Phototherapy in the educational setting

The Arts in Psychotherapy, Vol. 8 pp. 193-199, Ankho International Inc., 1981. Printed in the U.S.A.

PHOTOTHERAPY IN THE EDUCATIONAL SETTING

PATRICIA TURNER HOGAN, ACSW, LCSW*

The newly expanding field of the use of photography as a treatment tool is called phototherapy. In this paper I will describe and discuss a phototherapy program that I have used in educational settings. First, phototherapy will be de- fined and described briefly.

A definition of phototherapy that is being widely used is “use of photography or photographic materials, under the guidance of a trained therapist, to reduce or to relieve painful psychological symptoms and to facilitate psychological growth and therapeutic change” (Stewart, 1979). There are two important factors contained within this definition which should be emphasized and made explicit. First, “the use of photography or photographic materials” refers to both the passive and active use of the medium within a relationship. Active refers to the actual taking of photographs, and, in some instances, also to the use of darkroom facilities. Passive use of the materials refers to the response to images such as historical family pictures that are not actually being taken as part of the therapeutic program. Many professionals using phototherapy combine both uses in a variety of techniques to be described later in this paper. A second important factor in this definition is the use of the techniques by a trained therapist. While photography is a widely used medium in our society, its use to facilitate the helping process must be in fact combined with the skills associated with any psychological or behavior change process. The methods involved do not dilute the nature of the material considered in the therapeutic process; in fact, the contrary seems to be true so it is im- perative that trained persons guide the process.

PHOTOGRAPHY AS A THERAPEUTIC TOOL

In another version of its utility, the camera record jus- tifies. A photograph passes for incontrovertible proof that a given thing happened. The picture may distort, but there is always a presumption that something exists, or did exist, which is like what’s in the picture. Whatever the limitation . . or pretensions . . . any photograph seems to have a more innocent and there- fore more accurate, relation to reality than do other mimetic objects.

(Sontag, 1977)

Photography has certain characteristics which make it useful as a treatment tool. It provides the client and others with a recorded image of the self and this image provides a broad integrated perspective of the self. Most therapists rely on an elicited subjective and often abstract non- specific representation of the self as elicited from the client. Photographs, however, provide a concrete representation of many integrated aspects of the person which are a representation of a reality and not a personalized subjective view- point. A question raised that needs researching is-How objective are these images when we are collectively socialized to assume a role stance for the purpose of being photographed? This is a valid and necessary question, but it is the client’s reaction to perception of and feelings about the self-image that is the sought-after material.

Stewart (1979) emphasizes the commonality of the visual experience that we all share. Learning through information gathering and sharing has become more of a visual process. The use of visual media has increased correspondingly. In

*Patricia Turner Hogan is Assistant Professor, School of Social Work, San Jose State University. San Jose. CA 95129.

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PATRICIA TURNER HOGAN

treatment, learning about the self and others can at times be helped by the use of photography as our visual senses are theoretically less defended than our verbal parts. Another aspect of photography related to the increase in visual material in our society is what Stewart calls the “seductive” nature of photography. Most people respond to visual material and are particularly fascinated by visual representations of the self. Who can resist the impulse to look at a picture of oneself? This aspect enhances the usefulness of photography in treatment as it aids in establishing rapport and in maintaining interest in the process when it be- comes difficult to explore feelings and events. The seductive nature of photography also includes the general familiarity with it which may lower the initial risk of examining the material contained within. While initial defensiveness may be lessened, it has been this author’s experience that visua1 representations of the self can heighten an awareness of feelings and attitudes very rapidly and that this may be too painful for some persons at a particular time.

Another characteristic of photography is that a client can learn a set of specific skills. Theoreti- cally. any skill learning is an enhancement of the self-concept and is a positive reinforcer of learning ability. Stewart also views the acquisition of photographic skills as a “bridge to social con- tacts” since there is such a general fascination within our culture with both the processes and products of photography (Stewart, 1979).

Yet another aspect of the use of photography in the treatment process is its versatility. It can be used with many clients or with an individual, throughout the treatment process or in selected parts. As noted earlier, it can be used either ac- tively or passively. It can be used as an adjunct to a verbal process or it can be used as a nonverbal aid to elicit feelings and reflection. The field is new so there is still limited data regarding differential use with different kinds of client populations. Photographic materials have the additional advantage of being portable so they can be used in many diverse settings. The per- manency of photographs also assures an ongoing record that can be arranged in any sequence.

Techniques used can be grouped into five general categories: photos by the client, photos of the client, family album work, projective and self-portrait. The uses of each type of photograph will be briefly discussed here. Photographs that

have been taken by the client are indicative of values, interests and concerns of the individual. The client’s perception of others, relationships and the environment can be revealed through assignments to photograph various persons and places. A secondary purpose of such an assignment is that the client’s approach to a task can be observed. Photographs taken by the client of the therapist can be useful in opening up and clarifying transference issues.

Photographs of the client are a primary means of providing the client with feedback regarding appearance and presentation of self. The difference between self-perceptions and the perceptions of others may reflect unconscious distortions which may then be examined. Photographs of the client taken by others can make for discussion of the relationship with those persons. In a group setting, these types of photographs will effect some understanding of the various roles the client may assume in interactions.

Family album work is often the technique of choice when family issues are important. Recent or past photographs of family members can ease the correction of memory distortions about childhood events, appearances and role stances. They are also a means of developing awareness about family value systems. Historical and recent photographs can be compared as a means of viewing patterns in relationships and roles.

“Projective” photographs can be those taken or selected in response to a request by the therapist for a client to document a particular person, place or event. An example of such a request is for the therapist to ask the client to bring in a series of photographs (taken or assembled) of children. These are then examined for the values and perspectives contained within or projected onto the material. This technique is useful when significant material is being blocked or re- pressed. Secondarily, it is very useful as a means of value clarification.

Self-portraits are photographs taken of the client by the client or photographs of some object or person that represents some aspect of the ch- ent’s personality. This type of photograph can be usefu1 as a means of encouraging introspection and clarifying values and examining self-esteem.

CONTRAINDICATIONS

The literature on phototherapy contains little

PHOTOTHERAPY IN EDUCATION 195

discussion of contraindications. While this may be reflective of the fact that few exist, it also may reflect the relative newness of the application of these techniques and the body of literature re- porting their usage. Stewart (1979) gives three cautions, two of which relate to specific kinds of clients. Clients who are psychotic or have particular phobic disorders will not benefit from darkroom work. Feedback and confrontation techniques with realities about the self should not be used with clients whose self-esteem is very low, for it could be destructive. The third possible contraindication is that some assignments to take certain kinds of pictures may increase already present resistance which may be undesir- able and block the process.

PHOTOTHERAPY IN THE EDUCATIONAL SETTING

Phototherapy is being used in a variety of in- stitutional and noninstitutional settings with nu- merous kinds of client groups. Many therapeutic services are provided in “secondary” settings, ie, institutions that primarily serve another func- tion such as schools. In the educational setting, many children experience academic and/or behavioral problems which may be symptomatic of emotional maladjustment. Many schools provide auxiliary mental health services and phototherapy can be a useful additional treatment tool. This author has used the program described below in school settings with client groups hav- ing various learning disabilities, emotional disorders and physical handicaps.

The underlying premise of this program is that children who are experiencing academic and/or behavioral problems have an impaired self- image. It is also assumed that change is partially based on change in self-image and realistic perception of the self and behavior. There are two general goals for the program: (1) to have the children begin to understand their feelings and perception of themselves, and (2) to have the children develop a beginning awareness of the possible relationship between self-image and behavior. The groups are short-term so it should be emphasized that the goals stress the development of a heightened awareness which is then the baseline for further therapeutic work aimed at actual intrapsychic or behavioral change.

GROUP STRUCTURE

The phototherapy groups took place in both regular and specialized school programs such as day treatment settings. Although the author’s experiences are with children in special programs in both types of schools, this by no means implies that the use of phototherapy is limited to these settings. The groups were predominantly male, but this does not represent any preselection on the part of the therapist, rather that children in special classroom settings are predominantly male. The age range was from nine to sixteen years, but most groups were composed of la- tency age children. The groups were set up to last from four weeks to ten weeks with weekly sessions an average of an hour in length. The length of the program was tailored to the needs of the children as well as the structure of the setting. Each group session was structured around a specific exercise described below.

Selection of group members was done in two different ways. In one setting a presentation regarding the program was made to children already involved in a special class situation. The presentation stressed the opportunity to use cameras and to explore feelings about the self and towards classmates. Those interested be- came the group nucleus and other group members were selected by school mental health personnel. The other method of determining group composition was to utilize the class natural composition and have the entire class participate in the phototherapy group. There are advantages and disadvantages to each process: the formed group gives the therapist(s) the opportunity to exercise more control over composition, while using the natural group gives the opportunity for intervening with the process and issues that exist for the clients outside of the therapeutic situation. The primary disadvantage of utilizing the already formed group is that if the interactional process is a negative one, a therapeutic process may be more difficult to introduce and establish.

Group sessions were held both in the actual classroom and in other locations at the school. Again, there are pros and cons which are related to the client’s perception of the classroom. Chil- dren who view the classroom in a negative way may transfer those feelings onto a therapeutic process that is introduced into that setting. Con- versely, the lesser structure and different focus

196 PATRICIA TURNER HOGAN

of the therapeutic activities may dilute a negative set about the classroom by offering an alternative experience to academic tasks.

An important corollary issue is the determina- tion of the role of the teacher and other school personnel. Inclusion of the teaching personnel in the planning and actual group sessions is a means not only of gaining support for the program but, more importantly, the teacher’s involvement serves as a means of heightening sensitivity to self-image issues. While the techniques should be used by trained counseling personnel, the en- couragement of expression and understanding of self is something many teachers want to incorpo- rate into the academic environment as a means of self-image enhancement. This point will be elab- orated on in the discussion that follows the de- scription of group format.

The equipment utilized is the “instant” camera which is well suited to the group session format because it provides an image within a minute for viewing and feedback. The disadvantage of using the format is the combined cost of the film and flash necessitated by the slow film. In one group, a 35mm camera was used in conjunction with the instant format. While the clients enjoyed the SLR equipment, the lack of an image at the time of photographing is an obstacle to the group discussion format as described below. Another asset of the instant camera is its easy use that does not require any particular technical skill to make a “good picture.”

GROUP SESSIONS FORMAT

For each group session, preplanning is done by selecting the particular exercise to be done. Each session is roughly divided into three com- ponents: demonstration of the particular exercise, the picture taking and’group discussion of the photographs. In each exercise, the photographs taken are mounted on a small piece of mount board so the client may record responses. The board also serves as a record of the experience. The mounts used are the “photo comers” since the photographs can then be removed from the board if desired. In some settings, these photographs along with the child’s recorded responses are put up on classroom walls and used in an ongoing way.

Listed below are some sample exercises which

have been used in phototherapy groups (not in any specific order).

Exercise I: Me

The goal of this exercise is to have the client focus on positive and negative feelings about the self. The stress initially is on positive feelings and this total exercise (parts I and II) may actually be done over a series of several group sessions. Part I of the exercise is done as follows: (1) Each child has picture taken by another group member (any pose can be taken by child). (2) Each child then mounts the photograph of him/herself on supplied mount board and writes phrases beneath the photograph which reflect “What I Like About Myself in This Picture.” Some children may require assistance with writing. (3) The entire group is then assembled and each member shares picture and responses while the therapist’s role is to facilitate feedback from other group members. A second part of this exercise follows the same process but the responses to another photograph. of the self are “What I Would Change About Myself in This Picture” (part II).

Exercise 2: My Feelings

This exercise focuses on developing an awareness of how one appears when experiencing a variety of feelings. This perception of appearance is a base for developing congruence between feeling and appearance which is an important element in development and maintenance of relationships. The process is as follows: (1) All group members are asked to contribute verbally to a list of feelings which is recorded on a blackboard or easel, etc, so that it can be seen by all. (2) Each child is asked to select a feeling and think of an instance when it was felt. Each child is then asked to pose that feeling and the picture is taken by a classmate of choice. (3) The photograph is mounted on board and shared by the child in the large group. Group members are asked to guess what they think the child in the photograph is feeling and there is discussion as to why the photographed appearance may or may not be con- gruent with the feeling state. This can then be broadened to include issues of how the child typically responds and how this effects relationships. An alternative use of this exercise is to


have the child label feelings beneath a variety of group assembled, each child shares with other photographs of the self and then use this as the group members talking about the object and why basis for group discussion of a variety of emo- it is impo~ant. Therapist(s~ facilitate group dis- tional states. cussion and feedback+

Exercise 3: My Classmates Exercise 5: Things I See

Overall focus of this exercise is on interactions in relationships. The goals are to provide an opportunity to communicate feelings about relationships, develop beginning awareness of interactions with others and develop beginning awareness of others’ perceptions. The process for this exercise is: (1) Large group should be broken into pairs. These pairs can be predeter- mined by the therapist(s) or selection can be left open which gives information group dynamics and process. (2) Therapist(s) photograph the various pairs. These photographs are then mounted on boards. (3) Both children in each picture respond to these questions and write the responses on the boards:

What I Like About This Person What I Wish Were Different About This Person What This Person Likes About Me What This Person Wishes Were Different About Me

(4) These photographs and responses are shared with group members. Discussion can focus on various aspects of relationship such as nonverbal communication of feelings, accuracy of perceptions and how to communicate both positive and negative feelings constructively.

Exercise 4: Important Things

This offers an opportunity for self-image enhancement via photographing the self with object(s) of importance. Secondary goals are to provide an oppo~unity for enhancing self- confidence by discussing interests with peers and to increase peer knowledge of each other. The process is as follows: (1) Each client brings in an article that is “important,” “treasured,” “prized,” etc. Some limitations may have to be placed on such things as live animals. (2) Each child has picture taken with the object. Each child poses in manner of personal choice. (3) Each photograph is mounted on a board and words describing the object and why it is important are written beneath it. (4) With the entire

This is a more abstract exercise which may limit its use in some instances. The goals are dual: to have child develop beginning awareness of his/her response to surrounding and enhancement of self-image as a result of the creativity involved in this kind of assignment. This type of photograph can also be used as a projective de- vice. The process is: (1) Have the child take a picture which portrays something happy, pretty, ugly, sad, angry, etc. (2) The photographs are then utilized for discussion either individually or in a group setting. This exercise can be expanded in many different ways and may also take the form of an assignment to do a self-portrait.

Exercise 6: When I Grow Up and Other Fantasies

This exercise provides an opportunity for the expression of fantasy and for the reinforcement of positive fantasy, It also provides a format for giving feedback when appropriate regarding the relationship between fantasy and present self- image/behavior. The exercise can be done as follows: (1) Child thinks about “What I Want To Be” or other fantasy. (2) Child poses as person in that fantasy role and has picture taken by classmate. (3) Photograph is mounted on board and child writes the attributes of the fantasized person’s role beneath the photograph. (4) Group discussion can be focused on the attributes and their significance. Other fantasies, among many, that can be used with this basic format are: favorite television characters, favorite comic book characters or favorite historical person.

Exercise 7: Picture Book of Me

This exercise provides a record of the group experience as well as serving as the basis for fu- ture group and individual sessions or classroom work. The process is as follows: (1) Have child assemble all photographs taken of self during group sessions. (2) These pictures should be mounted on large board or in a scrapbook of

198 PATRICIA TURNER HOGAN

some type. Children should write words describing each photograph beneath it. (3) The finished collages should be shared with other group members and group discussion focused on group experience can be facilitated.

DISCUSSION

There are several aspects of therapeutic work in educational settings that have been highlighted for this author as issues: the relationship between education and therapy, the use of the school setting, the role of educational personnel and the relationship between academic and therapeutic activities.

Mental health services in the school setting have traditionally been auxiliary to the educational process. The functions of the school social worker or psychologist have generally been to consult with educational staff, make assess- ments, consult with families and make referrals for ongoing outpatient or inpatient services. In some settings, the role also includes ongoing therapy with a selected client caseload. In school settings for emotionally disturbed children such as the day treatment program approach, the role of the mental health worker is more extensive and the therapeutic program is considered to be of equal importance to the educational one. In both types of settings, however, there is a delin- eation between educational and therapeutic activities which is natural since the objectives of the two processes are very different. The experience of doing phototherapy in the schools has sharpened my awareness that therapy is also a learning or educational process-learning about perceptions of the self and one’s behavior. The use of photographs makes this learning process more concrete by the use of visual representations of the abstract, ie, the self. Creative teaching employs the use of visual materials and phototherapy utilizes visual material to learn about the self. Academic education is the foremost goal of the school institution and rightfully so, but perhaps phototherapy is a means of incorporating educational knowledge about the self. The phototherapy programs this author has been en- gaged in have all involved clients with some kind of identified problem, as is the norm with most mental health service populations, but it would seem appropriate to provide this kind of educa-

tional experience for all children, not just those who are already showing signs of some kind of maladjustment.

The idea of incorporating a visual process of learning about the self into the educational process leads to the question of whether this should occur in the classroom itself or in some other part of the school setting. As noted above, there has usually been a division between educational and therapeutic services, with the latter being delivered outside of the actual classroom. Academic tasks are by and large more concrete and skill-based although abstract thinking and conceptualization ability are also developed, while therapeutic activities have dealt with emotions and behaviors. The difference in focus has often resulted in the frequent difficulty experienced by school mental health personnel of incorporating and integrating therapeutic gains into the academic setting. If a process or learning about the self were to be in- corporated into the classroom, the integration between education and therapy could be en- hanced. Furthermore, the attitudes of many stu- dents to’wards the classroom setting and its academic tasks are negative and the therapeutic experience may serve to modify those attitudes somewhat. I am not suggesting that this type of program would supplant other types of therapeutic services that would more appropriately be offered outside of the classroom due to confi- dentiality and other factors.

An important aspect of using phototherapy in the classroom or school setting is the role of the teacher and the relationship between him/her and the mental health personnel. As noted earlier, the support of the teaching personnel is crucial whether sessions are held in the classroom or elsewhere in the school. While many teachers are not trained in therapeutic process, many are very aware of the impact of self-esteem on academic achievements and behavior. Phototherapy exercises and techniques can give the teacher some ongoing tools for use in the classroom with con- sultation of mental health personnel. An example of such use:

When frustrated by academic tasks, Johnny typically denies this frustration and instead begins bullying the boy in the next seat. Since this is a set pattern, the teacher takes a series of photographs of the sequence of behaviors. Put onto board labeled “When I Get


Frustrated, I Do . . .” Johnny will have a visual representation of his behavior pattern and the teacher can use this to increase Johnny’s awareness as a basis for developing alternative behaviors. Alternatives for handling frustration can be acted out, photographed and placed on board entitled “When I Get Frustrated, I Can . . .” Then appropriate handling of frustration can be rewarded.

A last consideration is whether a phototherapy program should focus at all on academic tasks or remain centered on emotions and behaviors. It has been my stance in the groups I’ve worked with to maintain the traditional separation in focus particularly since clients have been children who all have experienced some degree of academic difficulty. The reasoning has been that failure experiences with academics have created negative attitudes and resistances towards those tasks and if the therapeutic activity were per- ceived to be academic in any way, resistance to it would be heightened. Further thought and discussion, however, with others involved in phototherapy in school settings has led me to reconsider this stance. Others have talked of using phototherapy to approach some academic

tasks in a different manner that capitalized on visual approaches to learning. In my judgment, this is a potentially useful area that could result in a further incorporation of educational and therapeutic processes.

SUMMARY

This article has described a phototherapy program that the author has used in various forms with client groups in special education school programs. The discussion centered on issues and proposals raised by these experiences. There is a need for much more extensive use of these techniques and for controlled research testing of the efficacy of these techniques. Hopefully many mental health professionals and art therapists will become involved in the use of photography in the schools and add to the knowledge base.

REFERENCES

SONTAG, SUSAN (1977) On Photogruphy. New York: Far- rar, Straus and Giroux.

STEWART, DOUG (1979) Phototherapy: Theory and prac- tice. Art Psychotherapy. 6. 2-3.

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Phototherapy in the educational setting