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Social Work in Mental Health
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The Therapeutic Use of Photography in
Clinical Social Work: Evidence-Based
Best Practices
Vaughn A. DeCoster MSW PhD LCSW ACSW a & James Dickerson MSW
PhD LSW a
a Social Work Department , University of Southern Indiana ,
Evansville , Indiana , USA
Accepted author version posted online: 18 Jul 2013.Published
online: 20 Dec 2013.
To cite this article: Vaughn A. DeCoster MSW PhD LCSW ACSW & James Dickerson MSW PhD LSW (2014)
The Therapeutic Use of Photography in Clinical Social Work: Evidence-Based Best Practices, Social
Work in Mental Health, 12:1, 1-19, DOI: 10.1080/15332985.2013.812543
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Social Work in Mental Health, 12:1–19, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-2985 print/1533-2993 online
DOI: 10.1080/15332985.2013.812543
The Therapeutic Use of Photography in Clinical
Social Work: Evidence-Based Best Practices
VAUGHN A. DECOSTER, MSW, PhD, LCSW, ACSW and
JAMES DICKERSON, MSW, PhD, LSW
Social Work Department, University of Southern Indiana,
Evansville, Indiana, USA
This project systematically identified evidence-based interventions
using photography in mental health practice. The initial search
of the literature produced 4,929 hits, title reviews reduced this
set to 225 possible studies, abstract examination refined this list
to 81, and analyzing the articles determined that only 23 meet
selection criteria for inclusion in this project: psychosocial-oriented
intervention within the domain of social work practice with sup-
porting empirical data. The majority of interventions involved
assignments that included taking photographs or creating some
kind of photographic product (e.g., collages, time-series of snap-
shots). Typically, these photographic activities were done in group
or individual therapy and focused on social skills, coping skills,
self-esteem, or identity for adults and adolescents. The empiri-
cal support for these protocols was usually from case studies or
single-group design evaluations, all reported practical or theoret-
ically significant improvements, and three produced statistically
significant effects. This article will then discuss the implications of
findings and direction for future research.
KEYWORDS photography, photos, phototherapy, mental health,
clinical social work
Address correspondence to Dr. Vaughn A. DeCoster, University of Southern Indiana,
Social Work Department, 8600 University Blvd., Evansville, IN 47712. E-mail: vadecoster@
usi.edu
1
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2V. A. Decoster and J. Dickerson
INTRODUCTION
Photography has long been found to be an emotionally powerful means
of expressing human experiences. Not long after Louis-Jacques-Mandé
Daguerre’s development of a reliable photographic process in 1838, pho-
tography began to appear in the mental health profession. In 1856, London
psychiatrist Dr. Hugh Welch Diamond, considered the father of psychi-
atric photography, began photographing patients as a means to monitor
progress (Burrows & Schumacher, 1990). Over a hundred years later, mental
health practitioners continued to recommend the photographing of psychi-
atric patients and families to aid in assessment and to recall client specifics
(Coblentz, 1964; Graham, 1967). Smith, Sanders, Smith, and Weinman (1965)
used photographs of current hospitalized psychiatric patients to measure
patient awareness (orientation) and to evaluate the effectiveness of three
“socioenvironmental” treatment programs. At the macro-level, prominent
social workers of the late 1800s to early 1900s like Jane Addams and Paul
Kellogg strategically used photographs to advance their social causes. They
were later referred to as “social photographers” (Huff, 1998). Relatedly, Szto
(2008) details documentary photography’s role as a “social change tool” in
early, between 1897 and 1942, U.S. social welfare policy. Although these
and many other professionals recognized the potential of this medium, it
was not until later that its therapeutic use became more apparent in the
helping professions.
The 1980s through 1990s witnessed significant growth in the use of
photography in mental health with training workshops, the establishment of
a professional association, international conferences and a dedicated jour-
nal, PhotoTherapy Quarterly. During this same time clinical scholars were
prolific and, in particular, two seminal works in the field were published:
PhotoTherapy Techniques (Weiser, 1993) and Phototherapy in Mental Health
(Krauss & Fryrear, 1983). Practices involving photography flourished and
were typically classified into three categories: photo art therapy, therapeutic
photography, and phototherapy (Weiser, 2010). In photo art therapy, spe-
cially trained art therapists focus on the process of client photography as
therapeutic. Therapeutic photography, in contrast, centers on self-initiated
individual or group photo-based activities done outside a professional help-
ing relationship. PhotoTherapy, on the other hand, is the use of photographs
or photography by mental health therapists in psychotherapy. Although the
dedicated organization, the conferences, and journal ceased, the applica-
tion of photography as an accepted tool in professional health practices
remains. This is evidenced by the continued work throughout the helping
professions. Nevertheless, scholars have yet to conduct a systematic identi-
fication of evidence-based best practices. Hence, the purpose of this study
is to identify and rank-order empirically supported clinical practices that use
photography as an intervention.
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Therapeutic Use of Photography in Clinical Social Work 3
The social work profession strives for evidence-based practice, recog-
nizing its benefits and challenges (Jenson, 2005; Morago, 2006). The present
study’s investigators’ exploration of the literature on the therapeutic photog-
raphy yielded numerous possibilities for social workers. The interventions
appeared relatively easy, sometimes as simple as clients taking photographs
or collecting family snapshots then discussing these with their therapist.
As experts attest, though, photographs have a powerful affect on people and
whereas the activities appear uncomplicated, the actual therapeutic imple-
mentation requires practitioner expertise (Krauss & Fryrear, 1983; Weiser,
1993). One of the researcher’s advanced training in PhotoTherapy confirms
this observation. The initial literature review and training also raised con-
cerns about the clarity of procedures (systematic, repeatability) for these
potentially powerful methods and evidence supporting usage with specific
problems and populations. Hence, the apparent simplicity of therapeutic
photography without systematic protocols or clear evidence regarding the
benefits or risks turns unknowing clients into research subjects.
This project is part of a larger program of study to advance the scien-
tific rigor in the use of photography with mental health practices. This will
be achieved through the application of the scientific approach (i.e., applied,
translational research models) to the art of behavioral health practice using
photography. This advances an emerging trend of quantifying qualitative
methodology and data seen in the social sciences since the 1990s (Miles &
Huberman, 1994; Patton, 1990). Social workers and other mental health pro-
fessions pride themselves on being “scientific practitioners” yet, to date, the
literature lacks a review or a quantified assessment of this practice methodol-
ogy. Using a systematic method to evaluate past studies, this project identifies
best practices via methodological rigor and statistically significant outcomes.
METHODOLOGY
This study systematically identified, summarized, and rated clinical interven-
tions involving photography or photographs. Researchers adapted protocols
developed in other best-practice investigations (Cummings, Cooper, &
Cassie, 2009; DeCoster & Cummings, 2005), with specific steps: define study
inclusion criteria, systematically search literature, summarize interventions,
rate methodological rigor, then rank-order practices according to rigor and
significance of outcomes. This investigation’s dataset of empirical articles
began with an expansive literature search in English language peer-reviewed
scientific journals over the past 100+years (1897–2013), followed by a sys-
tematic review of article titles and abstracts; finally culminating with an
analysis of the final set of published studies.
A boolean search of six electronic databases (i.e., CINAHL—nursing and
allied health, MEDLINE, PsychInfo, PsycARTICLES, SocINDEX, and Social
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4V. A. Decoster and J. Dickerson
Work Abstracts) began the process, with resulting publications being sub-
jected to a systematic analysis in order to extract works relevant to the
present study. After trial searches that used various combinations of key
terms, the following search terms were identified as relevant: photography
or phototherapy or photographs or photos or images or pictures AND inter-
vention or activity or method or approach or model or strategies or treatment
or therapeutic AND health or mental health or psychiatry or social work or
counseling or psychology or therapy. Article titles from the initial search
were then reviewed for duplicates and ineligible titles (e.g., studies focused
on physiological medicine or non-photographic approaches easily discerned
from the title).
The second step involved reviewing the abstracts from screened titles
to further eliminate unqualified studies. Third, resulting articles from the
abstract analysis were read and included in the final collection if they met
these criteria: (1) Paper included totally, or in-part, a psychosocial oriented
intervention; (2) Intervention was considered within the domain of social
work practice knowledge or skill; and (3) Authors offered some form of
empirical evaluation of supporting data for the intervention effectiveness.
Finally, the remaining studies meeting selection criteria were summarized,
categorized, and rated using an adapted version of the Methodological
Quality Rating Scale (MQRS, Miller et al., 1995). The MQRS evaluates the
methodological rigor of a clinical study according to characteristics; such
as research design, theoretical foundation, treatment integrity, standardized
measures, dosage, subject attrition, and generalizability (see Appendix A).
Completing the process, studies were then rank-ordered according to this
methodological rigor score and the reported significance of outcomes to
create a listing of best-practices. The following is a discussion of those
findings.
FINDINGS
The systematic literature search initially identified 4,929 peer-reviewed arti-
cles. Title reviews reduced this set to 225 (4.5%) possible publications. Nearly
20% (892) of the preliminary articles rejected for this study focused on body
image and associated disturbances, and did not include any specific form
of photography. Other excluded works had foci such as self-concept (185),
eating disorders (169), visual perception (139), memory (109), human sex dif-
ferences (88), and obesity (67), again lacking any identifying photographic
elements. The next level of extraction, a review of the 225 article abstracts,
further eliminated those lacking a photographic component or health care
foci, resulting in a third set of 81 (36%) articles.
Of those 81 articles, only 23 (28%) meet the selection criteria. Excluded
papers, typically, presented basic (non-therapeutic) photography research
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Therapeutic Use of Photography in Clinical Social Work 5
or interventions that lacked empirical evidence or testing. Examples of dis-
qualified basic research articles included the popular photovoice technique
(Clements, 2012; Drew, Duncan, & Sawyer, 2010; Poudrier & Mac-Lean, 2008;
Wang, Yi, Tao, & Carovano, 1998), client photo stories (Lassetter, Mandleco,
& Roper, 2007; Sitvast, Abma, & Widdershoven, 2010; Wallis, Winch, &
O’Campo, 2009), and expressed emotion in photographs (Pulkkinen &
Aaltonen, 1998). Although the works depicted in these rejected studies may
have therapeutic value to participants, the projects were not designed or
intended for clinical use. Examples of excluded intervention articles lack-
ing empirical data included the application of hermeneutic photography to
foster meaning in mental illness (Sitvast & Abma, 2012), photo-reminiscence
(Krauss, 2009), phototherapy using snapshots and family albums (Weiser,
2008), photographs in perinatal social work (Minton, 1983), phototherapeutic
intervention to improve adolescent self-concept (Blinn, 1987), and instant
photography in psychotherapy (Hunsberger, 1984). Although these interven-
tions and techniques may have great promise there is a lack of supporting
evidence regarding effectiveness. The final dataset, consisting of the 23 iden-
tified studies was then summarized, categorized, rated for methodological
rigor, and then rank-ordered.
Table 1 summarizes the 23 studies included in this investigation as
evidence-based photographic interventions for clinical social work and indi-
cates the most frequently occurring modes of intervention are group (39%)
and individual (35%) sessions.
Many interventions had multiple focuses. For the 38 reported foci, 28%
involved some form of social or coping skill set like (i.e., communication or
interacting with others), 21% addressed some form of self-concept, esteem,
or identity, and 15% focused on enhancing some form of personal general
or event specific insight. Additionally, of the 23 intervention studies, 35%
targeted predominately adult, 26% elder, and 22% adolescent populations.
In regards to measurement and design, 48% used case-study, 35% time-
series single-group, and only 17 (%) used an experimental design. Selected
studies had an average of 21 subjects (i.e., participants, and/or clients), aver-
aging 33 years of age, with the majority (57%) being male. Psychologists
(43%), social workers (30%), and psychiatrists (13%) were the predominant
professions conducting this work.
Two categories of photography intervention emerged from the 23 stud-
ies: creating original photographs/photo-products or integrating existing
photos. From those two categories, 74% interventions involved the first classi-
fication of taking original photographs or creating some kind of photographic
product (e.g., a collage, a time-series, or a story) as part of a therapeutic
assignment. For example, elders were given Polaroid (i.e., instant) cameras to
photograph mostly themselves and others attending a senior activity center.
These photographs were later discussed in small groups and then publically
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TABLE 1 Summary of Studies
Author Mode Focus Target Population Intervention Design Ss Age Female Outcomes Discipline
Aronson (1976) Assertiveness,
attitude re self,
others
Elder, ADC Polaroid
assignments,
discussions,
public display.
Wkly 45 min.
session for
6 weeks.
E 15 75 90% ↑positive attitudes re
older & younger
people.
Psyc
Combs (1977) Ind Insight Adult, out-pt MH Photo assignments,
discussed with
therapist.
TS 22 20 50% ↑insight. Psyc
Cosden (1982) Ind Social skills, esteem Adol, resident
facility
Photo & darkroom
training,
self-directed
activity.
CS 2 20 0% ↑social interactions,
confidence, calm,
focus.
Psyc
Darrow (1983) Grp Identity, aggression,
closeness
Adol, out-pt MH Unstructured,
process-oriented
photography &
videography
TS 13 13 100% ↑grp interactions,
closeness,
expression of
conflicts, concerns.
SocWrk
DeCoster (2012) Ind Post-war
readjustment,
wellbeing,
post-trauma stress
Combat veterans Client-directed,
social worker
assisted, activity
of post-war
adjustment,
reminiscent
photo story.
TS 6 47 0% ↑general wellbeing,
reduced PSTD
symptoms (PCL-M).
SocWrk
Fryrear (1974) Grp Self-concept Adol delinquents,
incarcerated
Five wkly photo
sessions
w/partner
assignments.
E30−0% ↑self-concept,
satisfaction.
Psyc
Hogan (1981) Grp Insight, self-image School age children PhotoTreatment,
4-10 wks of
60 min. sessions.
−−−−↑insight SocWrk
6
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Kajiyama (2007) Ind Behavioral problems Elder
w/Alzheimer’s,
caregivers
Reminiscent
therapy, viewing
familiar personal
photos w/music.
TS 46 −−↑pos. interactions,
engaged, <
agitation. Caregivers
w/↑pos. & ↓neg.
emotions.
Psyc-Med
Kaslow (1977) Family Assessment Families Family photo
reconnaissance,
projective use of
personal photos
in family
sessions.
CS 3 −−↑depth of family hx,
memories, familial
interactions, insight
re roles, patterns.
Psyc
Kaslow (1979) Ind Assessment Adult, out-pt MH Photo
reconnaissance,
personal
projective use of
personal photos
in psychotherapy.
CS 1 −0% ↑insight Psyc
Levin (2007) Class Communication
skills
Elder, stroke Modified
PhotoVoice,
documentary,
5 wk curriculum,
2-3 hrs. per class.
CS 5 −−↑communication,
processing or
physical change,
1:1 interactions in
class.
Rehab
Lindfors (2009) Grp Trauma memories Adult, out-pt, PTSD Reenactment
PhotoTherapy,
staging &
photographing
episodes
w/partner,
reviewed by grp,
4 day intensive
workshop.
CS 1 −100% ↑insight, grp
discussions.
Psyc
Marchall (2007) Grp Attitudes re program Elder, caregiver Viewing 13 positive
photos of seniors
in ADC activities.
E 71 30-70 56% ↑Pos. attitudes re
ADC, p. <001.
SocWrk
(Continued)
7
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TABLE 1 (Continued)
Author Mode Focus Target Population Intervention Design Ss Age Female Outcomes Discipline
Milford (1983) Workshop Self-esteem, social
skills, grooming
Adol, grp home Non-directed,
self-portrait photo
albums done
w/partners,
1.5 hrs/6wks.
E 12 12-16 0% ↑self-concept,
grooming, behavior,
social skills, p. <
.10, .05, .02.
Psyc
Nelson-Gee (1975) Ind Verbal expression Child out-pt MH Polaroid used as
communication
tool, 2x wkly
sessions,
45-90 min. each.
CS 1 5 0% Verbal expressions,
use of "I", ability to
abstract, sequence
ordering,
cause-effective.
Psyc
Okura (1986) Class Insight, public image Elder "Who are you,"
auto-
photography,
bio-documentary
use12pics.
CS 60 73 50% Insight into aging as a
search for peace.
Gero
Schormans (2010) Grp Insight, public image Adult, learning
disabled
Photoshop editing
11 pre-selected
photos, grp task,
1-2 hr. meetings,
1-3x/wk for
3 mths.
CS 4 −50% ↑grp cohesion,
awareness,
self-advocacy skills,
sense of
empowerment &
community.
SocWrk
van den Steen (2005) Class Visualization of
combat trauma
Adult, combat vets Computer prgm to
create visual,
graphic, map,
text trauma event
timeline.
Self-directed.
QE 18 −0% ↑depth to stories,
event recall &
timeline.
Psyc-Med
Walker (1991) Ind Insight, mortality Adult, out-pt MH Non-directed, client
interpretation of
set of 4 photos,
wkly/3 mths.
TS 1 34 100% ↑insight, expression
of emotions, ↓
anxiety.
Psyc-Med
8
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Weiner (1997) Grp Ego-gratification Elder, dementia,
ADC
PhotoTherapy,
create ADC photo
albums.
TS −−−↑interactions, pos.
emotions, ↓anxiety.
SocWrk
Weiser (2004) Grp/Class Insight, past issues Adult, out-pt MH PhotoTherapy
5 primary
techniques.
TS 7 −85% ↑insight Psyc
Wikler (1977) Ind Termination from
client
Caseworker Photo exchange
between case
worker and
client.
TS 6 80% ↓guilt, loss, rejection,
↑self-confidence.
SocWrk
Wilson (2007) Class Empowerment,
needs assessment
Early adol,
underserved
PhotoVoice,
photographing
strengths, issues,
engage in critical
dialog &
collective action
plans. 90 min.
sessions lead by
grad & HS
student, 25 wks.
CS 122 11 53% ↑active engagement,
critical analysis &
action.
Public
Health
Mode Design Intervention Outcomes
Class CS - Case study Wkly - Weekly ↑Increase
Grp - Group E - Pre/post test control group experimental design Mthly - Monthly ↓Decrease
Ind - Individual QE - Non-equivalent quasi-experimental design
TS - Simple time-series design, single group
1. First colum lists only the first author of each study.
2. All outcomes were improvements and statsitically significant at p. <.05orbetter.
3. Subjects (Ss) included only those completing study for all conditions.
4. Ages are averaged across conditions.
5. - Not reported
9
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10 V. A. Decoster and J. Dickerson
posted at the senior activity center (Aronson & Graziano, 1976). In another
example, instant photography was used to take snapshots to stimulate com-
munication with a non-verbal 5-year-old boy diagnosed as “emotionally
disturbed with minimal brain dysfunction” (Nelson-Gee, 1975, p. 160). Later
studies included photography as a means to encourage self-expression for
persons with aphasia (Levin, Scott, Borders, Hart, Lee, & Decanini, 2007)
and sought to improve adolescent boys’ social skills through non-directed
photography activities with individual clients (Cosden & Reynolds, 1982).
Milford, Frynear, and Swank (1984) studied the use of patients creating
self-portrait photo albums with partners.
Further analysis of the present dataset revealed that several clinicians
developed and tested photo activities to foster insight among adults (Combs
& Ziller, 1977), latency age school children (Hogan, 1981), adults with intel-
lectual disabilities (Schormans, 2010), and American and Japanese elders
(Okura, Ziller, & Osawa, 1985). Similarly, group-based sessions involving
photographic tasks were developed to enhance the identity (i.e., self-
concepts) of male juvenile delinquents (Fryrear, 1974) and troubled female
adolescents (Darrow & Lynch, 1983).
Also identified during analysis were three groups of scholar-clinicians
who developed photography protocols for addressing trauma, one through
a psychodrama-like “re-enactment phototherapy” process (Lindfors, 2009,
p. 397), another by multimedia re-exposure of the combat experience (van
der Steen, Brinkman, Vermetten, & Neerinex, 2010) and a third through
post-war readjustment via photo reminiscence (DeCoster & Lewis, 2012).
Additionally, two projects sought to enhance the “ego-gratification” among
elders with dementia individually (Weiner & Abramowitz, 1997, p. 48) and
collectively for elders in an adult day program (Marshall, Craun, & Theriot,
2009). Similarly, one project used photovoice as a youth empowerment
strategy (Wilson et al., 2007).
Of the 23 studies included in the dataset, six (26%) studies incorporated
existing photographs, snapshots, into the therapeutic process. For example,
in one study a psychologist used photo reconnaissance as a psychodynamic
assessment tool in individual and family therapies (Kaslow, 1979). In another,
those working with Alzheimer disease patients found that patients who
watched videos of familiar, family snapshots would decrease in the likeli-
hood of exhibiting behavioral problems (Kajiyama, dib, Tymchuk, Boxer,
Kixmiller, & Olinsky, 2007). Incorporating snapshots also was shown helpful
at increasing insight in individual psychotherapy with adults (Weiser, 2004).
Lastly, exchanging personal snapshots of one another between clinicians and
clients eased feelings of guilt and loss at termination (Wikler, 1977). As men-
tioned previously, using a systematic method to evaluate past studies, this
project identifies best practices via methodological rigor and statistically sig-
nificant outcomes. The following section will discuss the methodological
rigor of this study.
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Therapeutic Use of Photography in Clinical Social Work 11
METHODOLOGICAL RIGOR
As part of the final analysis, researchers independently rated and scored
the methodological rigor for each of the 23 articles using the MQRS,
achieving a 92% inter-rater agreement. Overall, the MQRS summed scores
ranged from 0 to 17 out of a possible range of 0 to 32. The average
MQRS score was 8.5 (SD 8.54). Similarly, there was a mode and median
of 8.0 (see Table 2 for category specific ratings and summed scores).
Mentioned previously, the final step included a rank-ordered analysis of
the interventions by their MQRS values and whether authors reported
statistically significant findings (see Table 3). The majority of the selected
studies specified the underlying theory for the approach and addressed
treatment integrity through training or defined protocols. Half of the studies
identified the research design and almost a third discussed generalizability of
findings. However, roughly a fourth reported using standardized measures
or considered intervention dosage (i.e., clients receiving less than the
complete course of treatment). Findings also indicated a low number of
studies that incorporated post-intervention maintenance, discussed attrition,
and none conducted blind follow-ups to confirm effects. Although all
studies described their interventions as having positive effects, only three
specifically reported statistically significant improvements, with the authors
adjusting the rank-order accordingly.
DISCUSSION
This project systematically identified evidence-based interventions using
photography in mental health practice. The initial search of the literature
produced 4,929 hits, title reviews reduced this set to 225 possible stud-
ies, abstract examination refined this list to 81, and analyzing the articles
determined that only 23 meet selection criteria for inclusion in this project:
psychosocial-oriented intervention within the domain of social work prac-
tice with supporting empirical data. The majority of interventions involved
assignments taking photographs or creating some kind of photographic
product (e.g., collages, time-series of snapshots). Typically, these photo-
graphic activities were done in-group or individual therapy, focused on social
skills, coping skills, self-esteem or identity, targeting adults or adolescents.
The empirical support for these protocols was usually from case studies or
single-group design evaluations, all reported practical or theoretically signif-
icant improvements, and three produced statistically significant effects. Key
findings include these methods are adaptable, uncomplicated, theoretically
based, and supported by mostly case study evidence from marginal evalua-
tion methods. In general, the methods and improvement areas all are within
the realm of social work knowledge, skills, and practice principles.
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TABLE 2 Individual Article MQRS Ratings
First author (Year)
1.
Study
design
2.
Theoretical
foundation
3.
Treatment
integrity
4.
Measures
5.
Follow-up/
Maintenance 6. Dosage
7.
Dropouts/
Attrition
8. Blind
follow-up 9. Multi-site
10.
Generalize
Total
MQRS
score
Lindfors (2009) 1 4 2 0 0 4 4 0 0 2 17
Milford (1983) 4 4 2 4 0 0 0 0 0 2 16
Fryrear (1974) 4 2 2 3 0 2 3 0 0 0 16
DeCoster (2012) 1 2 2 4 0 0 3 0 0 2 14
Levin (2007) 1 2 2 0 2 2 4 0 0 0 13
Aronson (1976) 4 4 2 0 2 0 0 0 0 0 12
Marchall (2007) 4 4 0 3 0 0 0 0 0 0 11
Okura (1986) 0 4 2 0 0 0 0 0 2 2 10
Kajiyama (2007) 1 4 2 2 0 0 0 0 0 0 9
Hogan (1981) 1 4 2 0 0 0 0 0 2 0 9
Wilson (2007) 0 4 2 0 0 2 0 0 0 0 8
Weiser (2004) 0 4 2 0 0 0 0 0 0 2 8
Walker (1991) 0 2 2 0 0 4 0 0 0 0 8
Combs (1977) 2 4 2 0 0 0 0 0 0 0 8
van den Steen (2005) 2 0 2 2 0 0 0 0 0 0 6
Weiner (1997) 1 2 2 0 0 0 0 0 0 0 5
Darrow (1983) 1 2 0 0 0 0 0 0 2 0 5
Schormans (2010) 0 2 2 0 0 0 0 0 0 0 4
Nelson-Gee (1975) 0 2 0 0 0 0 0 0 0 2 4
Kaslow (1977) 0 2 0 0 0 0 0 0 0 2 4
Cosden (1982) 0 2 2 0 0 0 0 0 0 0 4
Kaslow (1979) 0 2 0 0 0 0 0 0 0 0 2
Wikler (1977) 0 2 0 0 0 0 0 0 0 0 2
Possible range 0-32
Actual range 0-17
Mean rating 8.5
Mode rating 8.0
Median rating 8.0
First column lists only the first author of each study.
12
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Therapeutic Use of Photography in Clinical Social Work 13
TABLE 3 Rank-Ordered Best Practices
Ranking Study
Improvements significant,
(p<.10 or better) MQRS score
1 Milford (1983) Yes 16
2 DeCoster (2012) Yes 14
3 Marchall (2007) Yes 11
4 Lindfors (2009) No 17
5 Fryrear (1974) No 16
6 Levin (2007) No 13
7 Aronson (1976) No 12
8 Okura (1986) No 10
9 Kajiyama (2007) No 9
10 Hogan (1981) No 9
11 Wilson (2007) No 8
12 Weiser (2004) No 8
13 Walker (1991) No 8
14 Combs (10977) No 8
15 van den Steen (2005) No 6
16 Weiner (1997) No 5
17 Darrow (1983) No 5
18 Schormans (2010) No 4
19 Nelson-Gee (1975) No 4
20 Kaslow (1977) No 4
21 Cosden (1982) No 4
22 Kaslow (1979) No 2
23 Wikler (1977) No 2
Second column lists only the first author of each study.
These interventions were creative, often non-directive with uncompli-
cated protocols, making replication as well as adaptation to other conditions
easy for clinical social workers. For example, Aronson and Graziano’s
(1976) intervention utilized five straightforward assignments over the course
of 6 weeks: take a Polaroid of a friend in the group, a favorite spot in
the senior activity center, an individual picture with artificial lighting that
was then followed by flash lighting, and finally the images of non-group
members were photographed. These assignments were discussed in-group
each week, then exhibited on a bulletin board for others to view. Whereas
Schorman’s (2010) project required social workers to have a working knowl-
edge of the photo editing software (i.e., Photoshop), the intervention itself
was straightforward. The group explored their thoughts, feelings, and per-
ceived stories from 11 images of other adults with intellectual disabilities;
this was followed by actively “transforming” the images using Photoshop to
fit their own strength-based narratives. In an effort to be more parsimonious
and direct, Okura, Ziller, and Ocura (1985) directed American and Japanese
elders to take 12 pictures so they could “ ... know something about the
things you feel are important in your life—your world. ... Tell us about
YOU” (p. 250). Additionally, numerous protocols were client directed.
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14 V. A. Decoster and J. Dickerson
Client-directed protocols involved the therapist serving as a facilita-
tor to the process and not as the primary source of healing. Lindfors’
(2009) re-enactment phototherapy with participants collectively working
through past traumas is one example of healing outside of the clinician-
patient paradigm. Similarly, there is Walker’s (1991) process for a terminally
ill client self-selecting one of four projective images and to talk about “...
her thoughts, feelings or fantasies evoked by it” (p. 125). Client-directed pro-
tocols allowed this woman to set the depth and pace of care to release
her suppressed emotions. In further support of client-directed protocols,
Weiser’s (2004) five PhotoTherapy techniques (i.e., photos created/taken or
of the client, self-portraits, family or photo-biographical albums, and photo-
projectives) emphasized client choice and personal interpretations because
“...photos are much like ‘mirrors with memory’, serving as markers of what
(and who) has mattered most, and later talismans holding back the blurring
that advancing years impose” (p. 23).
Unfortunately, the simplicity, flexibility, and variety of protocols suggest
a lack of sophistication in clinical application and imprecision for scientific
replication. A degree of systematization is needed to assure a consistent
intervention across time and provider. At present, many of the interventions
are highly dependent on individual practitioner discretion, skill, or expe-
rience. The growing field of translational research, the testing of clinical
protocols in the less than controlled environment of real-world practices
(Brekke, Ell, & Palinkas, 2007; Palinkas & Soydan, 2012), suggests these
adjustments are indeed acceptable, a realistic view of practice outside the
more controlled academic environment. The present criticism is not to negate
these methods from practice but to caution social workers to be precise and
transparent in their inclusion, expand deficit protocols, clarifying the meth-
ods, procedural steps, and adaptations. Therapeutic photography methods
and foundation theories are certainly within the knowledge and skill lev-
els of social work, making them accessible to practitioners. Furthermore,
the therapeutic photography’s predominate client-directed, client-centered
approaches, embracing experiential and interpretive diversity, cultural sen-
sitivity, with clients as the experts, shows to be an excellent fit within the
social work paradigm. The art of social work practice necessitates practi-
tioners to individually adapt techniques to address client uniqueness. This
practice reality of altering intervention protocols, unfortunately, complicates
building a foundation of empirically validated interventions.
This body of work certainly has intrinsic value, appealing to providers
and clients to communicate difficult problems or emotions, with incredi-
ble potential to access experiences even at the sub-conscious level. Client
self-reports of enhanced insight or feelings from a photographic activity or
a clinician’s observed improvement of their mood or behavior does have
merit. According to Bloom, Fischer, and Orme (2009), determining whether
therapeutic changes are meaningful requires significance at practical, theoret-
ical, and statistical levels. In other words, clinician beliefs that photographic
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Therapeutic Use of Photography in Clinical Social Work 15
interventions produce practical and theoretically significant changes in their
clients, without statistical evidence, are at risk of numerous biases (social
desirability, practitioner, cultural). The evidence supporting these methods,
as a whole, is marginal. Furthermore, the methodological weakness of exist-
ing research, with the average MQRS percent score of 26%, raises concern
for the scientific validity of supporting evidence. As with the inconsistency in
intervention protocols, social workers should not dismiss these techniques,
but endeavor to evaluate their effectiveness, as they should for all of their
interventions, using evaluation strategies now being taught in social work
programs and expected in today’s practice environment.
In conclusion, this project has shown the remarkable potential of
photography in mental health, based on solid theoretical foundations and
practice principles well within the social work paradigm. Social workers
should not be deterred from using these methods, as long as they recognize
and improve protocol and supporting evidence deficits. Hence, future work
in the incorporation of photography and images into mainstream clinical
social work practices needs to develop and empirically validate unambiguous
intervention protocols, preferably using an experimental design with random
assignment to condition and standardized measurement instruments. These
empirical deficits and needs are common for relatively new approaches; nev-
ertheless, the allure of photography and these studies show its promise as a
powerful tool to improve the lives of people being served by social workers.
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APPENDIX A Methodological Quality Rating Scale1(MQRS)
Methodological Criteria Rating (points)2
1. Study Design 0 =Single group, observation only; 1 =Single group pre-test/post-test; 2 =Quasi-experimental
(non-equivalent control group); 4 =Randomization with control group.
2. Theoretical Foundation 0 =No information on the theoretical basis for intervention provided; 2 =Some information
provided on the theoretical basis for the intervention; 4 =Theoretical basis discussed for
intervention described in detail.
3. Treatment Integrity 0 =No standardization specified; 2 =Intervention standardized by manual procedures, specific
training.
4. Measures 0 =Reliability and validity of measures not reported or inadequate; 2 =Reliability and validity of
some measures moderate to high, others not reported; 3 =Moderate levels of
reliability/validity reported for majority of measures; 4 =High levels of reliability/validity
reported for majority of measures.
5. Length of Follow-up or Maintenance Phase 0 =No follow-up; 2 =Less than the intervention phase; 4 =Equal to or greater than the
intervention phase.
6. Dosage30=0–2 sessions or no discussion of number of sessions received; 2 =3–9 sessions; 4 =10+
sessions.
7. Dropouts/Attrition 0 =No information provided on withdrawals or attrition; 1 =Insufficient information provided
on withdrawals or attrition; 3 =Provides numbers of study participants who withdrew and/or
were lost to follow-up, but no explanation provided; 4 =Withdrawal/attrition numbers
provided and explained.
8. Blind Follow-up 0 =Follow-up conducted by non-blind or by an unspecified person (or no follow-up); 2 =
Follow-up by person blind to participants’ treatment condition.
9. Multisite 0 =Single site study; 2 =Parallel replications at two or more sites.
10. Generalizability 0 =No discussion of generalizability of findings; 2 =Discussion of generalizability of results
(e.g., sample characteristics, site, treatment)
TOTAL POSSIBLE 32
1Adapted from Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.H., ...Tongian, J.S. (1995). What works? A methodological analysis
of the alcohol treatment outcome literature. In R.K. Hester & W.R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives. (2nd ed.,
pp. 12–44). Needham Heights, MA: Allyn & Bacon.
2Scores range from 0 (low) to 32 (high).
19
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