Recovery through the Eyes of Individuals with Multiple Complex Needs: A Photo-Elicitation Study

Background and Purpose: Mental health recovery has become a guiding principle in services for persons with serious mental illness. The applicability of recovery, however, is challenged by the existence of other forms of adversity, in particular homelessness and substance abuse. Further research is needed to understand the recovery experiences of those with multiple complex needs when transitioning to housing and greater stability. In this study, photo-elicitation interviews (PEIs) were used to examine recovery within this population over a 12-month period. Research questions include:

1)    What do PEIs reveal about mental health recovery over time?

2)    What are the spatial dimensions of recovery as manifested in photographs and accompanying narratives?

Methods: PEIs with 14 adults with co-occurring mental and substance use disorders were conducted from 2011 to 2013. Participants were purposively sampled from a larger qualitative study examining mental health recovery among homeless consumers newly enrolled in supportive housing programs in New York City. PEIs were conducted twice, 12 months apart, to capture changes in recovery experiences. At each wave, participants were asked to take 18 photographs about positive and negative aspects of their lives and then describe and narrate the photos in an interview.

Photos embedded within interview transcripts were independently co-coded by the authors and meetings held to establish consensus and develop themes. Content analysis was also used to categorize the photographs. The addresses of where the photographs were taken were located with the aid of Google Earth and Google Maps and reverse geo-coding was used to plot them on a map using GIS (ArcMap v.10.2). Geographic distributions of the photographs were analyzed to ascertain differences across participants and over time.

Results:  Content analysis yielded nine photo categories: 1) apartment, 2) health/mental health/substance use services and experiences, 3) recreation/leisure, 4) neighborhood scenes, 5) public art, 6) religious/spiritual activities and experiences, 7) social relationships, 8) work/school/volunteer experiences, and 9) transportation. Four themes emerged from the coding and thematic development: 1) comforts of home, 2) social relationships matter, 3) “not enough has changed” and 4) “I’ve come pretty far”.  Themes were juxtaposed cross-categorically with the content categories for each wave of the PEIs. The largest content category for the second wave of PEI was social relationships (27.3%), which was comparable to the baseline frequency. Except for health/mental health/substance use services and experiences (+17.7%), public art (-8%), neighborhood scenes (-10.4%) and recreation/leisure (+7.6%) categories, the photo content categories were comparable across the two waves of PEIs. The geographic spread of photo locations remained largely the same between baseline and 12 months with clustering in Northern Manhattan and the Bronx where most participants lived.

Conclusions and Implications:  PEI provided an innovative opportunity to explore the recovery experiences of individuals with complex needs over time.  It also brought active engagement by participants who shared aspects of their lives and narrated their meaning as they saw fit. Understanding of recovery is enhanced when viewed through participant-controlled visual and spatial media and should be employed in future research.