MODEL OF INTERVENTION WITH PHOTOTHERAPY TECHNIQUES IN A HOSPITAL ENVIRONMENT
MODEL OF INTERVENTION WITH PHOTOTHERAPY
TECHNIQUES IN A HOSPITAL ENVIRONMENT
Francisco Avilés, Maria Elena Bautista, Diana Cedeño, Diana Rico
This contribution summarizes the family therapeutic work and
the research experience with patients at the National Institute of
Pediatrics in Mexico City INP, using Phototherapy techniques. The
process of integrating a therapeutic team from the Institute of the
Family (IFAC), is described, as well as the family therapy sessions
and the research outcomes. Among the problems we a have worked
with chronic renal disease with kidney transplant, development and
learning disorders, grief elaboration and dysfunctional family
dynamics associated with. Advantages of using these techniques in a
hospital environment are discussed. An Intervention model is also
Key words: Phototherapy Techniques, Family Therapy
It would be hard to imagine our world without photographic images.
Photography was born in the mid-nineteenth century and since then we
have included in our daily lives with many and varied purposes and various
forms. Photography, as we all know, is the procedure whereby an image is
captured and later fixed permanently on a sensitive surface and / or a
digital file. It is in essence the miracle to stop time and keep it for the
lifetime and beyond.
At first only a few privileged people had access to the photographic
processes and could afford to pay the high cost involving equipment,
chemicals and time to carry out photographs. Little by little, and gradually
taking pictures has becomed an accessible reality to most of us. In recent
years, with the digital photography this posibility is closer than ever, we
can show them, communicate with them, present and represent our
We can say without doubt that we have created and that we live in a
world of images that represent us.
Pictures always contain information, stories to tell and share, evoking
thoughts, feelings and significant memories in people's lives. When
viewing an image, each person gets a different interpretation and associates
their own cognitive and emotional content. While the images contain
information, it is the observer who creates the meaning, so photographs can
be used as a powerful tools in therapeutic processes.
An important precedent in the history of photography applied to
mental health, is the photographic work of Diamond (1856), who
photographed his patients as an aid in the diagnosis and identification of
different types of mental illness; he discovered that the photographs had a
positive therapeutic effect when they are shown to patients. The findings
of their research were presented at the London's Royal Society of Medicine
in the same year. (Krauss 1983)
In the book Photoanalysis (1973), Dr. Akeret described methods for
the analysis of family photographs in order to obtain information from their
Stewart (1978) defines phototherapy as the use of photographs or
photographic materials, under the guidance of a trained therapist, to reduce
or relieve painful, psychological symptoms, to facilitate growth,
psychological and therapeutic changes.
David Krauss (1980) holds phototherapy as the systematic application
of the photographic image and / or photographic processes to create
positive changes in thoughts, feelings and behaviors of clients.
Fryrear (1980) makes an analysis of the major applications that until
then had been documented in the literature on the subject, these being:
evoke emotional states, facilitate verbal behavior, model, develop skills,
provide socialization, foster expression and creativity, help diagnose,
promote verbal communication between therapist and client, document
therapeutic changes, prolong meaningful experiences and promote self-
In 1993 Judy Weiser publishes a classic book called Phototherapy
Techniques, she did a broad description of the main techniques used and
notes that the personal photos and family albums are visual metaphors of
experience; adds that the photographs can be a window to unconsciousness
and help people understand more themselves.
The five techniques described by Weiser phototherapy are based on:
1. Photos that have been taken or created by the client
2. Photos that have been taken from the client by other people
3. Self-portraits, which are photos taken from clients
4. Family albums and other biographical photo collections.
A variant of the earlier techniques is what Jo Spence (1986) called
Therapeutic Photography , which encourages the realization of self-
portraits to be used later as tools to study body image in order to work
physical appearance and consequently the self-acceptance.
It is noteworthy, according to Judy Weiser, that Phototherapy is not a
therapeutic model in itself, but a set of techniques based on photographic
images to support therapeutic processes, thus, it can be useful regardless of
the therapists theoretical framework.
It is incorrect to speak of Phototherapist as a professional identity.
The overall objective was to determine in what way Photo Therapy
Techniques can contribute to the therapeutic work with families in public
Research was conducted at the National Institute of Pediatrics (INP)
from October 2007 to May 2008. We met four families and phototherapy
techniques were used during these sessions. The National Institute of
Pediatrics (INP) is an institution of public health, located in Mexico City.
Concentrates pediatric patients across the country at the third level of
attention, that is highly specialized.
Its purpose is to provide service to Mexican children, through medical
care, research and training of specialized human resources. The INP
serving daily more than 800 children and adolescents from 0 to 18 years in
various medical specialties. It achieves more than 20 surgeries and
endoscopies per working day.
Every two days an article is published in a high level scientific
journal. More than 700 undergraduate and graduate students are formed
annually. The child population of INP comes throughout all Mexico, so it
has a wide socio-cultural and socio-economic diversity, dominated by the
lower and middle levels.
Our model of intervention
The investigation team consists of family therapists with several years
of experience working in the institution on a voluntary basis. From our
experience we saw the possibility of conducting this investigation and
implementing an innovating a creative approach to help families in their
vital process within the institution.
We have a bio-psycho-social and spiritual approach. Our theoretical
framework is based on systems theory, social constructionism,
phenomenology and narrative therapy.
We do not make an interpretative work of the patients responses , we
accompany them through new questions to help and give a new meaning to
the experiences and put them into the right direction of the therapeutic
goals that we had stablish jointly. It works in the present, past and future
to build new narratives.
The model is under construction and is still being definied from the
direct experience of working with these families.
The ethical framework of our position mainly considers respect for
cultural diversity of ideas, values and beliefs, respect for the free
expression of emotions and acceptance of differences as an enriching
element of human experience.
The method that was used for research was the qualitative
(exploratory - descriptive method). We work with what we have called a
Participative Team, which is a model in co-therapy with a mixed team
formed by several therapists for family and couples, interacting actively in
The model proposes a three stage work. : Pre-meeting (planning)
which includes only participative team, 20 minutes approximately to agree
and stablish the guidelines to be followed. The sessions, with the family
(conducting) will last approximately 50 minutes of efective work and the
post-meeting (thematic discussion and emotional elaboration) which only
meets again with the participative team.
Characteristics of the sample
In regard to the sample, four families were studied, all of them of low
income, residents of Mexico City and metropolitan areas. The medical
diagnoses registered in the files of the identified patients were: chronic
renal desease with kidney transplant, goiter colloid, learning problems,
juvenile diabetes and mourning processes.
In the family dynamics we observed multiproblem families where
other members also present physical , mental and emotional health
Being middle and lower economic resources families they find it
very expensive to attend the sessions frecuently. It implies for supplying
members not to perceive the daily economic income, therefore we see to
give them appointments taking advantage that they are coming for other
medical services needed for the identified patients.
This article is not present in detail the therapeutic processes of these
families, our main interest is to present the model with which we work and
share the general conclusions reached.
PhotoTherapy techniques used in this investigation were: self family
portrait by the identified patient, Family portrait decided by other family
members, photographs of family albums and photographs taken during the
Working with photographs takes us to the following questions:
• What title would you put in this picture?
• What story does this image account for?
• What does it make you feel?
• What does it say about yourself or your family?
• What would have to change in this image so that you would have a
differente thought and / or feeling ?
• Who took this photograph?
Families are referred to us by the different medical services at the
In the first session families come to talk freely about their individual,
and family problems and about their experience at the institut.
In this finitial meeting a family dynamics assessment is made as well
as a consideration of the identified patient clinical file. We explained to the
family that we will be working with photographs and ask them permission
to take pictures and to record the sessions.
Once we have the authorisation we clarify the doubts, if needed.
Later on we ask the identified patient to take a photograph of the
family without him or her, who will decide how and where the members
of the family should be placed. Then he/she should decide his/her place for
a second photograph to be taken by a member of the participative team.
Next the therapeutic team with the family take a new photo
altogether. The photographs that have been taken are given to the family, as
gifts and a copy is saved for us to document our work.
We invite each family member to choose and bring a photo from the
family album, something that is meaningful in order to work with it for the
After the first meeting we gather the participative team to exchange
ideas of the session contents and to propose the general and specific
therapeutic goals that will guide for our future interventions.
General therapeutic objectives
For all the cases we propose the following therapeutic objectives:
• Stablish family working goals
• Clarifying doubts about the health condition and treatment of the
• Exploring and re-orienting family beliefs concerning health
problems and medical treatments
• Stick to the medical treatments
• Improving communication among family members
• Handle family stress through the medical procedures and frecuent
• Organizing family resources
• Exploring formal and informal support networks
• Negotiating feaseable agreements and individual responsibilities
• To Handle, contain and guide positively emotional expressions
• Create awareness concerning the importance of collaboration and
support among all the members.
After the social phase of the interview, we ask them to show us the
photographs they bring and each member of the family shares the photo
chosen and the reason for the choice.
Then we ask to put a title to the picture and to talk about their own
story of the image. What is usually first done is to describe the content of
those who are present, the place where it was taken, the person who took
the photo and and afterwards what does the photo mean to the people
Stablishing connections with these memories leads to people in a
very deeply and fast way to the emotional content that the images evoke.
During the exercise photographs are taken showing emotional
interactions and nonverbal messages that occur spontaneously and make
visible other aspects of family dynamics and resources from which we will
work the relational diagnosis and then the specific aims, being these the
ones that are derived from the particular problems of the family, and from
the observed and referred material.
It is important to say that our relational diagnosis takes into account
the problems of families but we focuses primarily on the system resources,
because it is with these that we work particularly.
Given the emotional intensity that this exercise brings, it is advisable
to ensure a post-meeting for the therapeutic team to exchange ideas,
experiences and to elaborate emotions that arise in each of the therapists.
This post-meeting is also important to consider aims to work
associated with the specific family dynamics.
The team's preparation sessions take place after each session of family
From the third to the seventh session
From the third session, even though the team has some pre-defined
goals to work, the families will be the ones that based on their needs and
priorities will determine the item or items to be addressed.
It is part of our model to respect the priorities of the family reason
why we give some time for the expression of these needs at the beginning
of each session.
It is noteworthy that we dont work all the sessionss with photographs.
In situations that demanded it, we request from meeting to another, to
bring again photographs of the family album to facilitate contact between
members, promote communication, share information and emotional
relevant responses useful for the therapeutic process.
We work based on the photographs that we have taken during the
sessions, we present them and formulating the following questions:
What is the story that these pictures have?
What do they say about you and your family?
In this session we make a review of the obtained achievements and
ask to each member of the family on an individual basis to express their
thoughts and feelings about the experience of having worked in the manner
proposed and the changes it has brought to his personal daily life, both
individually and for the family dynamics
In the closing session we invite them to express “what follows for
their family life”, reinforcing the positive aspects and the obtained
achievements , we work in order to stablish new goals for the future life
and give them the botton line of a collaborative work in the family.
Each therapist makes a devolution of his/her personal experience,
reinforcing individual and family resources. All together we make a ritual
Up till now the presentation of the model.
Next we shall share the difficulties we have encountered, the
contributions of our work and the conclusions which we reached in this
early stage, outlining the projects that will continue over the next steps and
making recommendations for future research.
Associated with the model: time agreed for the sessions:
Originally we thought it would be possible to work with
phototherapy techniques, in the same way as we do in family therapy
sessions excluding these techniques. Quickly we found out that the 50
minutes format was inadequate to the extent that this time does not allow us
to work deeper if we want that all family members can participate and
expressed themselves widely, which is not only desirable but essential.
Difficulties associated to the family dynamics
Eventhough these families are organized around the suffering
institutional identified patient, they experience as any other family system,
tensions, difficulties and failures both at individual and relational level.
This leads us to consider them as multiproblems families in which it
will be necessary to seek adaptive systemic changes for the entire family
and the individual needs of each member and not only focus isomophicaly
on the identified patient´s needs .
Even having previously established lines of work and aims to reach,
family needs have priorities and there is a need to address them at the
beginning of each session and to work as long as necessary. This implies to
changes the strategy and requires rethinking of the immediate objectives.
We consider important to be flexible and adapt to the demands of families.
Another difficulty encountered revolves around the availability of members
and economic problems associated, to the extent that members of the
families have to leave their daily responsibilities, work, schools and so on,
and that affects the economy functioning of the family; quite often the
main economic provider is unable to attend the meetings. The distance and
the time it takes to get to the hospital (on average more than two hours
round, time of meetings and two hours back) per trip, is also a factor to take
into account to set the frecuency and schedule for sessions.
Difficulties related to medical and institutional priorities.
At this early stage due to of refurbishment works and the scarse
availability of spaces in the hospital we did not have adequate facilities
according to the needs of our model. It is important to say that our
interventions are a support for medical services and that we are dependent
of their priorities. The health status of patients and last minutes medical
decisions obligued us to be flexible and respectful and often change the
direction and intensity of our work.
Contributions of our research
It is our understanding that this research is a pioneer in the use of
phototherapy techniques applied to families in a hospital environment with
a bio-psycho-social and spiritual approach in our country. We have no
information that these techniques have been applied by a Participative co-
therapy team in any other study, nor in our country or outside it.
• Working with cameras and phototherapy techniques generates
acceptance and enthusiasm in families and therapists
• Working with cameras and voice recorders was useful for the purposes
of this investigation
• Phototherapy techniques help establish a good therapeutic hitch
• It is esear to approach the privacy of families
• There are clearly observed potential alliances, coalitions and family
physical and emotional closeness between family members.
• Is it possible to include symbolically absent members
• Facilitates the grief work
• Promotes more verbal and nonverbal exchanges
• Photographs provide information about the socio-cultural context of
• Giving photographs of meetings with family members and the
therapeutic team, helps the creation of the emotional link and the
establishment of a collaborative work.
• Through photographs family members who no longer live are
symbolically present at these working sessions.
• Through photographic images, the participative team can get to
know the life stories of families and their contexts.
• It promotes greater awareness and attention to the needs of other
• We note that in the hospital environment the families with one
chronically ill member join spontaneously and bring support to each
other in various ways, both from instrumental and emotional point of
• Due to the intense emotional expression in the sessions, it is
imperative that the team should be made up by well-trained therapists
with expertise and knowledge of phototherapy techniques
• It is advisable to work in a space that allows movement,
comfortable and well ventilated
• We recommend working sessions from 90 to 100 minutes
• It is suggested to record, photographe and video film sessions as
teaching aids , if it is authorized by the family and the hospital.
• To promote an ongoing dialogue with medical specialists
responsible for the physical health of patients
• We propose a working model in which families work together with
their experience to help other families facing similar situations.
• It is proposed to design research projects to address specific
problems of each medical specialised service.
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