Abstract
Almost one-fourth of college students are living with a mental illness. Although much discussion has taken place on the mental health of today’s students, information from the students living with mental illness is lacking. The purpose of this study was to allow college students living with mental illness to document and communicate their realities with peers and university stakeholders through the participatory action research methodology, Photovoice. Seventeen college students who were prescribed at least one medication used to treat mental illness were given disposable cameras and asked to take photographs reflecting their realities of living with mental illness. Students met individually with researchers for reflection and as a focus group with other participants to discuss their photographs. All meetings were audio recorded, transcribed and qualitatively analysed. An additional meeting was held to communicate the students’ realities with campus stakeholders. Main themes identified were: insights into campus services, increasing awareness and educating others, support, and barriers to getting better. Photovoice was an effective methodology to allow college students living with mental illness to communicate with campus stakeholders to increase awareness and education. Through the sharing of photographs and reflections, policies and practices affecting students living with mental illness are being examined.
Introduction
Mental health of students on college campuses is becoming a growing concern. Approximately 25% of American college students are diagnosed or treated with a mental illness annually, and 73% of college students living with mental illness experience a mental health crisis on campus. 1 Research has shown that the experiences of college students living with mental illness differ from those of the general college population. For instance, students living with mental illness generally report less engagement, strained relationships, and lower academic performance.2,3 In alignment with this growing concern, literature has called for student input into campus services and policies to prompt recovery in college students with mental illness. 4
Background
Although statistics and surveys have given insight into the prevalence and struggles of living with mental illness on college campuses, needs of students still remain unmet. Key higher education stakeholders called for ‘Recognizing patterns in campus life that suggest the presence of mental and behaviour health concerns among individual students, groups of students, or the campus environment itself’. 5 Perspectives from students themselves have the potential to point out unexplored directions and untapped potential for addressing mental illness. To this end, we undertook a participatory action approach to allow students to share their experiences of living with mental illness on a college campus.
Photovoice is a participatory action research methodology as it emphasizes empowerment and individual and community strengths and balances research and action. 6 Its theoretical underpinnings promote deep understanding of lived experiences and encourage the participant to construct and share their reality visually.7–9
In the Photovoice method, participants are asked to photograph their everyday reality and focus on issues that are important to them.10,11 Those photographs are then used to aid in individual and group reflections to communicate realities and motivate change.12,13 Photovoice has previously been used for advocacy and to bring insight into health.6,14–18
The purpose of this study was to explore students’ experiences of living with a mental illness on a college campus from their own visual perspective and to put forth student-generated observations on current practices and experiences to improve the lived experiences of others like them.
Methods
Recruitment efforts for this study included an informational email through the campus student Listserv, flyers displayed throughout campus, and referrals from student service representatives. Participants were eligible to participate if they were a student currently enrolled in the institution, at least 18 years of age, their own legal guardian, and self-reported to be prescribed at least one medication used to treat a mental illness. Advertised incentives for participation included the provision of a meal at all focus group meetings and entry into a gift card drawing on completion of the study. All potential participants were asked to attend an informational meeting (Meeting 1) before agreeing to participate.
Full participation in the research included attending 4 meetings. As previously mentioned, Meeting 1 was an introduction to the research where interested individuals were provided study information, met members of the research team, and asked questions. During this informational session, potential participants listened to a presentation on Photovoice, which was provided by a member of the research team which included information on how Photovoice has been previously used (including ethical and legal implications), examples of previously published works and results, and how to actively participate in the research. If they chose to participate, individuals gave their consent and were then given a 24-exposure disposable camera and asked to envision they were preparing a photographic display titled ‘Living with my Mental Illness on a College Campus’.
Participants were instructed to take as few or as many pictures as they felt necessary up to the 24 exposure. The institutional review board that approved this research also required participants to avoid taking pictures of incriminating activities and of other individuals without written consent. Participants were also asked to reflect on each photograph they took in a provided journal.
Participants had 10 days to take photographs and return the cameras and journals via campus mail to researchers who then developed the photographs through a 1-hour photo processing centre. All photographs were developed in duplicate to allow participants and researchers to each retain a copy.
Once photographs were developed, at least 1 researcher met with each participant individually for Meeting 2 during which the participant verbally reflected on each photograph. To aid in reflections, researchers asked the participants to discuss each photograph using the SHOWED technique given in Table 1, which has been previously used in Photovoice research. 19
SHOWED technique.
At the end of Meeting 2, each participant was asked to choose 5 photographs of highest importance to them and which they felt comfortable discussing in a group for Meeting 3. During Meeting 3, all participants met as a group with the researchers. Each participant took turns presenting their chosen 5 photographs using the SHOWED technique. Other participants were encouraged to engage in dialogue and share similar or differing stories or experiences during the photograph presentations as well as ask questions of each other.
Meeting 4 was designed as a presentation to campus stakeholders. Campus administrators and student service representatives from areas such as Residence Life, Disability Services, Student Health Services, and Student Success were in attendance. Participants again were asked to present their 5 chosen photographs to the audience. After all students had presented their photographs, the observing representatives were encouraged to ask follow-up questions. A psychologist from the campus Counselling Centre was present for all meetings in case there was a need for consult or intervention. All meetings were audio recorded and transcribed.
Data were analysed using a modification of the 3-stage participatory group analysis developed by Wang and Burris. 13 The 3 stages are (a) selecting photographs that most accurately reflect the participants’ views, (b) contextualizing the photographs, and (c) codifying issues, themes, or theories that emerge. Stages (a) and (b) were completed by the participants in Meetings 2, 3, and 4 as previously described. The researchers collaborated to complete a qualitative analysis for Stage (c) that used a grounded theory approach. The authors jointly performed line-by-line open coding of the transcriptions, thereby creating a list of codes based on content, while also noting their relevance and frequency. Final coding structure was created using an iterative process. A theme, identified as a concept that emerged from the spoken expression of a participant, included common identifiers that were grouped together to provide structure. Discussion of emergent themes and reconciliation of discordant themes resulted in a basic thematic framework. Representative photos and their accompanying quotations were selected verbatim from the transcribed spoken word of the participants.
Results
Initially, 17 students enrolled in the study, and 12 completed the study in its entirety. This sample size is in alignment with other published Photovoice studies.15,20–22 The sample consisted of 4 men, 8 women, and 2 non-whites. The primary diagnosed mental illnesses were depression and anxiety. Saturation of concepts and ideas was reached, with no new concepts or themes emerging in further analysis after the eighth participant. Although participants were allowed to take up to the allotted camera exposure (24 photographs), the number of photographs per participant ranged from 8 to 24.
Researchers identified 4 over-arching themes from the photographs and reflections: Insights into Campus Services, Increasing Awareness and Educating Others, Support, and Barriers to Getting Better presented in Table 2.
Themes and representing photographs.
Insights into campus services
Participants praised campus services designed to help students struggling with mental health. They described therapeutic value and support they received from trained professionals, in some cases indicating that it had a large impact on their ability to successfully continue with their college studies. One student took a picture of her freshman dormitory and said,
I lived here my freshman year. This is also where I had my panic attacks; the worst I have ever had. I always missed home and I hurt myself a few times during my depression days. When I see it now, it just reminds me of how low I sunk since coming to college.
The student went on to describe that although there were some signs of depression and anxiety in high school, these symptoms came to full fruition after leaving home, but as she was on campus, there was help readily accessible. However, non-traditional students such as transfer and international students identified they were initially unaware of such services. They called for improvement in the university orientation process to allow for expansion of the number of representatives from various student service departments to attend and discuss their offerings and how they related to mental health.
Participants also shed light on utility of campus services that were not originally intended for the purpose of benefitting mental health nor previously identified as such by the general campus community. One example is the image of the campus bike-share programme. The reflection for this image reads, ‘When I get stressed, I get on a bike and bike around. It really helps me. It helps me to release stress and anxiety. You know that exercise has good effect on your mind.’ Although there were many previously identified benefits of the bike-share programme, mental health was not one that was previously described or tied to the necessity and continuation of having the programme on campus.
Another student photographed participation in a co-curricular activity designed to make students comfortable with public speaking by performing Improv acting in a small-group format. The student discussed how he and others found it helpful in also coping with anxiety. It was suggested that identified activities such as these could be advertised to help others with anxiety feel more comfortable in a group setting.
Increasing awareness and educating others
Participants called for more open dialogue and education about mental illness within the university, high schools, and community. One student stated,
Mental health awareness should be promoted more often to show the dangerous effects of mental illness and that it is a serious condition. Spreading awareness in general is important, but especially on a college campus where people get caught up in everyday things, they might not realize they have a mental illness.
They discussed the value of mental health education, not only for their peers but also for their parents.
During Meeting 3 discussion, multiple participants admitted that they had not told their parents about their mental illness due to fear of their reaction and the associated stigma. One student represented this through a photograph of a cross-stitching. As she reflected she said,
My mom taught me how to do it and I took a picture of it because it kind of represents my mom and my relationship, which is really good. But I haven’t told her that I am taking Prozac because she has that huge stigma, that ‘get over it’ that type of thing. I think that telling her would put a huge strain on our relationship.
Students suggested various means for educating the campus community and parents to increase awareness about mental illness including added information at parent-attended events and using space in the campus newspaper or other areas to promote awareness and availability of campus resources.
Some students noted that they decided to participate in the study because of their desire to use Photovoice to educate others on the realities of mental illness and also highlight that despite their diagnosis, they can be successful. One student took a picture of his locker full of books and said, ‘I’m taking 18 credits so I have a lot of books in there. It’s just to show that just because you have a mental illness doesn’t mean you can’t do well in school’.
Almost all participants were first diagnosed with their mental illness during their time as a college student. Some had a mental health crisis while enrolled, and they discussed and wanted to promote the importance of having faculty and staff trained on how to deal with emergency mental health situations and how to recognize symptoms.
Support
In conjunction with the need for awareness and educating others, students identified the importance of finding someone in whom they could confide and rely on for support. To illustrate this, 1 student took a picture of a coffee mug her roommate had given her. She said,
This is a cute little mug that my roommate got me when she was in Ireland over Spring Break. It is nice to have someone close to you who won’t ask you triggering questions and that they will just listen and truly understand. It is just so great to have a good friend.
Although students agreed on the importance of support and having a confidant, students also identified they were very particular about with whom they shared the information of their diagnosis. They were afraid others would label them as ‘crazy’ so they nearly all reported hiding their medication out of sight. One participant took a picture of her medications and discussed how the stigma associated with mental illness can be a barrier to finding an important support network:
Does anyone really understand struggle? People see a person living with cancer or HIV taking their pill ‘cocktails’ in order to sustain life and they look upon them as strong, fearless, and brave. Of these I only take three of these in public. People will never understand that I have to take these to sustain life. Why is my sickness looked down upon?
Students discussed that although there are ‘supportive people out there’ on campus, it can be hard to find them and hard to know who can be trusted.
Despite the recognition of the importance of talking with others and having support, surprisingly, most students were opposed to group therapy, which is offered on campus through the Counselling Centre. Still, all participants decided to participate in the study, largely due to gift card incentive. Repeatedly the participants discussed how they found the Photovoice process therapeutic and differed from group therapy because the focus was on the photograph instead of themselves as an individual and their personal illness.
Barriers to getting better
Participants identified barriers to getting better that seem to be unique to college campuses. One barrier is the inability to live with a pet in campus housing. Throughout the study, photographs of cats, dogs, and even horses were collected to discuss the importance of animals and how they aided in recovery. One student reflected on a photograph of her 2 cats that she referred to as ‘her babies’ and said,
These two are the only things that keep me sane. No amount of medication or psychotherapy can match what these two can do for me. Knowing I have babies that need and want me keep the bad thoughts at bay.
Individuals described the value and comfort of having something that showed affection and dependence regardless of their diagnosed illness or how they were feeling. Students advocated for re-evaluation of policies prohibiting animals on campus.
Other identified barriers to mental wellness were the intensity of balancing course workload, co-curricular programming, and adequate sleep. There were multiple photographs of beds and alarm clocks. One reflection is as follows:
An alarm clock and a bed are important for sleep, which sleep is an important factor in bipolar disorder. I don’t know if lack of sleep caused my symptoms, or if lack of sleep was a result of my symptoms. In reality, it was probably a combination of both.
Students wanted others to be aware of activities that affected their sleep such as choir practice that ran until midnight, campus meetings that did not start until 9
Discussion
The importance of making mental health needs and prevention strategies a priority on college campuses has been previously recognized. 23 Photovoice allowed participants to share their reality of living with mental illness on a college campus with their peers as well as campus stakeholders. The process facilitated conversations and open dialogue to best meet the needs of the estimated one-quarter of campus students living with mental illness.
Our findings are similar to a recent work by Kirsch and colleagues, 24 which used semi-structured interviews and concluded that students’ experiences with mental illness are a function of 3 different interrelating factors: the self, the social environment, and the school environment in which the student lives/learns. They also concluded that a fourth dimension, supportive university policy towards mental health concerns, affects student experience with mental illness on campus and must be addressed to effectively design mental-health-promoting interventions. Our study was able to incorporate this dimension by creating dialogue between the students who have lived experiences and campus administrators to identify achievable action to facilitate improvements.
Participants highlighted the benefits of campus services and the importance of making services known. As a result, preliminary discussions of having student service departments present at not only new student orientation but also the international and transfer students orientations have taken place after the conclusions of this study.
Also, participating students called for education of peers, faculty, staff, and parents about the struggles and realities with mental illness. They shared that their disease should not define them, and although they may take medication to treat an illness, they are still successful. After this study, campus-wide programming has taken place to educate faculty and staff about the realities of living with mental illness, warning signs, and resources available to refer students for help. As parents were mentioned as a targeted group for education, initial steps of including education for parents in the campus parent newsletter and orientation have begun.
This Photovoice study also highlighted the importance of support and how stigma can sometimes be a barrier for finding and receiving the support most needed. Education and changing the way mental illness is viewed by the campus is an important first step to addressing stigma. Since the completion of this study, the campus has begun a campus-wide campaign targeting students, faculty, and staff to engage in discussion and education through an online platform. The planned centre of this campaign will be the photographs and reflections collected from this study.
Students in this study also highlighted some areas that are the realities of campus life that tend to be a barrier for symptom improvement and success. For instance, they highlighted the importance of animals as a means of therapy, but currently this resource was not readily accessible. Animals have been shown as an effective means of therapy for those with mental illness. 25 After the completion of this study and the final meeting with campus stakeholders, the campus on which the study was conducted has started to allow therapy animals in some of the residence halls and have included animal therapy sessions in the campus Counselling Centre.
Another area the campus is further exploring is attempting to recognize the potential risk of late-night programming or student activity meetings held well into the evening hours that may interfere with sleep. Adequate sleep has long been described as a highly important factor in achieving and maintaining mental wellness among those who are diagnosed with a psychiatric disorder. 26 The National Sleep Foundation recently recommended 7 to 9 hours of sleep nightly for young adults and recommended against sacrificing sleep duration for school, work, or social responsibilities, highlighting the significant potential for sleep deprivation to contribute adverse mental health effects. 27
Although we did not set out to measure the impact of Photovoice on the mental health of the participants in our study, at the conclusions of Meeting 3, participants discussed self-identified benefits from participation. Previous literature findings have shown that students’ perceived closeness with peers has a positive influence and protective effects on mental health.28,29 After some of their affiliates attended Meeting 4 of this study, the campus Counselling Centre has initiated the use of Photovoice as an exploratory method to conduct group therapy.
There were some limitations within this study. First, the methodology was applied from previous Photovoice literature, and the authors designed the study based on their previous research and interaction with students with mental illness. Having potential participants assist in the study deign could have added an additional level of authenticity. In addition, this study included only 1 opportunity for group discussion among the participants, which could limit critical reflection. Future studies could include more than 1 meeting for group discussion. For these reasons, our work would be described as ‘fair’ quality of implementation of community-based participatory research. 6 Our inclusion criteria for requiring students to be prescribed at least 1 medication used to treat mental illness could also be an additional limitation of this study. There could be students who have been diagnosed with a mental illness and are only receiving psychotherapy without the combination of pharmacotherapy. These students are not represented in our sample.
Some of the findings from this study may be applicable to other college campuses; however, not all college campuses will have similar resources in place to help those struggling with mental illness. Previous literature has called for student input into campus services and policies to prompt recovery in college students with mental illness. 4 Our use of Photovoice addressed the call to obtain student input regarding mental illness on a college campus by effectively allowing students living with mental illness to share their realities with campus stakeholders to raise awareness and motivate change.
Footnotes
Acknowledgements
The authors would like to acknowledge the students who participated in this study, who shared so much of themselves to better the lives of other students living with mental illness.
Funding:
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions
ES and AW were both responsible for study design, data collection, data analysis, and the writing of this article.