Feb 29, 2012
Through the Eyes of a Survivor: A Pilot Study to Examine the Use of a Photovoice-based Support Group for Women Survivors of Family-Based Interpersonal Violence
|Laura Beth Haymore, MPH
Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
725 Martin Luther King Jr. Blvd. CB #7590
Chapel Hill, NC 27599-7590
|Mary Y. Morgan, PhD
Human Development and Family Studies
The University of North Carolina at Greensboro
PO Box 26170
Greensboro, NC 27402-6170
|Christine E. Murray, PhD, EdS, MEd
Counseling and Educational Development
The University of North Carolina at Greensboro
PO Box 26170
Greensboro, NC 27402-6170
|Robert W. Strack, PhD, MBA
Department Head, Associate Professor
Public Health Education
The University of North Carolina at Greensboro
PO Box 26170
Greensboro, NC 27402-6170
Stokes, Surry, and Yadkin County Domestic Violence Agencies
114 West Atkins Street
Dobson, NC 27017
|Paige Hall Smith, PhD, MSPH
Associate Professor, Public Health Education
Director, Center for Women’s Health and Wellness
The University of North Carolina at Greensboro
PO Box 26170
Greensboro, NC 27402-6170
Fax: 336- 334-3238
Family-based, interpersonal violence (including child maltreatment and intimate partner violence [IPV]) is widespread and carries many potential negative and long-term consequences (Arata, 2002; Black & Brieding, 2008; Campbell, 2002; Centers for Disease Control and Prevention (CDC), 2007; Coker, Smith, Bethea, King, & Mckeown, 2000; Frieze & Brown, 1989; Irwin, 1999; Kovac, Klapow, Kroenke, Spitzer, & Williams, 2003; Max, Rice, Finkelstein, Bardwell, & Leadbetter, 2004; Tjaden & Thoennes, 2000). Children who have been abused often later experience other forms of violence as adolescents and adults (Smith, White, & Holland, 2003; Widom, Czaja & Dutton, 2008). Hence, a need exists for interventions that help both recent and long-term survivors come to terms with their abuse, develop positive social support, and develop nonviolent lives and relationships (Larance & Porter, 2004; Morgan, 2007).
The current study aimed to implement and conduct a pilot study examining the effectiveness of a photovoice-based methodology to elicit experiences and offer support to women survivors of family-based interpersonal violence. Photovoice is a technique of putting cameras into the hands of participants and allowing them to take photographs and write narratives about those images, allowing participants an opportunity to define the problem through their own perspective (Wang & Burris, 1997).
Photovoice intervention methodology is informed by feminist theory and research, critical theory, and participatory action research. Feminist theory recognizes that knowledge is socially constructed (Gross, 1992; Campbell & Bunting, 1991). There is no universal truth; rather, what we know is influenced by systems of privilege and oppression that are structured in our social institutions. Feminist theory focuses on women’s experiences as a source of knowledge that has been traditionally ignored or marginalized. Second, feminist theory connects everyday life events with an analysis of the social structure (Cook & Fonow, 1990). This allows for a critique of what is accepted as normal and as a result provide a vision for what could be. Finally, feminist theory advocates for social transformation (Cook & Fonow, 1990; Hartsock, 1986; Lather, 1986; Thompson, 1992).
Feminist theory and research provide a gendered framework for undertanding and interpreting women’s experiences in ways that seek to help achieve gender equality. It is contextual, inclusive, and socially relevant (Nielsen, 1990). Women are considered to hold valuable knowlege about their own lives (Mies, 1983). Thus, collaboration and interdependence between the researcher and participant are valued elements of feminist research (Campbell & Bunting, 1991; Oakley, 1981). Feminist research is often “value-sustaining and politicized inquiry” (Thompson, 1992) in that it exposes power relations and critiques the status quo through a connection between the personal and the political. This often occurs through consciousness-raising (Fonow & Cook, 1991). At its best, feminist research is emancipatory (Alston & Bowles, 2003).
Critical theory presumes that people are capable of recognizing unjust social conditions and creating less oppressive ways of living than what they have known (Freire, 1973; Lather, 1986). The goal is to emancipate individuals by helping generate newer and freer possibilities for society (Geuss, 1981). This process requires mutual respect, trust, and cooperation between researchers and participants; the method is dialogue over a collective experience (Freire, 1973; Lather, 1986).
Participatory action research employs both feminist and critical theories to address practical concerns and contribute to social change by empowering the participants (Small, 1995; Reinharz, 1992, Lather, 1986). Photovoice is a type of participatory action research that engages a group of exploited individuals in recording and critically reflecting on their everyday lives (Brydon-Miller, 2001; Morgan, et al., 2010; Strack, Lovelace, Jordan, & Holmes, 2010; Wang & Redwood-Jones, 2001).
Review of the Literature
Photovoice is a methodology whereby participants are given the opportunity to photograph their everyday lives, create narratives about the photos, and dialogue with each other in order to make meaning of their collective experience. Wang and Burris (1997) were the first to describe the concept of photovoice as an active strategy for understanding and improving the health of individuals and society. Photovoice enables participants to use self-generated images to make a visible reflection of self in their current environment and in social situations. Participants are able to write narratives to accompany the images providing participants a unique opportunity to tell their story in a creative manner. According to Wang (1999), photovoice is a tool that can be applied to women’s health because the idea of this photographic technique is grounded in feminist theory. This is well suited for providing voice to women and allows women to carry out programs by and with women in order to honor their intelligence and first-hand experiences. In addition, Wang (1999) notes that photovoice has the potential to better the lives of women in areas such as education and violence prevention.
Visual reflections of oneself can help participants with family-based interpersonal violence experiences capture moments that played a role in their social relationships, while providing an outlet for their perceptions regarding current and past relationships (Harrison, 2002). The photographic images and narratives are not only a reflection of self, but also are reflections of what the participants choose to capture, record, and share (Harrison, 2002). These self-defined “truths” participants generate have the potential to help them move forward into a life that is not characterized by interpersonal violence. Photovoice can also be used by health promotion practitioners to foster social support (Wang, Cash, & Powers, 2000). It also allows women the opportunity to not only tell their story in a creative manner but also help them forge relationships that can serve as a foundation for new social networks.
Social Support and Intervention Approaches with Survivors
Using photovoice to create a common language of understanding among a small group of formerly abused women builds on our understanding of the importance of social support for healing and growth. Social support is an important component for victims of interpersonal violence because of the ability to increase perceived mental health, improve self-esteem, and reduce morbidity (Coker, Smith, Thompson, & McKeown, 2002). In addition, abused women who have support networks are more able to seek out resources that help them break free from the abuse. These networks increase the likelihood that abused women will have their needs met (Bosch & Bergen, 2006; Dunst, Trivette, & Deal, 1994), thereby helping them free themselves from the cycle of revictimization. Unfortunately, victims of interpersonal violence have reported that they often do not seek social support because service providers blame them for the abuse, they feel uncomfortable discussing their experiences, and/or they receive no help from formal and/or informal support networks (Coker et al., 2002). A lack of formal and informal social support has been associated with poor perceived mental health and psychiatric morbidity in abused women (Coker et al., 2002; Romans-Clarkson, Walton, Herbison, & Mullen, 1990).
Davis and Taylor (2006) conducted qualitative research using a feminist approach with women who were leaving abusive relationships. They found that allowing women time to talk about their past experiences with abuse and how they were moving forward provided women with both new insights about their experiences and opportunities to reflect. This process contributed to the women’s ability to heal and recover (Davis & Taylor, 2006). Taylor (2002) found women were more likely to tell their stories if they believed that self-disclosure would help other women in similar situations. The women felt socially responsible for other women who supported their ability to tell their stories.
Through participant observation of battered women support groups, Larance and Porter (2004) found that women were able to give a voice to their experiences of abuse and survival. The women were able to reflect on their experiences and have those experiences validated by other women with similar experiences of interpersonal violence. The process of these women telling and retelling their stories helped them to reveal and reclaim their identities while building supportive social networks with other women and service providers.
Process of Reclaiming Self
Merritt-Gray and Wuest (1995) described the theoretical framework of reclaiming self in order to explain the process of leaving an abusive relationship. Women are active agents in trying to find diverse ways to minimize and stop the abuse while also taking risks to leave and end the relationship (Merritt-Gray & Weust, 1995; Wuest & Merritt-Gray, 1999). Through these diverse methods women slowly begin to take on a new image not characterized by their violent past (Wuest & Merritt-Gray, 2001). Overall, the process of reclaiming self is a social and interpersonal process that illustrates leaving is not a singular act, but rather a cyclic process that can take many years.
In further research on the process of leaving and recovery, Farrell (1996) described the process of healing from an abusive relationship. The process of healing began by putting the abuse into perspective and reconnecting fragmented pieces of self in order to help produce a sense of wholeness (Farrell, 1996). In addition, the women felt an integral part of their healing was a direct result of their interaction with and support from other women who had similar experiences of interpersonal violence.
This pilot study, entitled “Through the Eyes of a Survivor,” was designed to examine the potential use of a photovoice-based program with survivors of family-based interpersonal violence. The purpose of this 10-week project was to further empower women who had survived family-based interpersonal violence by providing them with a supportive environment. In this environment, they could take photographs that capture their experiences with abuse and and write narratives about them. This study was a partnership between a university-affiliated research team and a rural domestic violence service agency. This pilot study was approved by the Institutional Review Board (IRB) at the University of North Carolina at Greensboro.
To be eligible for this study, participants had to have experienced some form of family-based interpersonal violence, had to have been removed from that violent situation for at least one year, and had to have received services from the collaborating domestic violence agency. The domestic violence agency’s program coordinator reviewed recent agency files to identify a list of five women who met the eligibility criteria and had previously sought the agency’s services. The women were invited to participate in the program and pilot study.
All five women agreed to attend a recruitment meeting where the study was explained by the first author and participants had the opportunity to ask questions. All five women agreed to participate in the program and study. A meeting time was set so that the women could sign the necessary paperwork and receive digital cameras and personalized journals that they would use during the study. The paperwork included a consent form and a confidentiality form. The forms indicated that the study participants agreed not to share what they heard or learned during the study, while agreeing not to disclose the location of the group meetings. As an incentive for participation, all five women received a “thank you” $10 gift card to a department store. The women were informed that they would be able to keep the digital camera if they completed all aspects of the program and study.
The main instruction provided to participants at the onset of the study was to take photographs representing the individual (the person and/or their partner), family, community, and societal factors that described their experiences with family-based interpersonal violence. Participants worked independently during the ten weeks on the photography and narrative component of this program. Specialized journals were developed as part of this process. The journals included questions that would help shape, but not limit, the women’s narrative stories about their photographs. The following questions were used in the journals: (a) What pictures did you take and why? (b) Were there pictures that you wanted to take but did not (and why)? (c) Why are these pictures important to you and what do they mean to you? (d) What do you learn about yourself, and/or your partner, family, community, or society by looking at this picture? (e) What do you think this picture tells other people about you and/or your partner, family, community, or society? and (f) What can these pictures tell or teach others about domestic violence?
Participants met together for a total of five bi-weekly meetings where they shared and discussed their photographs, narratives, and experiences in a supportive group setting. Each bi-weekly meeting lasted approximately for two hours. The first author and the domestic violence agency program coordinator co-facilitated the group meetings. After each meeting, the first author recorded field notes. These meetings were not recorded, and field notes contained no identifying information. Before the fifth and final meeting, participants were asked to choose photographs and narratives they had taken over the duration of the study that could be used as part of the data analyses and examination of this project. Participants were informed that they did not need to submit any photographs and/or narratives that they wished to remain private.
Data Collection and Analyses
The photographs, journals, field notes, and a focus group transcript were used as data for this study. Each participant determined which photographs the research team was allowed to keep. In addition, each participant provided a digital copy of each photograph and signed a separate photograph release form for each photograph she wanted released. The research team only accepted photographs that did not reveal the identity of the participant.
At the end of the fifth meeting, the women participated in a focus group discussion about their experiences with the photovoice program. The focus group lasted approximately 45 minutes and was digitally recorded. The focus group was based on a semi-structured interview guide, which included the following questions: (a) What did you think when you were first asked to participate in this program? (b) How did you like the process involved in this program? (c) If you had to change anything about the process, what would it be? (d) How has this experience helped you? and (e) Would you still want to meet as a group after this program is over? These questions were designed to elicit both general impressions about the program and suggestions for improving the program in future implementations of it. The first author, who facilitated group meetings, also facilitated the focus group discussion.
The focus group recording was transcribed verbatim. Multiple authors individually analyzed the transcripts providing repeated reviews of the data to determine all relevant topics and codes (a single word or limited number of words to categorize topics). Several common themes emerged that helped us assess the impact of the program and its strengths and weaknessess.
The participants were white women, ranging in age from 19 to 52 years old, who lived in a rural area. These women had been free of any abusive relationship between 3 and 20 years. Three of the five women had never participated in any type of support group, and none of them had received any private professional counseling. All five had experienced different forms of family-based interpersonal violence. Two of the women had experienced abuse by a male partner, one participant had experienced childhood psychological abuse, one participant experienced childhood psychological and sexual abuse as well as dating violence, and one participant had experienced childhood physical and psychological abuse and abuse by multiple male partners.
As a group, the women released 50 photographs and 34 narratives. The photographs and narratives demonstrate the diversity of applications of the photovoice approach within this program. Table 1 provides a description of each participant, presents one selected photograph and its accompanying narrative for four of the participants, and common identified themes. We decided not to present any of the images taken by one of the participants to maintain her confidentiality and also due to copyright restrictions (i.e., photos were taken from the internet to illustrate her feelings regarding her experiences). Information describing the participant as well as a selected narrative is provided in the table.
The photographs and narratives represent some of the ways in which the program participants used photovoice to illustrate their experiences as survivors. Some photographs and narratives were used to depict actual experiences in the participants’ own lives. Others illustrated emotional reactions to past experiences of abuse and were symbolic rather than literal illustrations of their experiences. Other photographs and narratives illustrated participants’ current progress toward moving on from past experiences of abuse. In addition, some photographs and narratives demonstrated participants’ general attitudes toward family-based interpersonal violence.
Focus Group Results
Benefits of the Photovoice Program
The primary purpose of the focus group session was to identify the potential benefits and problems or challenges faced by using a photovoice-based support group from the perspective of the participants. The four primary benefits that participants received from the program are summarized in this section.
Creative expression. The participants indicated that they benefited from the creative expression they were afforded through the photographs taken. They described how these photographs provided them with a creative and safe opportunity to openly discuss and reflect their pasts. Some found it easier to tell a story of a picture. As one participant said, “You’re telling the group a story about a picture, not about you.” Another said, “I think the pictures were really helpful as a jumping off point and plus, it got me to thinking about, well, both good and bad.”
Processing experiences. The photovoice program allowed participants to process their unique experiences and move on at their own pace. Participants felt the program was useful because it created a unique opportunity to discuss experiences before, during, and after the violence. A participant described the benefit of examining the actual experiences of abuse through the program as follows:
“I think that’s what some of us had done and we have not talked too much about what really happened in the middle of it. I think it’s kinda like a dance; we’re just kind of dancing around it and then if we kept meeting, we’d probably give into the meat of it.”
Another participant described the value of being able to process their experiences of moving on, as one of the women said:
“I think because we’ve moved on…. I guess I’m through with it. It’s over and done with and I’ve moved on. Hopefully.”
Even though the women had been free from violence for a wide range of years (3 – 25 years), they were able to share their experiences of recovery as described in the theoretical frameworks of reclaiming self (Merritt-Gray and Wuest (1995; 1999; 2001). The photovoice program allowed them to process their unique experiences and move on at their own pace.
Addressing blame. A third benefit for participants was that the program helped them to address the issue of blame and to realize that they were not at fault for the abuse. This sentiment is reflected in the following quotation from one of the participants:
“You know, you couldn’t prevent what he did. You didn’t know about the resources that were available or if they were available at all. So you blame yourself for what happened because you didn’t or couldn’t leave. Looking at the pictures helped me come to terms and realize it was not my fault.”
Social support. Participants indicated that they benefitted from the social support they received through the program, illustrated by the following statements from three different participants:
“This was a comfortable setting for me because I know that I wouldn’t feel judged because you guys had come out of the same thing.”
“The group was not rigid, like other support groups. There were no guidelines or manuals to follow. We just talked and lifted each other up. That made it easier to talk and figure out things out.”
“It [the intervention] has made me appreciate; it’s made me appreciate all of y’all. I knew you all but it, it made me thankful that I did know you. And I do know your story and I’ve just found really good friends in it. I’m thankful to be a part of it.”
Their statements are testament to the social support derived from the program and how it contributed to their empowerment. Furthermore, the social support created a safe environment where participants could openly talk and heal as a result of their interactions and support from each other.
Overall, the women indicated that they benefitted from the program because they were able to document their own stories creatively while being supported by other group members with similar experiences. The non-judgmental environment permitted them to reflect on their own experiences and where they were in the healing process.
Suggestions for improving the program in the future
Two encouraging findings for this pilot study of a photovoice program based on feedback from the focus group results are 1) the participants stated that they would like to continue meeting as a group following the termination of the formal program and 2) the participants indicated that they would like to help start other similar groups, perhaps by serving as facilitators of these other groups. Both indications demonstrated that the women were taking ownership of the program. In an effort to identify strategies for improving the program in the future, participants’ suggestions for improvement were noted throughout the program in the field notes and were also solicited during the focus group. These suggestions related to such issues as the timing and format of the program meetings and possible extensions of the program beyond its initial implementation.
Program Timing: Regarding the timing of the program, participants indicated that they would have liked for the program to have been longer and involved more meetings. When asked what she would have liked to change about the program, one participant noted:
“The length of time that we had to do this. I feel that, maybe, everybody felt pressured to have a picture to talk about at every meeting. So we all had pictures to talk about at every meeting. So I feel like if I would have had more pictures, I would have talked more personally about each thing.”
This statement suggests that participants may have felt that the ten-week timeframe, with five meetings within that time, was insufficient for providing ample time to share and process the many stories shared by participants. Another timing-related suggestion was to consider changing the length of time allocated for each group meeting. Although each meeting was scheduled originally for one hour, most meetings lasted for approximately two hours. The meetings were allowed to run for this length of time because the facilitator felt it best not to hinder the discussion or the participants. During the focus group discussion, however, participants reported that they wanted a clear start and end time for each meeting.
Program Format: Other suggestions mentioned by participants related to the format of the program. First, although the format of the journals provided to participants for their narratives was paper-based, participants explained that they found it easier to express their feelings if they could type rather than handwrite their narratives. Participants wanted and were provided with an electronic copy of the journal in addition to the hard copy. Participants also suggested that a mechanism be created so that they could share their photographs with one another prior to the group meetings. They indicated that this prior viewing of the photographs might facilitate more in-depth discussions because others would have a chance to formulate questions to ask before the meeting. One specific suggestion related to this was to create a secure on-line forum through which participants could communicate with one another between meeting times.
Another format-related suggestion related to the focus of the stories the women would have liked to share with one another. As the group progressed, participants reported that they would have liked to shift away from focusing primarily on the past experiences of violence to a greater focus on pictures and stories relevant to their present lives. This emphasis of focusing on the present and looking to the future is reflected in the following exchange between two participants:
Participant A: “I think with, I think even if you shared the pictures sometimes, it’s not domestic violence…. Even if we continued with the photos and I think that would be something to continue, it doesn’t have to be about that because I think now is the time that I want to start talking about other things….”
Participant B: “and celebrating the rest of our lives together.”
Participant A: “Exactly.”
Participant B: “Instead of revisiting.”
Program continuation/extension: The final suggestions made by participants related to how the program could be extended. In particular, participants were asked to share their opinions as to whether they would like or find it helpful to host a public exhibition of their photographs at the completion of the program. This question was asked in the focus group because photovoice studies have often resulted in participants conducting photo gallery exhibits as a form of social activism to change beliefs regarding a specific issue (Booth & Booth, 2003; Rhodes, Hergenrather, Wilkin, & Jolly, 2008). Hence, we had raised the possibility of a public exhibition at the beginning of the program; we clearly indicated that partcipants would have final control over whether we had such as showing, and if we did, what photographs were exhibited. During the focus group, participants revealed mixed reactions to a public exhibition. Some of the particiants indicated that they may have engaged in some self-censorship since they had known from the beginning that a public viewing of self-selected photographs was an option. This suggests that a public exhibition following the program should be considered carefully in future implementations of this program.
Some of the concerns raised about the potential of a public exhibition included how intimate the stories are that would be shared through the gallery, fears of being judged by individuals who could not understand their experiences and the related choices that they made, and the possibility of stereotypes about victims of violence being raised. On the other hand, participants also indicated that they believed that a public gallery could hold the benefits of changing the public’s opinions about family-based, interpersonal violence and changing social norms regarding violence against women and children.
Prior research suggests that women who are survivors of family-based interpersonal violence and have supportive social networks are more likely to have improved self-esteem and are less likely to report poor mental and physical health (Coker et al., 2002). The idea of social support and healing is supported by the existing literature (Davis & Taylor, 2006; Farrell, 1996; Larance & Porter, 2004; Taylor 2002). The findings of this small pilot study suggest that a photovoice-based support group may offer several benefits for survivors. Because this program was implemented with only five participants in one community, it was not meant to be representative of other women in other communities.
Our findings suggest that the program did help the participants to creatively express their stories of past victimization, discuss the range of their lived experiences with violence, address issues of blame, and increase their available social support. Our findings suggest that five meetings over ten weeks provided time for the women to connect as support group, find common ground, and process many of their expriences in a creative and benefical way. Photovoice did, as Wang (1999) discussed, provide a forum that honored their intelligence and first-hand experiences. Our findings reflect the ways the participants were empowered to move to new ways of thinking about their experiences and the role of photovoice, founded in feminist and critical inquiry, in facilitating that process. Photovoice is a creative outlet that can be used by women who demonstrate low literacy. Such women could record their narratives with digital or audio recorders and have narratives transcribed by project staff. Alternatively, project staff can take field notes of participants’ stories during group meetings and then meet separately with the participants to ensure that their stories and messages are correct. Photovoice is a relatively inexpensive, uncomplicated method that can be added to existing support groups and networks. Disposable cameras that take digital images are readily available, and quality images can be printed off personal computers or at chain photo stores at relatively little cost.
Implications for Practice and Theory
The sample size in this pilot study was small. Future research exploring this methodology should be conducted with larger samples and with other groups of women in different communities. In addition, there is a need for an extensive evaluation of a similar program with a larger more diverse sample size. Basic research about the process of moving on and recovering from experiences of victimization is needed. Evaluations may warrant a focus on characteristics of participants that may make them more or less amenable to this approach (e.g., length of time since abuse, existing level of social support; multiple victimization experiences, and cultural background). For groups that may want to offer a public gallery of the photos at the close of the program, the first step would be to discuss this at length with all of the participants to assure them that they retain full contol over whether they want to include any of their photos and how their photograhs are used.
This pilot study contributes to the existing body of literature on research and theory grounded in the experiences of vulnerable populations, by combining multiple theoretical frameworks and methodologies to create an innovative program that has the potential to help survivors move on and recover from their experiences of victimization. This 10-week intervention program allowed the women—even though they had experienced different types of violence—to come together in a supportive, safe environment to discuss their photographs, narratives, and experiences with one another in a creative non-judgmental way. This program illustrates the way in which photovoice can be used to empower at-risk groups, including those who have experienced family-based interpersonal violence.
We would like to thank the domestic violence agency that helped to recruit the participants who took part in this study and made this project a reality. In addition, we would like to thank the participants themselves for their willingness to participate and for being open about their lived experiences.
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