Re-spect-ing the Image: Lessons Learned from Using Nature Photography
By Stephen Obold Eshleman and Shelley E. Varner Perez
Below is an elaboration of earlier work that was presented as a poster at the 2019 Association of Professional Chaplains conference in Lake Buena Vista, Florida, and later published in JPSM: Humanities. More recently, this approach was shared as part of the Oregon Health & Science University-sponsored All-City Palliative Care Lecture series, and the recording titled “Perfectly Hidden & Revealed” can be accessed here: https://www.ohsu.edu/center-for-ethics/all-city-palliative-care-lecture-series.
As a CPE resident, the impetus for utilizing nature photography to invite spiritual reflection began with my (Obold Eshleman) perceived struggle to connect with “non-religious” patients. Many Americans hold fuzzy stereotypes of chaplains showing up for Christian prayer at end-of-life. Sensitive to societal typecasts of chaplaincy, I sought to overcome barriers and stereotypes to connect with patients on a human level.
In 2018, using my own nature photographs, I embarked on a quality improvement initiative to invite spiritual reflection with patients (Obold Eshleman & Varner Perez, 2022). My ACPE Certified Educator, Janet L. Hanson, and my staff colleague (Varner Perez) provided input about idea development and application. In brief, I approached outpatients and, with their permission, showed them four laminated photos. I asked the patient to gaze carefully at each photo and, using guided questions, I invited the patient to select an image that is meaningful to them.
My rudimentary goal in using nature photography was as an entrée into discussing “what matters” in a psycho/social/emotional/spiritual sense, particularly with the so-called “Nones,” a term used for people who claim no religious identity or who do not regard religion as the sole or most valuable means of furthering spiritual growth (Smith, 2021). Religious surveyors have documented well the changed and changing American religious landscape. Now, outside of formal faith communities, chaplains carry increasing responsibility to support people’s emotional, existential, and spiritual needs, particularly within secular healthcare settings. I wondered how nature photography in the context of a chaplain’s visit might invite patients to encounter spiritual truths without using “religious” language.
Learnings Gathered
The combination of visually exploring a photograph and using guided questions provided an opportunity to explore subjective spiritual truths and existential concerns alongside individuals’ illness narratives. The chaplain used what Pargament (2007) identified as implicit spiritual assessments, in addition to discerning spiritual and existential needs and providing appropriate interventions based on the patient’s narrative. Initial learnings showed photography may capture qualitative aspects of spirituality not readily visible through analytical observation. A sampling of themes emerged, including belonging and self-worth, coping with uncertainty, unity with the larger world, future focus, and decision-making.
Additionally, photography created a structure to facilitate open-ended conversations about “what matters.” Though conversations with chaplains tend to be open-ended, I discovered photography provided a framework (lens, if you will) to focus the conversation so the encounter did not stay within the realm of a social visit. More than a framework, photography provided a figurative language for discussing the sacred and existential that did not use religious words. Photography helped guide many encounters to the “heart of the matter.”
Furthermore, photography introduced a subjective lens to inform decisions about treatment, quality of life, and person-centered care. As patients projected themselves through an image, they reflected upon their present situation, drawing together their outer world and its inner significance. In this way, the image brought the “nearly known” into greater self-awareness and fostered a sense of coherence and clarity. Therefore, photography served as a low-risk, positive, authentic experience of uncertainty (Miller et al., 2013).
Assessment or Intervention? Both?
I began using nature photography as a spiritual assessment tool, but as I experimented more, I realized the line between assessment and intervention often becomes wonderfully blurry. Sometimes, it became difficult to determine where the assessment ended, and intervention began. Here is an example:
A 77-year-old palliative care patient with severe aortic stenosis selected an image of an old truck in a field of sagebrush (Fig. 1). Without prompting, he remarked, “I’m just sittin’ in the weeds.” I had to clarify whether he was describing the truck in the weeds or had already made an interpretative leap and was describing his own situation. He was already ahead of me and was “seeing” (projecting) himself as the truck.
He said, “I’m not sure if I want to restore it.” We went back and forth, and I kept having to clarify whether he was talking about himself or the truck. He said, “If I were earlier in life, I’d want to restore it.” I asked, “You mean the truck?” He said, “No, surgery (to repair the stenosis).” With the aid of the photo, I realized the patient was processing a conversation he had with the palliative care team the day before about whether to pursue restorative treatment or comfort measures.
Curious to probe deeper into his reflective musings, I asked, “Which image would you choose of how you wishyou would like your life to be?” In the same group of photos as the truck was an image of a waterfall (Fig. 2). He pulled the waterfall photo to the top, gazed at it for a while, and smiled slightly right before he said, “I want to do a cannonball and jump in.” There was a sense of desired playfulness in his voice.
I asked what he saw in the image that elicited his comment and he remarked about the clearness of the water and the solid rocks, and used the words “pure,” “peace,” “grace,” and “serenity” to describe how he would like his life to be.
Then he paused briefly, raised his head, looked me in the eye, and asked, “Is it wrong to want to die?” I responded, “You likely already know the answer to that question.”
My interpretation of the encounter was that the patient was on the cusp of an emotional/spiritual threshold. Something happened, aided by the photos, which freed and empowered his spirit to experience his longed-for “purity,” “peacefulness,” and “serenity.” A day later, he chose to forgo restorative treatment and pursue comfort measures.
Importance of Language
My practice of using photos has changed as I have become increasingly aware of how I use language as prompts for patient responses, specifically conditional language (e.g., would). Conditional language allows for prolonged speculation of various meanings. Exploring various meanings with patients may lead to different ways of thinking (prompted by photos and language use) and allow for new insights. Companioned by a chaplain, new insights may inform how a patient perceives themself and their situation (coherence between the outer world and inner significance) as they discover, realize, and claim their own agency.
What Types of Photos Work Best?
Nature photography allows patients to interact with an artistic medium and their inner reality, allowing them to discover, contemplate, and express dimensions of their subjective “truths.” Therefore, photos that prompt meaningful exchanges tend to be evocative images rather than serene or soothing landscapes. Photos that allow one to focus inward and access one’s thoughts and feelings work the best. Hence, images that represent emotional tension may prompt greater depths of spiritual reflection. I learned it is often less threatening for many patients to reflect on an image that captures their attention than to speak directly about their fears, concerns, loneliness, and emotional or spiritual pain. True to Parker Palmer’s “third thing,” the photograph serves as a “third voice” in the encounter, interceding between the patient and chaplain (Palmer, 2014). Emotion and imagination work in tandem to encourage spiritual reflection.
“Magic Sauce” – Why This Approach Works Photography appears to work well because art holds the capacity to approach one’s soul metaphorically. Our souls, which tend to be shy and vulnerable, serve as “cocoons” for how we perceive meaning in life, sheltering and transforming our subjective truths and existential/spiritual concerns (Palmer, 2004). Emily Dickinson poetically mused, “Tell all the truth, but tell it slant,” meaning it is best to get at subjective truths in a roundabout way. If subjective truths, which reside in our souls, are to be spoken and heard, then they must be approached “on the slant.” The photograph serves as a means of seeing “on the slant” (a projection of ourselves) through metaphor. Thus, as Goto (2016) describes, photography becomes an imaginative[1] process to explore new avenues of discussion about what matters by creating images that correspond to the contextual concerns that touch our very quest for meaning. In other words, photography as a metaphor for “soul work” becomes a way to re-imagine a “heart-to-heart” conversation (Smith & Read, 2017). Through this creative process (and I might add a serendipitous creative process), one can make meaning of one’s inner and outer realities. Chaplains can create and hold sacred space for patients by using the image-on-the-slant metaphor to invite new insights.
Moving Forward
Photography and its interpretative spiritual framework are highly subjective (a bit like the old Rorschach inkblot tests) and have not been formally evaluated. Because this approach incorporates a significant degree of speculative “thinking,” there are differences in subjective experience generating multiple interpretations. An important and ongoing question is: How does one distinguish “fact” from “inference” when utilizing such a subjective and implicit assessment and intervention? Moving forward, we hope to describe the intangible benefits of this approach, recognizing that 1) a person’s strengths are drawn from within (not driven from without) and 2) any new insights (let alone motivation for change) are purely the patient’s own and not imposed by others. We hypothesize that chaplain-guided spiritual reflection using nature photographs may improve patient dignity, resiliency, and agency.
Corresponding author: Stephen Obold Eshleman (soboldes@lhs.org)
[1] Respect, from the Latin verb respecere, literally means “to look back at” or “to see a second time.” Understood with this meaning (and not as a sense of admiration), the authors use re-spect to communicate the project’s goal to invite patients to view circumstances in their wholeness, including illness. Respect also reflects the malleability of language, particularly the power of figurative language that photography invites.
[2] “Imaginative” in this sense, does not suggest “fanciful” or “unrealistic” but rather a capable and expressive approach to invite soul reflection.
Bibliography
Goto, C. T. (2016). Reflecting theologically by creating art: Giving form to more than we can say. Reflective Practice: Formation and Supervision in Ministry, 36, 78-92.
Miller, A., Grohe, M., Khoshbin, S., & Katz, J. T. (2013). From the galleries to the clinic: Applying art museum lessons to patient care. Journal of Medical Humanities, 34, 433-438.
Obold Eshleman, S. F., & Varner Perez, S. E. (2022). “I Don’t Do Religion”: Using Nature Photographs to Engage Patients in Spiritual Reflection. Journal of Pain and Symptom Management, 64(5), e305-e309. https://doi.org/10.1016/j.jpainsymman.2021.07.034.
Palmer, P. J. (2004). The truth told slant: The power of metaphor. In: P. J. Palmer PJ (Ed.), A hidden wholeness: The journey toward an undivided life (pp. 89-112). Jossey-Bass Publishing.
Pargament, K. I. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. The Guilford Press.
Smith, G. A. (2021, December 14). About three-in-ten U.S. adults are now religiously unaffiliated. Pew Research Center. https://www.pewresearch.org/religion/2021/12/14/about-three-in-ten-u-s-adults-are-now-religiously-unaffiliated/.
Smith, A. P., & Read, J. E. (2017). Art, objects, and beautiful stories: A “new” approach to spiritual care. Journal of Pastoral Care & Counseling, 71(2), 91-97.
Vessel, E. A., Starr, G. G., & Rubin, N. (2012). The brain on art: Intense aesthetic experience activates the default mode network. Frontiers in human neuroscience, 6, 66.