English title dissertation Phtotgraphy as a nursing instrument in mental health care. How to use clients'photo stories for recovery
Name PhD (surname first) Sitvast, Jan
Doctor is (has been) nurse
Date of promotion 06/12/2010
University Vrije Universiteit Amsterdam
Promotores prof. dr. T.A. Abma en prof dr. G.A.M. Widdershoven
Abstract (English)

The general aim of this thesis was to examine how nurses can use photography to assist
psychiatric patients in making meaning of experiences of illness and to help them in the
process of recovery. The study is based on a hermeneutic-phenomenological perspective,
focusing on processes of experiencing and meaning making in the life world. Existential
issues, e.g. the way how people give meaning to their suffering, play an important role in
this process of being-in-the world. From a hermeneutical-phenomenological perspective,
caring can be seen as the core mission of nursing, tying in with a definition of health and
health promotion that is broader than the absence of physical defects and functional
impairments and encompassing quality of life and the possibilities for directing one’s
life, even when one feels impeded by the impact of sickness. Caring can be seen as
rooted in the nurses’ response to the suffering of patients, which we conceptualized as
a lack of agency (Ricoeur, 1992). ‘Agency’ concerns the extent of direction people feel
in exercising influence on domains of their lives that matter to them. Whereas patients’
suffering compromises their agency to direct their own lives (being impeded by the
impact of illness), nurses’ caring focuses on giving attention to the patient’s needs,
e.g. safety, comfort, relieve of pain and stress, etc. By responding to their needs, nurses
empower patients and strengthen their agency. Processes of meaning making and
expression of suffering in narrative play a crucial role. Since narratives are based on
a shared understanding between patients and nurses and other caregivers, narratives
are relational. Relational narratives are developed through dialogical interaction. We
connected this conception of a relational narrative with the agenda of recovery and
empowerment, which stands for the struggle of patients in mental health care to live a
life beyond illness and regain more agency and more direction in life in order to realize a
better quality of life. Basing ourselves on Gadamerian hermeneutics we postulated that
the (facilitation of) expression of this struggle plays an important role in the process of
meaning making which underlies recovery.
Departing from these notions we examined hermeneutic photography, assisting people in
constructing meaning from experiences in their life world. More concretely we examined
our application of hermeneutic photography: the photo-instrument. We did so from two
perspectives, that of meaning making and that of the therapeutic potential in the context
of nursing. In chapter 2 we studied how the hermeneutic philosophy of Ricoeur could
provide us with a theoretical framework to understand processes of meaning making.
In chapter 3 the focus is still on processes of meaning making, but now more from a
phenomenological point of view, i.e. departing from the existential problem of suffering
we found in empirical data. In chapter 4 and 5 we shifted the focus to the therapeutic
significance of the intervention. In chapter 6 we described the methodical steps (actions)
of hermeneutic photography as a nursing intervention and discussed what it might
contribute to professional agendas of recovery-oriented rehabilitation.

The specific application of hermeneutic photography that we used was the photoinstrument.
The photo-instrument has been developed by the author in an action
research during which the intervention has been adapted, complemented and refined
over a period of two years (2000-2002) and repeatedly tested with new groups of patients
in mental health care (Bouhuis et al, 2003). The result was a protocolled intervention
that nurses and other health professionals can use to direct group sessions with patients
who are no longer in a hectic period of psychiatric crisis and are now working on further
When we pull together everything that has been argued in this thesis, then we reach the
conclusion that the photo-instrument is an apt intervention for nursing professionals to
facilitate a process of meaning making in patients who struggle with experiences with
illness and suffering. It does not focus on suffering alone, but encompasses the possibilities
for making one’s own choices and taking up new roles and responsibilities. These latter
issues we have identified as a form of moral learning. The collaboration between patients
and nurses to this aim can be seen as one of the strengths of the intervention. The photoinstrument
allows patients to direct the interaction more on their own terms. Making
photographs they are no longer the passive receivers of services of caregivers. Expressing
themselves with images and words they play an active role in the communication with
caregivers. Another asset is that the intervention facilitates a patient to take a metaposition
in relation to his suffering, thus creating room for reflection.

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