Hermeneutic Photography: An Innovative Intervention in Psychiatric Rehabilitation Founded on Concepts From Ricoeur Yorumbilimsel Fotoğrafçılık: Ricoeur'un Kavramlarına Dayanan Psikiyatrik Rehabilitasyonda Yenilikçi Bir Fotoğrafçılık Jan SITVAST ÖZ Bu makale akıl sağlığına ilişkin yorumbilimden, daha spesifik olmak gerekirse Ricoeur'un yorumbiliminden geliştirilip kavramlaştırılmış girişim ve yaklaşımlar hakkındadır. Bu girişime foto-enstrüman diyoruz. Hastaların yaşadıkları dünyadaki deneyimlerinden anlam çıkarma sürecinde hastalara yardımcı araç olarak fotografi kullanılmaktadır. Hastaların yaşamla olan bağlarını güçlendirmeyi ve pekiştirmeyi amaçlar. Öykü anlatmayı kolaylaştırarak bunu başarmayı amaçlar. Ricoeur tarafından yorumlandığı gibi mimezis, yaklaşımın tedavi sürecini açıklayabilmemiz, kişinin güçlendirilmesi ve kendini toparlamasının etik savlarını onaylamamız açısından bu kavramın merkezi önemde olduğu saptanmıştır. Başka bir yönü de Ricoeur tarafından tanımlandığı gibi fotografi girişiminde amaca yönelimde bir araç olan anlatımla eylem arasındaki uyumdur. Aynı zamanda mesleki uygulamada (girişimi uygulayan hemşireler) elde edilen deneyimler teoriye geri bildirim sağlamakta yeni içgörülerle (örn: ikonik, görüntülerle canlandırma) bu teoriyi zenginleştirmektedir. Anahtar sözcükler: Yorumbilim; akıl sağlığı bakımı; metaforlar; benzetim; fotografçılık; derlenme; ızdırap çekme. ABSTRACT This article is about an intervention or approach in mental health care that has been developed from hermeneutics, more specifically the hermeneutics of Ricoeur. In this intervention photography is used as a means to assist patients in a process of meaning making from experiences in their life world. It aims at empowerment and strengthening the agency of patients. It does so by facilitating storytelling. Mimesis, as interpreted by Ricoeur, was found to be a central concept with which we could explain the therapeutic working of the approach and legitimize its ethical claims of empowerment and recovery. Another aspect is the concordance between narrative and action, as described by Ricoeur, which has a pendant in the goal orientation of the photography intervention. At the same time demonstrations and experiences from professional practice (nurses applying the intervention) will give us feedback on the theory and enrich it with new insights, e.g. on 'iconic representation'. Keywords: Hermeneutics; mental health care; metaphors; mimesis; photography; recovery; suffering. ORIGINAL ARTICLE / ORİJİNAL MAKALE University of Applied Sciences Hogeschool Utrecht, Netherlands Correspondence: Jan SITVAST, M.D. e-mail: jan.sitvast@hu.nl Psikiyatri Hemşireliği Dergisi 2014;5(1):17-24 Journal of Psychiatric Nursing 2014;5(1):17-24 Doi: 10.5505/phd.2014.69772 Submitted: March 28, 2014 Accepted: June 10, 2014 17 we refer to our extensive reports in publications elsewhere. [1-6] The photo-instrument is an intervention in mental health care where patients are invited to share with care professionals the photographs they made of their life world.[1,2-6] More specifically these photographs are of a journey into domains of their lives where they experienced a connection with 'a valued life' beyond illness and hospitalization. Persons with a severe mental illness participate in a photo-group where they make photographs with a disposable camera (or nowadays a digital camera). The assignment is to make photographs of what one considers valuable or what is seen as dear to someone. The photographers are then interviewed about their meaning. This is done by the nurse leading the group. Participants are invited to prioritize and select photographs that illustrate or tell the story they want to tell. Photographs and text together form a photo-story that is exhibited at a photoexposition. The process is repeated in a follow-up series of sessions with a new assignment that embroiders on the earlier one. This new assignment focuses on photographing a wish or a goal and what it takes to realize this.[1-6] We will first describe how the photo-instrument is a form of hermeneutic photography. Then we will discuss how the Introduction In this article we will discuss how the photo-instrument, an innovative intervention in mental health care, relates to care ethical issues and is embedded in the philosophy of Ricoeur. The article summarizes studies that have been undertaken by the author in the period 2006-2011 and of which the results were published as a thesis to take a PhD-degree.[1] We do not intend to go into the scientific evidence and research methodology on which our claims are based as the present argumentation is a recapitulation of findings from earlier studies with a focus on the ethical and philosophical inferences and their relations with the praxis of nurses facilitating recovery. For an account of the validity of primary research findings intervention relates to the recovery movement in psychiatric rehabilitation and can be connected with care ethical issues like empowerment and relational autonomy. Recovery will be discussed as a focus for interventions rather than a process per se from the patient's perspective, notwithstanding both aspects cannot be separated (and indeed will be related to each other). The hermeneutic character of the intervention will steer our argumentation to a discussion of storytelling as the main vehicle for recovery. We will describe how concepts from the hermeneutic philosophy of Ricoeur give the photoinstrument a strong theoretical underpinning. Hermeneutics in nursing has until now often been a theory of interpretation and a method of analyzing research texts,[7-10] but we focus on the process of meaning making by the participants of our study themselves and how this can be facilitated by nurses. In nursing the hermeneutic dimension has been given little attention in relation to clinical interventions, but in the Nordic school of nursing that puts caring in the center there are renowned examples of authors who set value by processes of meaning giving: Katie Eriksson's reflections on understanding suffering[11] and Lennart Fredriksson's 'caring conversation'[12] for instance have deeply influenced our own thinking. Ethical Issues A proper informed consent procedure was performed to acquire permission of participants of photo groups for publication of their photographs in scientific journals. The original studies that preceded the present argumentation were executed in accordance with the norms and regulations under Dutch legislation on medical research (the WMO-Law) and were approved by the appropriate Medical-Ethical Board. Hermeneutic Photography The photo-instrument is a potentially strong medium that makes visible what otherwise may remain hidden. Awareness of values in life and what one holds as dear tend to be buried under daily routines and overwhelming burdens of illness. The photo-instrument focuses on meaning making. We therefore consider the photo-instrument a hermeneutic instrument. In nursing research hermeneutic photography was first used by M. Hagedorn,[13] but as an aesthetic technique for generating data. Photography can be used for therapeutic ends because of the potential of photographs to mirror the personal history of the person who has made the photograph.[14] In the Photo-instrument service users made their own photographs. In another variant a professional photographer photographed service users while they were in action.[15] Both are forms of hermeneutic photography in which the photographs are not just an anecdotic report on activities that were performed, but invite a person to see himself as part of a story, an inner discovery journey during which meaning was given to experiences in the life world. Reflecting on the pictures afterwards helped service users to recognize how certain things impacted their lives and how they could integrate them in a broader meaningful context and develop a new perspective. Working in a mental health setting at the time that we developed the intervention and did our PhD-research we were confronted with patients who often had difficulty to voice their life story and cope with the consequences of psychiatric illness in their day-to-day lives. Sometimes they learned from treatment conversations to distrust their feelings and thoughts. Often they were not asked to tell their feelings and thoughts, except for diagnostic and treatment purposes. Nevertheless they felt an urgent need to make sense of their lives, integrate illness experiences and recovery into their life story and find a (new) perspective to live for. This is conditional for achieving harmony with oneself.[16] Recovery In the psychiatric rehabilitation of chronic patients nurses have realized the importance of the concept of 'recovery'. Instead of focusing on improving skills and adapting deficits in psychosocial functioning as an effort of making the best of one's losses, nurses now try to optimize and utilize possibilities, talents and other sources of strength.[17,18] Recovery does not necessarily mean that one becomes free from the symptoms of a severe mental illness. It is much more about distinguishing that part of your life that is affected by mental illness from a core of your identity where values and strivings reside. The Photo-instrument is meant to be a nursing intervention on the basis of hermeneutic photography, that is: photographs are used as a tool in processes of meaning making and construction of one's identity and future. In this way we hope to contribute to a more recovery-oriented rehabilitation that focuses on strengths, hope and patients making their own choices. There is a core of wholeness in every individual, even in a person whose first appearances impress as bizarre, lunatic or strange. In the photographs made by service users we see a whole person, someone like us who has goals, strivings and ambitions that cannot be reduced to the status of being a patient. These photographs enable us to recognize true faces behind the sometimes distorted faces of suffering. Everyone Has the Right to Determine Who He/She Is We believe that hermeneutic photography is an example of empowerment. Why is it empowering? We think that the claim of empowerment can only be justified when the right of someone to determine who he or she is will be respected. Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing 2014;5(1):17-2418 The concept of empowerment emphasizes the subjectivity of the individual and the control over one's own life. In hermeneutic photography we do not apply a professional gaze that diagnoses certain characteristics, or personality traits of a person as sick, inadequate or deviant. Service users have gone through that sometimes for many years in treatment programs. We focus on strengths: talents, skills, strong beliefs and interests capable of motivating people, affiliations with other people, etc. Central to our approach is the idea that you cannot empower someone else. Empowerment happens from within an individual himself. Empowerment requires an atmosphere of trust and respect. These conditions are guaranteed by the lead that service users can take in the project when they take us on a journey to their sources of strength. We foster a dialogical relation in the project. In the end the individual's right to determine who he or she is, contributes to restoring a sense of authorship and agency. Relational Autonomy Empowerment is a dialogical process based on the reciprocity of dependency: today you need me to help you but tomorrow I need you. As humans we are vulnerable. One day or another I fall ill or I will be stricken with misfortune. But even in good health and well-being I need the other to realize aims in life and share everything of value that I care for and care about. In this way we are connected with each other.[19,20] Individual autonomy is not, as we are led to believe by some neo-liberal thinkers, made up by isolated individuals making conscious independent and rational choices, but must be perceived as an ongoing process of interdependent individuals within a communicative setting.[21] People make choices that are shaped by influences from the environment. We use the notion of relational autonomy[22] to denote this interdependency. Nurses can help persons with a psychiatric disability to become empowered by stimulating them to define themselves not as patients but on the basis of authentic choices, their historical identities and own perspectives.[4] This may result in new goals in life and may be considered a step in the rehabilitation process. When people have difficulty to talk about emotional experiences or find words for feelings that are complicated and diffuse, then there is a need for non-verbal and creative means to stimulate the process of meaning making and goal setting. We therefore consider hermeneutic photography as complementary to the traditional verbal exchange in goal setting talks of practitioners of psychiatric rehabilitation with their clients. Mimesis and Ricoeur Photographs are images. We think that images play a role in triggering people into reflection on personal history and values. Images invite people to widen their horizons and enter a process of meaning making of their experiences. There is interplay between factual images and imagination, which contributes to strong 'dense' images. These images are laden with meaning. They keep coming back in the mind, are memorized and in this way become mentalized. Thus they serve as mental icons and may become a compass for further trajectories of recovery. Our understanding of how this works was enriched by reading the works of Ricoeur.[2] Especially 'The Rule of Metaphor. The creation of meaning in language'[23] and 'Time and Narrative'[24] are relevant for us, because these studies focus on processes of meaning making in the context of storytelling or narrative. In these key studies Ricoeur developed a theory about how people make sense of their experiences in real life and attribute meaning to them by constructing a story. People tell stories or narratives to reorganize disjointed bits of information in a new meaningful structure that has the following elements:[25] the action of the story (the sequence of events), the scene (where and when did things happen), the agent (who did the action), agency (how did he or she do it) and the purpose (why did it happen). In constructing a story someone brings together these elements and relates them to each other in the plot of the story. This is called the emplotment of a story. In 'The Rule of Metaphor' and 'Time and Narrative' Ricoeur wondered how this emplotment came about. According to Ricoeur emplotment is the outcome of a transformational process that he identified as 'mimesis'. He distinguishes several steps. First there are lived experiences. Usually someone feels the urge to get grip on them. However, this is hard when you are still immersed in the situation, for instance when you are a patient and live through the direct aftermath of a psychiatric crisis. That's when someone needs to create some distance between him and an overwhelming experience in order to be able to reflect on what has happened. When someone succeeds in finding the necessary distance then his position does not longer fully coincide with overwhelming events. A meta-position is created from where it is easier to open up to other meanings than seemed dictated by the facts of an experienced event. This is what Ricoeur called a widening of horizons. The process of mimesis is one in which past memories and anticipations (hopes, wishes, fears) of the future join the reflection of experiences in the present, in this way making possible a fuller and maybe more authentic (in terms of someone's history) account of what events mean to someone. What triggers this process is imagination: a creative play in which the mind juggles with associations and images. Ricoeur claimed that metaphors and imagery have a central role in this creative play. Metaphors are a figure of speech which transfers meaning from one domain to another, for instance from perception into cognition in 'I can see what you mean'. Imagery is the more general SITVAST J, Hermeneutic Photography and Recovery 19 naming for figures of speech in which an image carries a connotated meaning, as for instance in 'Photographs are a vehicle of messages about oneself '. Metaphors and imagery enable someone to jump from one line of thought to another and in this way reformulate lived experiences. These reformulated experiences then condense in a narrative plot. The Role of Images in Mimesis What is of special interest in the context of hermeneutic photography is the role of images in Ricoeur's concept of the mimetic process. Ricoeur's theory enabled us to recognize phases in the patients' trajectory of meaning making: through distanciation of lived experiences to a condensation in a narrative plot. Pieter for instance, a participant in one of our photo projects, made a photograph of a mouldered elm ravaged by a storm and used it as a metaphor for what a psychosis had done to his mind. In this way he could reflect on his situation, rethinking where his position was in his contact with caregivers. The story that he emplotted around this imagery helped him to find a new balance in his life and take new initiatives, actions based on his novel understanding of himself. According to Ricoeur, action, lived experience and its emplotment in stories are strongly interlinked. In premeditated action he sees a parallel with narrative as the action scenario resembles a story plot.[26] Yet Ricoeur focuses on textual aspects, paying less attention to performative aspects. We however found that patients used their photographs not only as imagery, but also to situate their story in reality. Distanciation was often followed by certain factuality; connecting patients again with concrete palpable reality (see textbox). In this way patients re-appropriate their lived experiences again, an act that was reinforced in the second series of sessions by the focus on photographing a wish or a goal and what it takes to realize this. Textbox Ellen, a participant in one of our photo projects, photographed a lane in the wood that she already visited in her youth. The dark lane with light shining through the trees evoked strong emotions and associations with her course through life. In the image memories merged with anticipations and hope, which was mirrored in the alternation of light spots and dark corners. The grounding of the photographs in local contexts and strong sensorial experiences lent her narrative a powerful appeal. Images remained linked up with strong sensory perceptions. This gave stories a freshness and acuteness in communication, deriving from 'dense impressions', not fully accounted for by Ricoeur. He downplays the role of the image, because he claims that images can only become intelligible through interpretation in language. Our finding that images retain strong links with sensory perceptions enriches Ricoeur's theory, acknowledging that taking photographs is a distanciating act, putting a camera between you and the perceived reality and that image as a result of this act invite further reflection. We described the sensory impact of images in terms of iconic quality.[2] Like in religious icons, photographic images can be charged with associations and impressions that make sense of an experience, or in other words represent it. We conclude that the concept of iconic representation, also embraced by Ricoeur, should not be restricted to verbal icons. The sensible, sensual plenitude that Ricoeur[23] ascribes to poetry can also be found in sculpture and in photographs. In photographs too, we observed a fusion of sense and sensa: sounds, images and feelings that does not only provide an occasion for an unfolding of the imagery, but also exerts a force in it self upon the world, including language (Goodman, cited with Ricoeur, 1977). This force is based on the principle of psychological association and is realized in the act of expression. In fact, the effort of expression evokes the psychic associations (Ullmann cited with Ricoeur, 1977) of lively impressions from memory and emotions that makes the image 'iconic'. This is the figurative ability of images, the potential of making-seen, the 'setting before the eyes'. In metaphor, the verbal moment and the non-verbal moment cooperate. As Ricoeur says, 'metaphor owes to this liaison its seemingly essential concreteness' (23: 246). Ricoeur argues that images alone (apart from their functioning in metaphors), seem closed to themselves and stand for a sort of 'private' mental experience that impedes the mimetic process, the 'seeing as' that makes the sense and image hold together. On the basis of our findings however we think that the 'thingyness', the 'iconic solidity' of images, however self-contained it may be, lends a vividness to what is told, be it a metaphor or more concrete information about someone's life world, reifying it and making it more compelling and easier to remember. This is related to the domain of psychology and neurology, which we will not go further into here. Iconic Photographs in the Context of a Caring Conversation Still, we may conclude that the iconic quality of images is very important in the context of the nurse-patient relationship, because it grounds the communication between nurses and patients in the sensory lived-through experiences of the patient. Photo-stories protect nurses from a too rapid and premature thinking in actions and things to do. We did not research this specific aspect, but we assume that this effect is brought about by the density of meanings in certain photographs that possibly lends them an urgency that is sometimes lacking in 'ordinary' conversations between patients and nurses. These iconic photographs probably make a strong Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing 2014;5(1):17-2420 appeal on the viewer to further explore the condensed meanings with the patients who made them. They seem an entry for learning more about the identity of the patient and his needs. We think that iconic photographs facilitate recognizing someone's identity and his needs. If so, this is of imminent importance for certain basic competences of nurses. According to Tronto,[20] nurses need to be attentive and sensitive to patients' needs, combining a concern for someone with skilled expertise in order to realize good care. Attentiveness, which comes even before the diagnostic process of assessing health problems, at a later stage, enables responsiveness of care to the unique person and his particular needs. It takes into account the susceptibility of the patient for certain specific nursing interventions. In other words: does the nurse sense how a patient will receive and respond to care that she will give? In the rush of busy routines under time pressures that are always present, nurses tend to forego this process of tuning to the person of the patient and pass on to the pragmatics of daily care. We think that photographs invite the nurse to suspend acting from a problem-oriented way of working and that by sharing the meanings of a photograph they may come to know a patient better. For instance, patients suffering from a chronic illness sometimes compare their body with a motor that sometimes falters (but then can be repaired). This may be helpful to invoke an image and voice a perception of realities and inequities of a life with pain that is less threatening than the idea of an irremediable illness and a body that betrays us in an unpredictable way. The imagery of a mechanical device may help the narrator to open up to a differentiation between pain and suffering, making a distinction between who we are and the inflictions that beset us.[27,28] In this way the metaphorical transformation of meaning that we endow to our lived experiences may help us in restoring the idea that we are to some degree the agents of our own lives. It reduces the suffering that comes from experiencing powerlessness in the face of illness and pain. Reclaiming Life: A Moral Learning Process Hermeneutic photography facilitates story-telling through which patients not only represent their lives, but also reconstruct them. With Nussbaum we hold that feelings and emotions as they are expressed in narratives reflect a personal standpoint and value commitment.[29] This is the ethical aspect. People start telling stories because they encounter dilemmas and face conflicting duties in everyday life where they are challenged by concrete practical affairs. Their deliberations are presented as anecdotes, puns and stories. These stories do not only represent the reality of someone's life with illness, crisis and traumas, but are also a vehicle to give meaning to a dramatic episode in one's life.[30] They often reflect notions about the good life.[31] Nurses who enter on a dialogue with patients can be considered co-creators of patients' photo-stories to some extent. Nurses leading photo groups facilitate patients to deliberate on underlying experiences and in this way they foster a moral learning process in which patients start redefining their existence and a new perspective of the good life can be constructed.[32,33] From being a psychiatric patient one may become a person with a mental illness: someone who has goals, strivings and ambitions that cannot be reduced to the status of being a patient. To say 'I am' is to say 'I want, I move, I do" (34: 321). The notion of existence here is associated with the notion of action and the power of acting. Ricoeur holds that suffering occurs where the power of acting decreases and someone becomes the patient of actions by others (versus being an agent of one's actions), as often is the case in mental illness when one becomes the object of treatment. Being an agent of one's actions, includes being subject to morality by which we understand the articulation of ethical aims in norms that help someone to characterize his action as good, just and wise.[34] In the photo-instrument this takes the form of a dialogical process of formulating and recounting of actions and how they match with someone's concept of the good life.[4] We think that the concrete factuality of images helps patients to reconnect again with the pragmatics of daily life in a dynamic movement of appropriation that follows upon distanciation and a widening of horizons. We follow Ricoeur here again where he, in Time and Narrative[35] described the dialectic relationship between distanciation and appropriation as 'moments' in the process of mimesis. The relevance of these dialectics for Recovery from the patient's perspective finds an adequate pendant in Phil Barker's claim that recovery processes can be understood as a 'reclaiming life'.[36] We will explain this further. The Concept of Face and Voice By means of structured photography assignments the intervention facilitates reflection on things that a participant considers as important and valuable here and now. The next step, in a new round of making photographs, is intended to photograph a wish that one would realize in the near future. Thus we connect the present with past memories and anticipations (hopes, wishes, fears) of the future that invites patients to formulate a new perspective. Participants are also asked to picture (and photograph) what it takes to realize their wish in terms of learning new skills, assembling strength or organizing support. This is premeditation on the action part that grounds the photo story in reality. Reflection and dialogue on the necessary actions often elicit further goal setting. If these goals are realistic and can be attained then this raises hope. In working on recovery service users need readiness: a readiness to go forward, pick their own goals and go for them, but without neglecting limitations and handicaps. This implies that mentor nurses and others must offer a dialogical contact. During this process of dialogue, participants realize that their SITVAST J, Hermeneutic Photography and Recovery 21 mental illness and its consequences for daily life may interfere with their plans. It has to be fit in somewhere. This is the assimilation and acceptation of vulnerability for psychiatric crisis. Without it recovery becomes a hazardous adventure. [16] At the same time service users often have to deal with stories that do not reflect who they are and undermine their sense of identity, integrity and dignity. Professional narratives tend to be plotted around setting a diagnosis and therapeutic actions that need to be taken to restore the patient's health. The patient's narrative is then reduced to a therapeutic narrative, which often leads to the feeling of not being heard and recognized. The concepts of face and voice can be used here to explain that people want to be acknowledged as a certain kind of person.[4,37] Especially in informal talk people will share personal experiences in order to maintain respect and to prevent a loss of face that would incur feelings of shame. As this is an interactive process of construction one might speak of enacted identity narrative.[38] Narratives may represent a polyphony of narrative voices that make up our identity.[39] Their function may be twofold: a transformation of the self or a replay and an upkeeping of face. We use the concepts of face and voice as operationalization of the relational and ethical context of (photo-) storytelling. With Ricoeur we consider face as essentially standing for a reciprocal relationship between a person who suffers and someone giving care. This reciprocal quality had been lost in the imperative call that the concept of face had with Levinas. According to Ricoeur with Levinas face is the face of a master of justice, summoning the other to respond to suffering in a dissymmetrical way (34: 189). Discussing the concept of solicitude Ricoeur argues that in the end we receive just as much as we give when we help someone who is suffering, even where this person we help is the object of our actions in one-way direction. He claims that what we receive in return, namely the chance to experience that we humans are vulnerable, can be of great cathartic value (34: 188). Translated into the praxis of nursing this experience or awareness contributes to be truly present in our contact with patients[40] and be with a person who is suffering. Nurses that accompany service users on their journey of recovery, as they do in photo groups, must refrain from acting on the basis of their knowledge of psychiatric malfunctioning (of course at other moments -in situations of psychiatric deteriorationtheir expertise may be needed and treatment must be given). They must adopt the role of facilitator who makes possible the journey. It befits them to be thankful for the privilege to be let in on the journey that touches on very personal and sometimes painful confrontations and choices and learn about the life of their patient in a way that they probably would never have from patients' charts and histories. We think that this learning is a reciprocal process for both service users and nurses (see also textbox with case description). It helps nurses to become sensitive to the strengths of service users and how to use this in their professional support of recovery.[15] The journey of discovery on which nurses and patients embark together fosters an increased sense of closeness and at times even equality with the staff, comparable with findings from other studies where nurses participated in a lifestyle program together with their patients.[41] Textbox Marjolein participated in a photo group in a residential setting of a mental health institute. She had been an inpatient for quite some time, but was going to spend more time in her own house as part of a resocialization program. She felt torn apart by ambivalent feelings: fear that she could not cope and hope that she can live on her own. She did not dare to reflect on her situation. She selected a photograph she took of a professional camera and told that she wanted to make semi-professional photographs. This seemed an unrealistic phantasy as if she could not face reality here and now. How can we understand this living in one time-frame, Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing 2014;5(1):17-2422 Figure 1. Photograph by Ellen of a dark lane in the wood. Figure 2. Photograph made by Marjolein. "I want to buy a semiprofessional camera!" when someone lives his life from day to day, in terms of the theoretical notions on mimesis? We followed Ricoeur in his Aristotelian interpretation of mimesis as a constructive and creative reformulation of reality. Ricoeur claims that this is based on an exchange between expectations based on experiences from the past, circumstances in the present end anticipations of the future. One may say that this exchange between aspects of meaning giving from three time-frames is incomplete in Marjolein's way of coping with suffering. However, as Ricoeur[35] also stated, narrative identity oscillates between two limits: a lower limit where permanence of time is predominant and an upper limit where self-constancy is at stake. On the one hand we wish to convince others that we are the same person from who we were before and who we are now. On the other hand we want to show that we are whom we pretend we are and that others can count on us to be that person. The notion of self-constancy with Ricoeur is essentially an ethical one and carries in itself aspects of a promise. If someone can count on me, then I am accountable for my actions. We can see how both ends, permanence and promise, are linked up in Marjolein's story. The permanence is reflected in the fact that photography has always been with Marjolein and her family. The promise is that Marjolein pledges her future to learning how to making photographs in a semi-professional way. The narrative unity of her life, or in other words the degree to which Marjolein is able to relate circumstances from the present to memories and anticipations, may be considered an unstable mixture of fabulation and actual experience (35: 162), because she doesn't reckon with her unstable psychic condition. We should, however, take into account that the context in which her photo-story is conceived and received is a photo group that prepares a photo-exhibition. This context directed Marjolein towards making a statement. Her story can be read as an illocutionary act. Marjolein didn't only refer to her hobby of photography as something that is interesting to know but she also implicated something more, namely that she intended to go for it. It is a performance in speaking. Conclusions The hermeneutic philosophy of Ricoeur clearly enriches the praxis of caregiving of the photo-instrument by lending it a theoretical framework that legitimizes its care ethical principles and explains its hermeneutic working. At the same time experiences from the practice of the photo-instrument may contribute to a further development of theoretical notions in Ricoeur's philosophy, as for instance in the case of 'iconic representation' and its role in action-oriented performance. The connection between narrative (e.g. photostories) and action (recovery in psychiatric rehabilitation) in Ricoeur's philosophy makes it a strong middle ground where praxis and philosophy can meet. Mental health nursing can only profit from this meeting. The article is based on a thesis that can be consulted at http://DARE.UBVU.VU.NL/handle/1871/28777. References 1. Sitvast J. The Photo-instrument as therapeutic intervention in mental health care. How to use clients' photo-stories for recovery. 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