Advancing towards inclusive social research: visual methods as opportunities for people with severe mental illness to participate in research

This article explores the possibilities offered by visual methods in the move towards inclusive research, reviewing some methodological implications of said research and reflecting on the potential of visual methods to meet these methodological requirements. A study into the impact of work on social inclusion and the social relationships of people suffering from severe mental illness (SMI) serves to illustrate the use of visual methods such as photo elicitation and graphic elicitation in the context of in-depth interviews with the aim of improving the aforementioned target group’s participation in research, participation understood as one of the basic elements of inclusive approaches. On the basis of this study, we reflect on the potential of visual methods to improve the inclusive approach to research and conclude that these methods are open and flexible in awarding participantsa voice, allowingpeople with SMI to express their needs, and therefore adding value to said approach.


Introduction
The term inclusive research first appeared in the 1960s when it came to light that the voices of people with intellectual disabilities were not represented in research. From that time on people with disabilities have gradually been incorporated into research work. At first, there was a desire to include their voice, perspectives, and views. Later, this approach took a significant shift towards their inclusion in all phases of research. In the last decade, there has been a proliferation of studies in countries like the UK in which people with disabilities have played an active role in research on issues affecting them (Tuffrey-Wijne & Butler, 2009;Walmsley & Johnson, 2003). Inclusive research includes several different methodological approaches which may generally be characterized as placing the voices of the participants at the center of research activities, providing for more empathic and democratic approaches (Walmsley & Johnson, 2003).
This idea of making research in the field of social education more inclusive has spread and is now used with different vulnerable groups or participants (Aldridge, 2012). Thus, the concept of inclusive research also applies to research processes involving the participation of people with mental health problems (Shields, Wainwright, & Grant, 2007). Although incorporating vulnerable people and groups in research leads to important challenges, it constitutes an essential objective. Efforts must therefore be made to find means and resources that allow research to reach these people and facilitate their participation in different times and stages of the process. It is in this sense that our article considers the contribution of visual methods.
The aim of this paper is therefore to explore the potential of visual methods to facilitate inclusive research. In the following section, we review some methodological implications of inclusive research and consider the possibilities of visual methods in facilitating this approach. We then present some examples of the use of visual methods associated with in-depth interviews taken from research aimed at studying the impact of work on the social inclusion and social relationships of people with severe mental illness (SMI) and determining their perspectives regarding elements that affect their social inclusion. Using this experience as a basis, in the final section we reflect on the advantages and limitations of visual methods as a strategy for fostering inclusive research and the potential of these methods in research related to the social inclusion of people with SMI.

Inclusive research and visual methods
The principles underpinning inclusive research are the same as those which form the basis of participatory research: commitment to social change and empowerment of the participants. These general principles are specified in various recommendations aimed at finding ways of ensuring that people with disabilities have opportunities to participate in research that affects them, not only as informants but above all incorporating them in decision-making circuits. This includes seeking out ways of guaranteeing that people with disabilities are suitably represented at different stages of the research, and promoting collaborative projects with people with and without disabilities, allowing points of view to be balanced and thereby improve the rigor and scope of the research (Gill, 1999;Walmsley & Johnson, 2003).
Different authors acknowledge the complexity of implementing the principles of inclusive research (Barton, 2005;Dowse, 2009;McClimens, Grant, & Ramcharan, 2007;Shields et al., 2007). For McClimens et al. (2007), the desired collaboration between researchers and participants is sometimes not the most efficient way of conducting research, while it also involves challenges regarding both the extent to which people with learning disabilities understand the aims of the research and all the implications to which they give their consent. Shields et al. (2007), referring to inclusive research with people with mental health problems, consider that aims must be very clear from the beginning to avoid relational difficulties that might impede progress. Barton (2005) and Dowse (2009), reflecting on emancipatory research and collaborative research, respectively, emphasize the difficulties of achieving truly balanced power relations between researcher and participants.
Incorporating vulnerable people and groups in research entails significant methodology challenges. A key element in promoting inclusive research relates to the possibility that people are free to express their point of view with their own voice, that their perspective be respected and their work adequately acknowledged (Gill, 1999). From a methodological point of view, it involves any researcher who collaborates with participants adopting the role of facilitator, ensuring that the subject matter and the process of the research emerges from participants' own interests. It also means striving to recognize, listen, and understand. Researchers must also examine the extent to which they are aware of and able to engage with certain participant voices to develop the ability to identify and distinguish these voices as those of researchers (Barton, 2005).
Therefore, making the voices of participants heard entails much more than just talking and listening to people. It is necessary to identify strategies that allow them to express themselves, diverse methods that can be adapted to different people and are less directed by the researcher. It was the inclusive approach to research that therefore led us to study the suitability of using visual methods.
The use of visual methods in the field of qualitative research has evolved significantly over the last 30 years. Researchers initially used visual recordings to obtain a visual story as evidence (Yates, 2010). Although this use has not been abandoned, Chaplin (as cited in Holm, 2010, p. 327) argued that visual images are conceived as having a great potential in research as a means of creating new knowledge. Some authors go a step further and highlight the value of these methods in involving socially excluded groups and empowering the more disadvantaged, giving them choices in relation to the subject matter and research design that the traditional role of interview or questionnaire respondents cannot give, and as useful tools when participants have communication difficulties (Finlay, Sheridan, McKay, & Nudzor, 2010;Packard, 2008).
The last decade has seen an increase in the use of visual methods in research into people with SMI. Most of these studies were conducted in the field of psychiatric nursing and psychology and revolve around two broad topic areas: studying the life spaces of people with chronic mental illness, particularly their supported housing and day care centers (Bryant, Tibbs, & Clark, 2011;Kloos & Shah, 2009;Montgomery et al., 2008), and studies seeking to take a closer look at their views of life, their illness, and how this affects their own experiences. Some of these studies aim to provide an in-depth comprehension of the person with SMI (Erdner, Andersson, Magnusson, & Lützén, 2009;Erdner & Magnusson, 2011;Sitvas, Abma, & Widdershoven, 2010, 2011, while others aim to increase professionals' empathy when they meet a patient diagnosed with mental illness (Thompson et al., 2008) and still others provide evidence to support the development of patientfocused interventions (Fleming, Mahoney, Carlson, & Engebretson, 2009).
Most of the studies reviewed opt to include the photograph as a form of photo elicitation (Erdner et al., 2009;Erdner & Magnusson, 2011;Sitvas et al., 2010Sitvas et al., , 2011Thompson et al., 2008). Photographs taken by participants constitute the basis for in-depth interviews and become a form of promoting dialogue between the researcher and the participant. Researchers using photo elicitation argue that photos allow meanings, emotions, and feelings to be revealed which do not normally appear in an interview situation.
Other visual methods employed in research are drawings and diagrams, which, like photographs, are used to elicit information and tend to be included under the term graphic elicitation. The reviews carried out by Kearney and Hyle (2004) and Mitchell, Theron, Stuart, Smith, and Campbell (2011) regarding the use of drawing in research show that it can be a suitable method in helping participants depict thoughts and feelings which are often difficult to express through words.
Those who defend the use of visual stimuli argue that, particularly when produced by participants themselves, they foster empowerment, an element of special importance when working with people or groups who have traditionally not been listened to (Mitchell, 2011). This participative basis of visual research is also highlighted by Packard (2008), who considers this type of method to contribute to empowering participants by creating more ethical research contexts and realities and generating new forms of knowledge that cannot be drawn out any other way.
In inclusive research, methods must be flexible and open and foster people's capacity for expression, adapting to their real characteristics, and possibilities for communication. Visual methods are not only useful when people have difficulties with oral communication; they can also be useful when what the person wants to express falls within the domain of emotions and feelings or when evoking experiences which are difficult to communicate through words (Bagnoli, 2009;Harper, 2002;Keats, 2009;Pink, 2006;Prosser & Loxley, 2008) and even in researching identity positions that are usually silent (Croghan, Griffin, Hunter, & Phoenix, 2008).
The social and work inclusion of people in a vulnerable situation, such as people with SMI, is a complex subject. It becomes necessary to seek out resources that allow the establishing of bonds between researcherswho have no personal or professional relationship with the participantsand participants; that is, bridges must be established between the world of the researcher and that of the participant (Harper, 2002). The use of visual stimuli is expected to foster the establishing of empathy and a more honest relationship.
Although there is fairly widespread recognition of the value of visual methods, and particularly photographs, in awarding a voice to disadvantaged individuals or groups, we cannot ignore some specific criticisms. As soon as the research process involves analysis, not of each individual case, but also on a more transversal level, we run the risk of blurring the voices and losing their original meaning. In addition, research has theoretical approaches, objectives, theoretical, and conceptual starting points that make it difficult to retain the exact voice of participants (Luttrell & Chalfen, 2010). The researcher undergoes a transformation, and sensitivity and an ethical attitude are required in order to not distort these voices or transform them for personal gain. Suffice to say, however, that these difficulties are similar to those faced by researchers when working with material from interviews and other material obtained exclusively via oral communication.
Ultimately, it is a question of power relations between researchers and participants. In interviews, the power tends to be in the hands of the researcher, who initiates the interview, determines the subject matter, controls the script, and decides when the conversation ends. This control may be reduced when participants become part of the research team. The idea that the power is only in the hands of the researcher is only partly true, however, as interviewees may determine their level of cooperation in the interview, change the focus of the conversation, and even decide to finish it themselves (Karnieli-Miller, Strier, & Pessach, 2009). The issue of power relations between researcher and participantsis also related to ethical aspects of anonymity, confidentiality, and image control. These are aspects that affect the behavior of not only the researchers but also the participants (Lomax, Fink, Singh, & High, 2011).

Photo and graphic elicitation to improve participation of people with SMI in research: some examples
The examples of photo and graphic elicitation, we present here form part of research that studies the effect of the role of work on the social inclusion of people with SMI. The aim of the research, conducted in 2011 and 2012, was to determine the perspectives, views, and experiences of people with SMI regarding elements that affect their participation in working, social, and relational life.
The seven people that participated in the study were contacted in co-operation with professionals working at two supported employment services in a mediumsized Spanish town. They were selected and invited to participate in the study on the basis of their not being a typical, extreme, or intensely unusual, while attempting to include different personal and professional situations that might represent significant characteristics of people with SMI participating in supported employment. Selection criteria required that people: (1) participated as clients in supported employment actions; (2) had a minimum of three years' employment experience; and (3) were working on the ordinary job market at the time, or had previously worked and were currently looking for new work.
We based the study on two in-depth interviews using visual elements: drawings and photographs taken by the participants. We also conducted semi-structured interviews with professionals from the supported employment services. These interviews gave us access to people with SMI with whom we had no personal or professional relationship. They also helped us learn about the general life pathway and current situation of the people participating in the research, which in turn allowed us to contextualize each case and focus the interview on the basis of a better understanding of each participant's situation. Having this information available to us allowed us to deal with the more objective data that may arise from the interview with the participants and to have complementary elements for understanding the image interviewees wished to convey about themselves. After inviting the participants to take part in the study, the aims of the research and methodology were explained to them and their confidentiality and anonymity were guaranteed, as was their right to abandon the research at any time. They signed an informed consent document.
The first interview with each participant was based on a script produced by the researchers and aimed at obtaining information regarding the participant's personal, educational, and vocational pathways, placing special emphasis on significant elements which, from their own point of view, have affected their educational and vocational pathway. The aim was to identify difficulties perceived in their social and work inclusion experience from their own point of view and expressed in their own words. The interview included an exercise that comes under the graphic elicitation method. It consisted in producing a drawing called the 'river of life,' which requires the person to draw a river symbolizing their life path, indicating the circumstances surrounding their educational, vocational, and general life paths that have contributed to the 'river' having the shape they have drawn.
The interviews focused on how they saw and evaluated their personal life path and the people, services, and institutions that had played a significant part in it. Drawings were expected to help participants express their emotional lives and allow more concise presentations of the key elements of their experiences. The little structure of these activities, with no barriers or limits, was designed to allow participants to communicate their personal experiences without the influence of the researcher's preconceived ideas, which may otherwise be unintentionally imposed.
At the end of this first interview, we gave participants a disposable camera and asked them to photograph objects, people, or situations that make them feel good and others that make them feel bad in relation to their life path, with special attention to their employment history. The aim of the second interview was to take a more in-depth look at the person's perceptions of their life path, and determine their point of view regarding their opportunities for social participation and which aspects make their life path more difficult or easier, placing emphasis on work aspects and the role of work in their life.
We told them to ask permission before taking pictures of people and recommended that photographed people not be easily identifiable. This recommendation, although designed to ensure the anonymity and confidentiality of the people appearing in the photos, had the disadvantage that it somewhat limited participants' freedom and necessitated them having the ability to find a way to use some symbolic visual language if they wanted to photograph people or groups important to them. If the person agreed to participate in a second interview, a date was agreed for submitting the photographs and a further date for the second appointment. The camera had a capacity for 24 photographs and they could take all of them if they so wished.
The methods of photo elicitation and graphic elicitation are used in this interview. During the first part of the interview, the person is asked to comment on the photographs: what they have photographed, why, the significance to them of what appears in the photographs. In the second part, they are asked to do a drawing of how they see themselves in ten years' time. They are then asked to explain this drawing and comment on it.
The transcribed interviews include each participant's narrations for the drawings and photographs. An initial content analysis of the text is conducted to select relevant topics in each individual case and for all cases as a whole: the illness, the role it has played in their vocational pathway, their experience and awareness of the illness, the impact of the illness on their surroundings, the role of work in their lives, and specific people they identify as supports in their life. An individual report is compiled which includes the drawings and photographs which have been commented on, and a transversal report is compiled for all cases. The study material is returned to both the services and the participants, and the photos are also returned to the latter.

Examples
Below, we present some examples illustrating the use of visual methods in the aforementioned research. These examples help us to reflect on how far these two visual methods helped us to complement the classic oral interviews, how far they facilitated the person's more active participation in the research, and whether they gave a voice to participants.

Drawing the river of life
The river of life is a type of drawing that aims to help the person show situations, people, and events which have been particularly significant in their life until the present day and have conditioned their personal life path (Fisher &White, 2001). In our research, participants are asked to do the drawing at the end of the first interview.
Most participants do a simple drawing, with one or two lines symbolizing the path of the 'river,' as shown in the example in Figure 1. This drawing was done by Max (false names are used), a 41 year-old man, diagnosed with paranoid schizophrenia and who at the time of the interview was about to start a new job as a production worker in a food company. In the drawing, he put the illness at the bottom of the curve, while at the top he wrote: father, work, wife, and the names of his two sons, the people who, as is revealed throughout the two interviews, are most significant in his life and to whom he attributes a support role which he values enormously. The researchers did not ask him directly about his mental illness and it is on the basis of the drawing that Max and other participants express the fact that their illness, which they tend to put at the bottom of the curves in this drawing, has an important, intense impact, and many consequences in different spheres of their lives. Below is the transcript of the fragment when Max expresses the initial impact of the illness, as well as other stressful circumstances that marked the start of a crisis: Max: You see (referring to the drawing) that the lows are particularly because of the illness, and the beginning was during military service 1 .
Interviewer: That can't have been a very good experience, I suppose? The rivers of life drawn by the participant show how the illness is continuously present in their life path and that the time when it manifested itself is a reference point, normally around 18 years of age.

Drawing about the future
Participants are asked to draw on a piece of paper how they would like their lives to be in the near future. The aim here is to obtain each participant's view of what he or she wants to fill their lives with, what is significant for them. Robert is a 49 year-old man diagnosed with anxious-avoidant disorder. He finished upper secondary education and at the time of the interview was doing training at a prevocational center following a long period without work. In the drawing about the future, Robert does at the end of the second interview (Figure 2), he expresses the situation he would like for different spheres of his life. (2) being with people I love; (3) living somewhere I feel fine; (4) being able to do pleasant and useful activitiessport, work, leisure, in general; (5) having social relationships; (6) trying to be as happy as possible).
In the narration that accompanies his drawing, he comments that the numbers are related to his priorities for the future and clarifies the meaning of each of the drawings in his composition. (1) Being healthy; (2) Being with people I love; (3) Living somewhere I feel fine (not referring only to a nice place to live but living with people he gets along with); (4) Being able to do pleasant and useful activities (sport, work, and leisure) (he draws a swimming pool, because swimming is the sport he likes to do); (5) Having social relationships (the drawing represents a place for going out at night where people meet); and (6) Trying to be as happy as possible. Throughout the conversation Robert expresses doubts about the clarity of his drawing and endeavors to explain it. This is a feeling that most of the participants convey when asked if they want to do the river of life drawing and drawing of the future. As with Robert and other cases, drawing the future highlights the importance they award to relationships with people, doing useful activities such as work, and health.

Taking photographs about what is pleasant and what is unpleasant
As we have already mentioned, participants were asked to take photographs of people, objects, or situations that they liked or made them feel good, and others that made them feel bad or they found particularly unpleasant. The researchers avoided giving excessive instructions so as not to condition the type and content of photographs. In the second interview, the photographs were used as a starting point for the conversation. Participants chose the photographs they wished to comment on. Figure 3 is a photograph taken by Robert showing the difficulties he has facing up to everyday activity in the street: traffic, vehicle noise, and roadworks. Robert suffers from agoraphobia and the visual and auditory stimuli in the street destabilize him and make him feel uneasy: R. This would also be a bad picture, which is when there are things that bother me; one I've said, which is walking down the street, the other is traffic and trucks in particular, and the third is roadworks.

I. Why roadworks?
R. Also because they make so much noise.
I. Sorry, when you see them from your home or when you see them in the street?
R. Both. When they start in the morning and you feel … if they are doing something nearby, which is very possible because they do so many of them … you start to hear hammering, buzz saws and that starts to make me despair, and seeing them also causes me a lot of anxiety and bad feeling.
Another example would be the photograph by Pere, a 35 year-old man diagnosed with personality disorder and paranoid schizophrenia. At the time of the interview he was working part-time in an abattoir in the afternoons and following a supported employment program. His photograph was of his zodiac boat, which he goes out in and sometimes uses to fish. Although, according to Pere, 'it's not a boat for enjoying with other people,' he also comments that he often goes out with a couple of friends and sometimes they go fishing with him. The boat is an important object he fills part of his time with and it allows him to have social relationships, which he values very positively.
Figures 4 and 5 are photographs taken by Max. Figure 4 is a half-full garbage bin with some garbage on the ground.
M. This is chaos, disorder.
I. Number 12 is chaos, disorder. For him it symbolizes a lack of order and dirt, which for Max are very destabilizing. This photograph leads to him speaking about the difficulty he has working in environments that are particularly dirty or disordered, and confronting work tasks when the environment is not sufficiently ordered and clean. Figure 5 is also a photograph taken by Max. It is of a pair of hands, which belong to his father. Max says of these hands that they are 'hands that have worked.' On the basis of this photograph, he acknowledges and expresses his gratitude to his father, who is now elderly and has health problems, and with whom he has always had a very close bond. These examples illustrate how with each photograph participants introduce subjects and express sentiments and both pleasant and unpleasant feelings provoked by the different situations or objects. Although each photograph has a particular meaning, it is also relevant to observe the group of photographs taken by each participant as a whole. Thus, for example, Max took a series of photographs of hands belonging to members of his family, Robert photographed diverse landscapes: urban landscapes and more rural environments. This vision of the whole also provides a global view of how the person experiences or interprets some aspects of their life. In the case of Max, the people in his family are, from his point of view, those who have given him support. For Robert, the city with its noise, traffic, movement, provokes unpleasant feelings, while more rural landscapes denote tranquility, peacefulness, and silence; aspects he values enormously. The narration which accompanies it aids comprehension of this global view.

Conclusions
If we are to foster inclusive research in the full sense of the term, some intermediate steps are required. This is the case here. Although our research did not involve people with SMI participating as researchers per se, it was founded on an inclusive approach. Our intention was to give participants a voice and provide them, by means of visual methodological strategies, with the freedom to mention the issues and situations that concern them. A willingness to help people who form part of a vulnerable group to speak up determined the choice of methods and their application, as well as the timing and sequencing of tasks.
We found that introducing visual methods into interviews within the context of qualitative research proved very interesting with regard to eliciting participants' perspectives and promoting dialogue with them. In the research presented here, although the researchers did not ask participants to talk about their disease at any time, most freely chose to do so on the basis of their drawings, going on to explain how it affected their life and thus demonstrating it as a crucial and present element on their life path. The visual elements therefore helped establish, in line with that stated by Harper (2002), bridges between researchers and participants, an essential factor in developing inclusive research.
Visual methods allow people to express themselves through their own voice. Our aim was for the person to feel free to express what they wanted to say and to share without being limited to the ideas, preconceptions, and objectives of the research. Alongside the drawings, we have found the use of photographs produced by the participants themselves within the context of in-depth interviews to foster their empowerment, not only because they can decide what they want to photograph, but also because it is the participant that decides what they want to say about each photograph. It is the participant who guides the interview, not the researcher (Prosser & Loxley, 2008) and we believe that this truly reflects a turning point towards a more inclusive research model, as participants become the focal point, choosing for themselves what they wish to discuss.
Visual methods can have an empowering effect on participants. Some authors emphasize the value of visual methods in empowering disadvantaged groups (Yates, 2010). With respect to this, in the research presented here, the researchers yield some of their power as they do not control the script for the interview, rather it is up to the participant to decide what to talk about, how to talk about it, and when to finish the interview. Another aspect that fosters this empowerment is the fact that visual methods adapt to the ability and expressive needs of the individual. The two graphic methods used: the river of life and the drawing regarding the future, constitute different forms of thinking about their past life path and desired future path, respectively. Drawing requires an effort of synthesis, highlighting the most relevant and significant times and circumstances of the person's life. Photographs, on the other hand, focus on exploring present time. Individuals find a way of expressing their thoughts and feelings as far as they wish.
Photo and graphic elicitation has clear advantages, but also some drawbacks that the researcher must evaluate when deciding whether to use photographs or drawings. The depth of the discussion is marked by the participants themselves, which means that anyone who does not want to address any given area does not have to. When all is said and done, if inclusive research is opted for, there is surely no other option than to run this risk and the job of the researcher is to manage the consequences. Photo and graphic activities foster participation, although it must also be taken into account that some people feel uncomfortable doing them, especially when they are asked to draw. In this respect, as Mitchell et al. (2011) recommend, we tried to make it very clear to the person that what is of importance is the content and that under no circumstances are the artistic aspects of the drawing valued.
Another aspect to consider is that exploring individuals' personal lives can also have a disempowering effect. We must ask ourselves the extent to which introspection, favored by visual elements, might be disempowering for participants. To minimize this possible effect, it is important to ensure that individuals have the power of decision regarding their participation in the different phases and accept the proposed activities. It is also important to clarify the purpose of the research, which, in our case, was to improve social education practice related to the social and work inclusion of people with SMI. Introducing visual elements in the interviews helped differentiate them from other professional-client interviews to which people with SMI are very much accustomed. Aldridge (2012) suggests that visual methods can encourage introspection and allow experience to be represented and testified to. In this sense, asking participants their views on the subject, based on their own experiences, in order to help improve services and practices was perceived as an opportunity to express themselves and give their views, rather than as a threat to their privacy.
Other elements of these methods that mean the interviewees do not hold all the power are related to the ethical aspects of anonymity, confidentiality, and image control (Lomax et al. 2011). For example, we asked them not to take pictures of people who could be identified. This idea, aimed at protecting the image of those people who might appear in the photographs, resulted in some participants having to think of symbolic forms (objects, body parts, etc.) to represent the person and others simply avoiding these types of pictures.
To sum up, then, the research we have undertaken allowed us to observe that visual methods have a great potential for directing research towards an inclusive approach, in the sense that they provide the interviewee with more freedom to decide what they wish to talk about and how. In the case of research, where participants are people with SMI, the use of visual methods accompanied by narrations provides a context that places emphasis on the person rather than the illness (Fleming et al. 2009). Although participants in our study were not able to decide on the research objectives or the methods used for data collection and analysis, we believe that the use of visual methods has been proved to have advantages over more traditional qualitative research methods, as they are less structured, more open, more creative, and less intrusive, all aspects which are valued in an inclusive research approach.