking pictures to relieve his headaches; with his photographs, he described his need to express “what [he felt] at the time and what [was] in [his] heart […] something along the lines of longing”.6 

In the modern day, photographers continue to use photography as a means of therapy. Gabriel Isak puts forward minimalist and surreal landscapes with anonymous subjects and cold colors, exploring his experiences with depression.7 Christian Hopkins’ images focus on the vulnerability of Major Depressive Disorder, including themes of loneliness and lethargy.8 And the surreal, yet hyperrealist works of John William Keedy portray his struggles with his diagnosis of anxiety disorder, as he challenges the stigma of mental illness.9

Photography for anxiety, depression, and other conditions

Whether cameras or photographs are used as therapeutic tools, a variety of clinical evidence points to the efficacy of photography in helping treat mental health conditions or improving mental wellness.

In a study involving 10 dementia caregivers being given cameras to document what caregiving meant to them, significant decreases in caregiver burden and depressive symptoms were seen.10 A study of 14 outpatients with chronic schizophrenic or psychotic disorder found significant reductions in levels of depression and general symptoms as well as significant improvement in cognitive abilities and functionality, when photo therapy was utilized.11 When told to take four pictures every week over the course of four weeks about what made them happy, a study of college students found significant improvements in Beck’s Depression Inventory and Beck’s Anxiety Inventory.12 Taking pictures may allow patients with psychotic disorders to overcome verbal barriers in order to communicate their emotions.13

Beyond exposure to photography itself, even photography related experiences may assist in improving clinical symptoms. In children with diplegic cerebral palsy, basic photography training was found to significantly increase health-related-quality-of-life, life satisfaction, and self-esteem compared to a control group.14 In another study, featuring a unique “Positive Photo Appreciation” program combined with positive psychotherapy, featuring appreciation and collage production sessions in addition to photography sessions, significant improvements were noted in geriatric patients in regard to depression and psychological distress scales, even when tracked with 3 month follow-up; furthermore, participants found the photography activities to be fun and voluntarily organized similar activities after the study.15 When enrolled in a 6 week workshop teaching basics of photography, veterans receiving outpatient mental health treatment created a 6 image portfolio expressing the theme of their personal recovery; Likert scale questionnaires scores significantly increased, indicating that photography may improve “personal reflection and organization of thinking”, in addition to promoting “recovery discussions, communication, social support, and sense of purpose”.16

A New Frame of Mind

The art and aesthetics of photography inspire both those taking the photographs and those viewing them. The near-ubiquitous nature of smartphones means that many, if not all, carry professional photography capability in their pocket, simplified to tapping a virtual shutter button. Perhaps beyond being an accessible tool for art, photography can help to promote mental wellness and, in addition to other pharmacological and/or non-pharmacological treatments, assist with easing symptomatic burden for patients with psychiatric illness. 

Works Cited

1. Nicholls B. Only 7.5% of photos are taken with cameras – phones now rule photography. Digital Camera World. 2024. https://www.digitalcameraworld.com/news/rip-cameras-925-of-photos-are-now-taken-with-smartphones

2. Pearl S. Through a Mediated Mirror: The Photographic Physiognomy of Dr Hugh Welch Diamond. History of Photography. 2009/06/29 2009;33(3):288-305. doi:10.1080/03087290902752978

3. Bitonte RA, De Santo M. Art Therapy: An Underutilized, yet Effective Tool. Ment Illn. Mar 4 2014;6(1):5354. doi:10.4081/mi.2014.5354

4. Hammond A, Adams A. Ansel Adams: Divine Performance. Yale University Press; 2002.

5. Kaimal G. The Expressive Instinct: How Imagination and Creative Works Help Us Survive and Thrive. Oxford University Press; 2022.

6. Ho F. FAN HO, Hong Kong Master Street Photographer #1. In: Wang-Lee E, editor.: Leica Liker; 2013.

7. Isak G. Behind The Artwork – A focus on Gabriel Isak. In: Fuggetti C, editor.: Collater.al Web Magazine; 2019.

8. Noorata P. Young Photographer Takes Surreal Self-Portraits to Cope with Depression. My Modern Met. 2024. https://mymodernmet.com/christian-hopkins-photography/

9. Keedy JW. A Life Of Anxiety Documented. In: Singh M, editor. Health Shots – Your Health: National Public Radio; 2014.

10. Wharton W, Epps F, Kovaleva M, et al. Photojournalism-Based Intervention Reduces Caregiver Burden and Depression in Alzheimer’s Disease Family Caregivers. Journal of Holistic Nursing. 2019;37(3):214-224. doi:10.1177/0898010118801636

11. Buyukgok D, Celik Aypak O, Cıkrıkcılı U, Eren N, Ucar Isaret S. The Effect of Art Group Psychotherapy with Photograph in Chronic Psychiatric Disorders: A Pilot Study. European Psychiatry. 2017;41(S1):s774-s774. doi:10.1016/j.eurpsy.2017.01.1464

12. Tourigny L, Naydenova IN. Using Therapeutic Photography Techniques to Increase the Wellbeing of College Students. Journal of Counseling Psychology. 2020;3(1)

13. Moretti V, Brunetti C, Candaten A, et al. Take a picture! The role of visual methods in understanding psychiatric patient’s everyday life. Acta Biomed. Jul 29 2021;92(S2):e2021028. doi:10.23750/abm.v92iS2.11945

14. Alkan H, Topuz O, İnce B, Kapıkıran Ş. The Effects of Basic Photography Education on Quality of Life, Self-Esteem, Life Satisfaction and Moods in Children with Diplegic Cerebral Palsy: A Randomized Controlled Study. Physical & Occupational Therapy In Pediatrics. 2021/12/01 2021;42(1):1-11. doi:10.1080/01942638.2021.1923613

15. Ishihara M, Saito T, Sakurai T, Arai H. Sustained mood improvement by the positive photo appreciation program in older adults. Int J Geriatr Psychiatry. Jun 2021;36(6):970-971. doi:10.1002/gps.5493

16. Quaglietti S. Using Photography to Explore Recovery Themes With Veterans. Journal of Creativity in Mental Health. 2018/04/03 2018;13(2):220-230. doi:10.1080/15401383.2018.1425174

Strategies for Success and Health

1. The Transformative Power of Exercise: Being immersed in the relentless schedule of medical school often feels like a 24-hour commitment to studying. In such a scenario, incorporating activities like exercise might seem like an unnecessary diversion, potentially eating into precious study time. This is a challenge I’ve faced and continue to navigate through my medical school journey. However, integrating exercise into my routine has been nothing short of transformative, both for my mental and physical well-being. It’s not an exaggeration to say that it has been a lifesaver in these intense three years of medical training. 

*Go the extra mile* In addition to exercising, take the extra step to choose healthy snacking while studying.The usual go-to snacks for long study sessions — large bags of chips, sweets, and other high-salt, high-fat options — are temptingly convenient but far from beneficial in the long run. Replacing these with healthier alternatives like carrots, low-salt/fat snacks, smoothies, and an assortment of fruits and vegetables has been another game-changer. These healthier choices contribute not just to physical health but also to better concentration and stamina during long study hours.

2. Prioritize Hobbies Like Studying: In the high-pressure environment of medical school, it’s common to internalize a sense of guilt for engaging in activities outside of studying. This is a mindset I had to actively unlearn. Recognizing that hobbies and leisure activities are not just frivolous pastimes but essential components of a well-rounded life was crucial. So, go to the movies, try a new restaurant, or travel to a friends house to hang out. Choosing at least one leisure activity to do a week, can make all the difference. 

*Go the extra mile* In the relentless and high-stress environment of medical school, the concept of taking an entire day off each week to decompress can seem daunting, almost impossible. As someone who has navigated the rigorous demands of medical studies while managing personal health issues, I understand this challenge intimately. Yet, I’ve discovered that dedicating one day a week to complete rest, relaxation, and enjoyment is not just beneficial, it’s transformative. Initially, the idea of taking a full day off seemed impractical to me. However, over time, I’ve realized that this practice is crucial for maintaining my health, preventing burnout, and actually improving my performance in medical school. It’s a reminder that success in this demanding field requires not just hard work and dedication, but also regular periods of rest and disengagement. This balanced approach has been a key factor in my ability to continue pursuing my medical career despite the additional challenges posed by my health.

3. Being Adaptable: Having a type A personality often means a preference for structure, order, and meticulous planning. This trait, while beneficial in many aspects of medical school, can also become a hurdle, especially when it comes to adapting to unexpected changes or health needs. As someone with this personality type, I’ve often found it difficult to deviate from my meticulously set schedules. My journey through medical school, compounded by my experience as a breast cancer survivor, has taught me the crucial lesson of adaptability. Understanding that my body has undergone significant trauma meant acknowledging that I couldn’t always keep up with the same intensity of study as my peers. My susceptibility to illness and chronic fatigue required a reevaluation of how I approached my studies. Understanding this, I had to embrace flexibility. Knowing that it’s okay to take things slower or seek accommodations if needed.

​​4. Practicing Self-Compassion: As a medical student who has faced significant health challenges, I’ve learned the hard way that being hard on myself only exacerbates stress and hampers progress. Adopting a more compassionate and gentle approach has not only improved my mental health but also enhanced my academic performance. It’s a continuous process, one where I constantly remind myself that being understanding and soft with myself is not a luxury, but a necessity. This approach has allowed me to navigate the demanding world of medical education with greater ease and resilience.

The path through medical school while managing health issues is not a straight line. It demands resilience, adaptability, and a strong support system. Remember, taking care of your health is not a detour from your medical journey; it is a vital part of ensuring you can become the best healthcare professional you aspire to be.

Call to Action:

Are you a medical student navigating similar challenges? Share your experiences and strategies in the comments below. Let’s build a community that supports and uplifts each other through this journey. Remember, every individual’s journey is unique, and what works for one person might not work for another. It’s important to find the balance and strategies that work best for you.

The first idea that may help placate burnout is an acceptance that the nature of life is simply absurd. Many of us go into the field of medicine because it is a career laden with meaning and purpose. The actions we take as physicians aren’t in the name of a faceless conglomerate but rather (largely) in service of the greater good of the individuals we call our patients. We can derive meaning from our patients and their stories. However, this motivation may be a double edged sword as we can become excessively attached to the notion of meaning. When the inexplicable happens, our thoughts circle in an attempt to find some meaning, “Why did the patient code? Was it my fault? Did I do everything possible?”. For our well-being, and that of the patient it may be necessary to potentiate our love for meaning with a healthy dose of absurdism. Acknowledging there isn’t always a bigger meaning, or takeaway. We can do our best to learn and practice but at the end of the day there is only a limited amount of control and influence we have over any given situation. The nature of life is so absurd that sometimes things will happen despite our best efforts, and the understanding that our control over life is limited is a painful but simultaneously liberating realization that can enable us to focus more on what we
can do next time as opposed to what we couldn’t do last time.

Second is the idea of embracing this absurdity and finding joy in it. In Camus’ essay he focuses on the brief moment in which the boulder rolls down the hill, and Sisyphus makes the decision to go back down for what must be the thousandth time, and decides to push it back up. He writes “At each of those moments when he leaves the heights and gradually sinks towards the lairs of the rocks, he is superior to his fate. He is stronger than his rock”. For Sisyphus, a radical acceptance of his fate and the present moment is his only escape from the pain of the task. In medical training this may be a necessary mentality to adapt to prevent burnout, or simply to ensure we can persevere. We can do as much as we can to advocate for ourselves but at some points complete acceptance of how things are in the moment can provide relief from thoughts that may only serve to exacerbate the frustrations during training. Thoughts like, “I can’t believe I have to do this again!”, “How long will it take? Haven’t I been here long enough?”. Camus notes that the fate of Sisyphus is only tragic “at the moment which it becomes conscious” and it is his attitude walking down that hill that draws the line between the experience being a punishing fate, or simply fate. If we wake up on a Sunday, immediately dreading Monday, the tone of the future is already set and the anticipatory pain only exacerbates the challenges we face.

Perhaps in embracing what is, and acknowledging that the training process is difficult, but not ruminating on it, we can create space for joy. Instead of spending our time in anticipatory dread or frustration, we are afforded the opportunity to shift our focus to the present moment and in doing so we create the space for the joyful moments. The moments that remind us why we went into medicine in the first place. Perhaps it is a connection made with a special patient. A “thank you”. A laugh shared with colleagues at 2am. The realization that you know more than you think. That you have done something special for someone else. All of these moments, from the start of our medical training to the end of our careers, add up to create a professional who is a reflection of these different moments. Of the people they have interacted with, and the patients they have cared for since the first day. Perhaps on the 1000th time we see a patient, on the 1000th time the boulder rolls down the hill.

Non-Psychiatric Effects on Children

Regarding non-psychiatric effects of warzones on children, it has been reported that Traumatic Brain Injury (TBI) is the most common cause of death [2]. Children also experience intracerebral and subdural hemorrhages and epidural hematomas [2]. These can be caused by blunt injuries due to explosives [2]. Additionally, children suffer from nutritional deficits and dental and dermatological pathologies [3]. Infections are also more likely to spread during these conflicts due to lack of clean water, nutrition, and immunizations [4]. These infections include measles, polio, diphtheria, tetanus/pertussis, varicella, COVID-19, among others [4]. Also, before and after birth, there are higher rates of mortality, stillbirths, and low birth weights in these populations [5].

Psychiatric Effects on Children

Regarding the psychiatric effects of these warzones and conflicts, children are at an increased susceptibility for the development of stress due to encountering the death of family members and other tragic incidents [3]. Anxiety disorders and major depression are 2-3 times more prevalent in conflict-affected populations than the general population [3]. Children are also susceptible to posttraumatic stress disorder (PTSD) [3]. Besides these disorders, children are at an increased risk for the development of immediate stress reactions, such as apathy and dependent behavior [5].

Management of Children’s Psychological States

Regarding the management of PTSD in these vulnerable children, there have been three psychosocial interventions shown to be promising [6]. These are Teaching Recovery Techniques, Writing for Recovery, and Advancing Adolescence [6]. Teaching Recovery Techniques are lessons given by professionals to teach children about trauma and ways to deal with loss and PTSD symptoms [6]. Writing for Recovery consists of allowing children to write about their emotions and describe their traumatic experiences, and it guides children to develop positive insights from their traumatic experiences [6]. Advancing Adolescence is a two-month program that revolves around providing a safe space to children, supporting them socially, allowing them to express themselves, and providing them with group activities [6-7]. These group activities include fitness, arts, and vocational and technical skills [6-7]. Out of those psychosocial interventions, only Teaching Recovery Techniques were shown to decrease PTSD scores [6].

In addition to these psychosocial interventions, there are general approaches in the management of conflict-affected children’s psychological states. Immediate approaches include distancing the child from the area of harm, providing basic health and safety needs, and assessing the child’s psychological state [5]. It is important to provide children with a sense of safety and security [5]. This sense of security, in addition to the other aforementioned approaches, should be performed in accordance with a trauma-informed care perspective [5]. This perspective provides children with safe places, positive social interactions and relationships, and the ability to express emotions and learn how to control them [5]. This perspective aims to re-establish children’s routines from prior to the conflict so that they can have stability in their daily lives [5]. Also, a psychological assessment should be performed, and it should be individualized and centered around the needs of the child, which may differ largely from the needs of another child [5]. Following the assessment, evidence-based interventions, such as the three psychosocial interventions mentioned above, should be applied [5]. If group-based interventions are used, the sessions should be fewer and have lower participation thresholds to decrease stress during sessions [5]. These interventions should aim to build the children’s resilience [5,8].

Social and environmental conditions should also be taken into account. Humanitarian aid and sufficient medical, cultural, and educational facilities are needed for the proper development of children [5]. The facilities can be established with the aid of non-governmental organizations and should have child-friendly spaces [8]. Psychological support should also be provided to parents, if an assessment illustrates the need for support [5]. It is also recommended that physicians keep parents involved in the care of their children [5]. Parents should be informed of the progress of their children’s treatment and play a part in the decisions pertaining to the treatment [5].

To ensure proper treatment of the children, clinicians should be culturally competent and medical interpreters should be used to provide children and their families with a culturally-centered care that will build rapport [8]. Clinicians should also undergo disaster training to be adept at treating children afflicted by conflicts [8].

Conclusion

Children in warzones experience psychiatric and non-psychiatric effects that range from anxiety and depression to traumatic injuries and mortality [2-3]. To provide the best psychiatric care to children, evidence-based interventions and trauma-informed care that aim to foster resilience should be used [5,8]. The care should not be restricted to caring for children but also include improving the environment, assisting parents, and ensuring the readiness of the medical team to help the children and their families in these situations [5,8].

References

1. UNICEF. UNICEF in the State of Palestine Escalation Humanitarian Situation Report No.16 [Internet]. Jerusalem: UNICEF; c2024 [cited 2024 Jan 29]. Available from https://www.unicef.org/sop/reports/unicef-state-palestine-escalation-humanitarian-situation-report-no16

2. Kocik VI, Borgman MA, April MD, Schauer SG. A scoping review of two decades of pediatric humanitarian care during wartime. J Trauma Acute Care Surg. 2023 Aug 1;95(2S Suppl 1):S170-S179. doi: 10.1097/TA.0000000000004005. Epub 2023 May 12. PMID: 37166192; PMCID: PMC10389486.

3. Klas J, Grzywacz A, Kulszo K, Grunwald A, Kluz N, Makaryczew M, Samardakiewicz M. Challenges in the Medical and Psychosocial Care of the Paediatric Refugee-A Systematic Review. Int J Environ Res Public Health. 2022 Aug 26;19(17):10656. doi: 10.3390/ijerph191710656. PMID: 36078371; PMCID: PMC9517743.

4. Ottolini M, Cirks B, Madden KB, Rajnik M. Pediatric Infectious Diseases Encountered During Wartime-Part 1: Experiences and Lessons Learned From Armed Conflict in the Modern Era. Curr Infect Dis Rep. 2021;23(12):27. doi: 10.1007/s11908-021-00770-1. Epub 2021 Dec 9. PMID: 34903952; PMCID: PMC8656442.

5. Bürgin D, Anagnostopoulos D; Board and Policy Division of ESCAP; Vitiello B, Sukale T, Schmid M, Fegert JM. Impact of war and forced displacement on children’s mental health-multilevel, needs-oriented, and trauma-informed approaches. Eur Child Adolesc Psychiatry. 2022 Jun;31(6):845-853. doi: 10.1007/s00787-022-01974-z. PMID: 35286450; PMCID: PMC9209349.

6. Alzaghoul AF, McKinlay AR, Archer M. Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review. BJPsych Open. 2022 Aug 8;8(5):e153. doi: 10.1192/bjo.2022.552. PMID: 35938530; PMCID: PMC9380009.

7. Panter-Brick C, Dajani R, Eggerman M, Hermosilla S, Sancilio A, Ager A. Insecurity, distress and mental health: experimental and randomized controlled trials of a psychosocial intervention for youth affected by the Syrian crisis. J Child Psychol Psychiatry. 2018 May;59(5):523-541. doi: 10.1111/jcpp.12832. Epub 2017 Oct 2. PMID: 28967980; PMCID: PMC5972454.

8. Kadir A, Shenoda S, Goldhagen J, Pitterman S; SECTION ON INTERNATIONAL CHILD HEALTH. The Effects of Armed Conflict on Children. Pediatrics. 2018 Dec;142(6):e20182586. doi: 10.1542/peds.2018-2586. Epub 2018 Nov 5. PMID: 30397168.