Introduction

Human life inevitably involves encountering various forms of difficulty and loss. Each of these experiences may lead to the emergence of a psychological crisis, understood as a specific mental state marked by heightened anxiety and internal tension. A crisis arises when an individual is unable to cope with a challenging situation or problem [1]. It can therefore be viewed as a natural reaction of a healthy person to an event that exceeds their existing coping capacities. This state is accompanied by a real or perceived loss of control over the situation and an inability to identify effective solutions, resulting in intense stress [2]. Experiencing a crisis is a common phenomenon – over the course of life, anyone may face circumstances that overwhelm them. Psychological crises are a natural aspect of functioning in contemporary society, with nearly 9 out of 10 adults experiencing at least one traumatic event in their lifetimes [3, 4]. An individual may perceive a crisis as an opportunity for personal growth and for discovering a deeper sense of meaning in life. Experiencing a crisis situation can facilitate the acquisition of new skills and coping strategies that may prove valuable when facing future challenges [5].

A psychological crisis manifests as a disturbance of emotional equilibrium, heightened tension and arousal, as well as a range of difficulties affecting emotional, cognitive, physiological, and behavioral functioning. In the emotional domain, individuals may experience anxiety, helplessness, fear of losing control over oneself and one’s life, guilt, threats to identity, as well as anger or despair. Cognitively, a crisis is reflected in difficulties understanding the situation, a belief that no solution is possible, and a sense of internal fragmentation. Typical indicators of crisis also include physiological reactions, such as disruptions to circadian rhythms (e.g., sleep disturbances) or somatic symptoms (e.g., diarrhea, nausea, or heart palpitations). A crisis may further manifest through chaotic, inconsistent, or atypical behaviors – including difficulties performing everyday tasks, making decisions, maintaining interpersonal relationships, or effectively using social support [6]. An individual undergoing a psychological crisis typically feels that all familiar coping strategies have been exhausted, yet the situation fails to improve. At the same time, they are unable to identify new courses of action and cannot manage the difficulty independently [7]. The accompanying sense of helplessness may contribute to maladaptive responses, the emergence of psychopathological symptoms, and, in some cases, an elevated risk of self‑directed harmful thoughts or behaviors [8].

Self‑care during a psychological crisis begins with meeting one’s essential needs, remaining open to support from close others, and seeking assistance from qualified professionals (psychologists, psychiatrists, or psychotherapists). An insufficient response to a psychological crisis may contribute to the development of post‑traumatic stress symptoms. However, when appropriate support and professional intervention are provided in a timely manner, the likelihood of post‑traumatic stress emerging during the crisis is significantly reduced [9]. The complexity of the modern world forces service workers, including nursing and national security personnel, to understand how to protect others’ mental well-being. Medical personnel encounter patients in distress and trauma almost every day, and national security personnel must be familiar with the negative consequences of crisis, both on micro (individual) and macro (society) levels. These realities of society today reinforce the necessity for students in these disciplines to train in the principles of crisis intervention.

The participatory photography method is grounded in health promotion principles and in theoretical literature on critical thinking education, feminist theory, and community-based approaches to documentary photography [10]. Through Photovoice, participants become visual ethnographers, taking photos to answer questions, discussing their photos with each other, writing captions for selected photos, and presenting their reflections (photos and their titles, grouped thematically) [11].

Photovoice has been used as a teaching tool by undergraduate and graduate students across various fields, including nursing and medicine [12-14]. Previous studies have shown that the use of Photovoice in clinical education led to an increase in students’ ability to empathize with patients [15], express emotions and empathy [13], engage in learning [16], and critically think, observe, and interpret [17]. Photovoice can be an interesting tool for improving the quality of the teaching process. Therefore, within the courses offered at the Jagiellonian University, it was decided to incorporate experiential learning activities into the psychological crisis training curriculum to encourage reflection, critical thinking, and self-awareness.

The aim of the study is to analyze and contrast subjective perceptions of psychological crisis among graduate students in assistance-related (nursing) and security-related (national security) disciplines. In the past, Photovoice was used as a teaching method, but previous studies lacked a control group to compare its effectiveness.

Material and methods

The study group consisted of 50 graduate nursing students at the JUMC Faculty of Nursing in Krakow, Poland, who were participating in an optional course in Crisis Intervention. The control group consisted of 49 graduate students during their Master’s Degree training in the National Security program at the Jagiellonian University, who participated in the mandatory Psychology in Crisis Situations course. Only a few of them were Territorial Defense Forces members. The total group included 30 men in the national security group, and no males in the nursing group. The mean age was 22.1 years (SD = 1.1) in the nursing group, and 23.2 years (SD = 3.2) in the national security group. The national security group was facilitated by the primary investigator, while the group of nurses was facilitated by another instructor who had received prior training in the Photovoice methodology. The participants in the study groups were active nurses with a bachelor’s degree and at least one year of clinical experience. This indicates that they were in the early stages of their careers.

Young people focus primarily on images rather than text in the modern world [18]. It was assumed that using a participatory photography approach to active learning could stimulate students to reflect more deeply on the course topics and their personal perceptions and attitudes toward the crisis, both their own difficulties and those of their patients. The Photovoice method was chosen because the current generation of students is well versed in taking photos and interacting with them online, for example, via social media.

Both participant groups volunteered to join the study as part of their structured training program. The structured Crisis Intervention training in the Nursing program consisted of 20 hours of tutorials and 5 hours of lectures (25 hours total). The National Security program training consisted of 15 hours of tutorials and 15 hours of workshops. Both courses aimed to provide participants with knowledge of psychological crisis, trauma, and crisis intervention (psychological first aid) in relation to various health situations. Topics covered included theories of psychological stress, the relationship between stress and health, the importance of social and psychological support, the aftermath of crisis events, principles of psychological intervention in crisis situations, and the professional consequences of confronting crises and trauma (including burnout prevention).

The traditional Photovoice format was condensed into a single-photo assignment due to practical constraints related to curricular time and student workload. This methodological adaptation aimed to sustain participant involvement while enabling meaningful narrative expression. Although abbreviated, the approach remains consistent with key participatory action research (PAR) principles by focusing on student agency and collective reflection. By visualizing and discussing lived experience, the single-photo exercise preserves the democratic intent of Photovoice within a condensed educational format. In contrast to traditional multi-week cycles, this study employed a “short-term pedagogical adaptation” in which participants were asked to take or select a single photograph that represented their perception of a psychological crisis. They were instructed on the ethical issues surrounding photographing, including the protection of personal image rights.

The instructions were intentionally open and vague to encourage students to independently determine their understanding of the task and its implementation. Students worked individually. They could (but were not required to) create a series or story of up to three photos. After completing the task, students uploaded their photos, along with a title, to a university server designated by the teacher. The Photovoice activity was not graded to avoid competition among students for taking “good” photos and to avoid any negative connotations between the photographs. The participant’s captions accompany each image. In the next stage, students analyzed their photos together during class. Each student had the opportunity to present their photos in a group, listen to the discussion, and then explain the motivations behind taking that particular photograph and its meaning. The teacher asked participants questions about the photograph. These were based on the SHOWeD questions, established by Wang and Burris for Photovoice [10].

To enhance pedagogical impact, each stage of the SHOWeD inquiry (See, Happening, Our lives, Why, eDo) [19] was deliberately aligned with specific learning outcomes. ‘See’ targeted observational acuity by sharpening students’ ability to identify details and patterns in complex situations. ‘Happening’ fostered analytical reasoning as participants interpreted contextual dynamics. ‘Our lives’ developed empathy and perspective-taking by relating images to personal or shared experiences. ‘Why’ promoted higher-order critical thinking by probing root causes and underlying structures. Finally, ‘eDo’ encouraged applied problem-solving and agency by requiring students to propose actionable responses or strategies. By linking each prompt to cognitive or affective competencies, the framework enables intentional skill development and provides a replicable structure for curriculum designers.

Following the photo discussion, students were informed of the possibility of including their photos in a research study while maintaining their complete anonymity. Each student could opt to have their photos removed from the database without affecting their course grade. In accordance with the ANA 2025 Code of Ethics, participants were informed of the “reversibility” of their data, but none of the students chose to remove their photos from the permanent database after discussion. The research has been accepted by the Ethical Committee of Jagiellonian University Medical College, Krakow, Poland (no. 118.6120.126.2023). Based on students’ responses, they were asked to prepare a short description of the photograph and submit it to the database. All comments were uploaded to the MAXQDA database (VerbiSoftware, 2025).

MAXQDA software, a qualitative data analysis tool, was used for data analysis. The software was used to analyze the resulting photo descriptions and identify common themes. Transcripts were analyzed by applying thematic analysis [20] using MAXQDA. Thematic analysis consists of six steps: (i) familiarization with the data, (ii) generating initial codes, (iii) searching for themes, (iv) reviewing themes, (v) defining and naming themes, and (vi) producing the report. Familiarization and code generation (steps i-ii) were conducted independently by three researchers, and ideas and conflicts were discussed in regular meetings. Searching, reviewing, and defining themes (steps iii-v) were done by the first author and discussed within the group after each step before proceeding. Coding discrepancies were resolved through consensus meetings, during which coders discussed differing interpretations until agreement was reached for each theme.

The interpretation was qualitative, involving thematic analysis of the photos, their captions, and descriptions, a common approach in interpreting Photovoice data [21]. The model used narrative analysis methods to distinguish between documentary and symbolic photographs and photographs taken in a series [16]. The model also described the students’ photographic process, including the type of camera used, the time allocated to the task, and their image-production strategies, such as taking a single photograph or a series of photographs.

Results

At the end of the project, 97 students completed the photographic assignment. The study database contains 97 photos, of which 50 were taken by nursing students and 47 by national security students.

In the first stage of analysis, photos and descriptions that did not meet the task requirements were rejected. Specifically, we excluded any submissions that: 1) did not depict or reference a psychological crisis, 2) were not original works created by the participant (e.g., images downloaded from the internet without attribution or permission), 3) included identifiable individuals without proof of consent, 4) violated ethical guidelines, such as displaying sensitive or inappropriate content, and 5) lacked an accompanying descriptive caption or narrative explanation as required by the assignment. This approach was intended to ensure that all analyzed materials were relevant, ethically appropriate, and suitable for the study’s aims.

From the perspective of photo production, 93 students used cell phones, four students downloaded photos from the internet, one student created a drawing using graphics software, and one other student created a two-picture series. Most of the photos document real-life experiences (69); some were taken in the moment, while others required a constructed scenario, such as a still-life painting. Several photos connect objects metaphorically, as symbols. One student took a series of photos. The photos are relevant to the assignment and depict the crisis, although in some cases the associations are rather superficial (e.g., a “chinchilla that does not want to take a bath”). The photos present beliefs about the crisis and explain the structure of this thinking in the accompanying narratives. These narratives often serve as the starting point for reflection on beliefs and the ability to implement individual personal behavior. The photos document themes of crisis situations, showing real-world content.

Identified themes

We identified four themes that participants raised in the interviews. These were often interconnected and referred to aspects of the psychological symptoms of crisis.

Loss of health or life

Students most often referred in their photographs to the psychological crisis associated with health impairment and death. This concerned the loss of their own health or life, as well as that of people in their immediate environment and domestic animals. They depicted numerous situations that may lead to such outcomes, including illnesses (both somatic and mental), random events (such as fires or road accidents), natural disasters (such as floods), and various forms of addiction (primarily the misuse of psychoactive substances). This was especially evident in situations where the health impairment occurred suddenly or had chronic consequences. Such circumstances require modifying one’s previous way of functioning, including limiting work, studies, and social participation, changing one’s place of residence, or undergoing long-term hospitalization or rehabilitation. These changes may lead to a sense of loss and frustration. A natural reaction in such situations is anxiety about the future, pain, or the loss of previous independence. Individuals who are ill or caring for someone who is ill often experience sadness and anger and may feel emotionally overwhelmed.

Financial difficulties

The second factor most frequently identified by students as triggering a psychological crisis is financial difficulties, and, in extreme cases, poverty (such as loss of employment, loss of housing, or a shortage of financial resources resulting, for example, from a low pension). Economic instability, indebtedness, and the lack of means to meet basic needs contribute to prolonged stress, which gradually intensifies feelings of helplessness, anxiety, and vulnerability, ultimately increasing the risk of developing depressive and anxiety disorders.

Mental overload

Students frequently depicted psychological crises arising from mental overload, including excessive burdens related to both professional and private responsibilities. Constant tension resulting from a high number of tasks, elevated expectations, or time pressure leads to an accumulation of stress that eventually exceeds the body’s adaptive capacity. Prolonged functioning under such conditions may result in reduced effectiveness, decreased motivation, frustration, disruption of circadian rhythms, and emotional difficulties. Individuals experiencing psychological overload often resort to maladaptive coping strategies, such as “escaping into sleep” or using alcohol or other psychoactive substances. Such behaviors may serve as a form of psychological compensation, seemingly alleviating tension and feelings of being overwhelmed; however, in the long term, they increase the risk of addiction and the development of serious emotional and somatic disorders.

Loneliness

The fourth most frequently indicated cause of psychological crisis among students is the feeling of isolation and the lack of support from others. Social isolation, insufficient support from family, friends, or colleagues, and the absence of a sense of belonging significantly reduce one’s ability to cope with stress and emotional strain. Prolonged functioning under such conditions leads to increasing feelings of helplessness, sadness, and frustration, which in turn contribute to the deepening of the psychological crisis.

Selected photos depicting the crisis

The following section presents three photos, taken by three different participants, and their associated captions in more detail: Figure 1, titled “No way out”, depicts a symbolic picture of a wilted plant, and Figure 2 depicts the personal experience of the participant related to her work. Figure 3, titled “Water”, is a picture of a natural disaster, with a symbolic connotation of a psychological crisis. In Figure 1, the photographer created a still life depicting a) an actual situation (plant) and b) a symbol (a human being in a psychological crisis). The caption shows which elements are related to a psychological crisis. Figure 2 shows documents used by medical personnel in the event of a refusal of admission to the hospital. In addition to the documentary aspect, the photographer explains in the description her personal experience with patients who were in a psychological crisis. Figure 3 is both realistic and symbolic. It shows a realistic photo of the flood, but with a more profound explanation of the psychological crisis that might appear.

Discussion and conclusions

When taking photos, photographers’ personal attitudes become visible, and the photos reflect individual thinking or collective understandings of the crisis. The comparative study demonstrates that Photovoice is an effective tool for diagnosing the “hidden curriculum” and potential personal biases in professional crisis training.

1. For nursing: work-related conflicts, elevated expectations, illness.

2. For national security: international conflicts, natural disasters, and poverty.

3. Both groups focused on health impairment (although more often in the group of nurses), mental overload (focused on university tasks), and loneliness.

4. For pedagogy: modified Photovoice is an effective way to develop “aesthetic and personal knowing”, meeting program objectives more dynamically than traditional lectures.

The Photovoice method was expected to engage students in learning and facilitate a deeper understanding of psychological crisis. It was expected to foster reflection and empathy for those experiencing crisis. Photovoice assignments, by revealing the photographer’s lived realities, offer a practical way to bring the hidden curriculum and personal bias into actionable reform. For example, integrating an anonymous Photovoice-based reflective session on trauma into the nursing curriculum could uncover specific patterns of assumptions or blind spots. Facilitated group analysis of these images and narratives would allow student experiences to directly inform a co-created code of empathy and understanding, followed by scenario-based workshops targeting interpersonal skills and early support strategies. Such a curricular change ensures that Photovoice discoveries not only diagnose the hidden curriculum and biases but also empower students and educators to co-design increasingly compassionate and psychologically safe environments.

In the National Security program, there were students who were refugees from Ukraine. In their case, they documented trauma related to war (destroyed buildings, dislocation). Both groups included risk factors of crisis (health impairment, poverty, natural disasters) and described symptoms of psychological crisis, which are feelings of isolation, a sense of loneliness, or an absence of a sense of belonging. These results mean that the teaching process was effective, and, at a cognitive level, the students learned the most important aspects of psychological crisis. However, the two groups differed in their perceptions of the crisis. Nurses focused more on their own experiences with patients, while national security students focused on their relations to society (psychological crises resulting from natural disasters or military conflict). In the second group, there were students who experienced dislocation due to the war in Ukraine and military soldiers who participated in humanitarian missions. Both could be found in their pictures. It demonstrates the importance of personal experiences in relation to the process of taking photos. The participants were satisfied and enjoyed the assigned task. In the feedback, they expressed positive emotions towards the task. The photos provided a visual anchor that allowed them to reflect on themselves and their experiences of the crisis.

Analysis of the photographs indicates that nursing students most frequently associate psychological crisis with excessive task overload and a lack of adequate social support, which was linked to feelings of loneliness. This outcome likely stems from the high demands of the field of study’s curriculum, which includes both theoretical coursework and clinical placements, resulting in a substantial task burden and time pressure. Moreover, the nature of nursing education requires frequent patient contact and emotionally challenging situations, which may contribute to a perceived shortage of emotional support. Additionally, in their photographs, nursing students identified various strategies for coping with psychological crisis, including so-called “sweet crisis interventions”, involving the consumption of sweets, as well as therapeutic approaches such as pharmacotherapy and professional psychotherapeutic support.

Among students of national security, financial difficulties – including poverty – were most frequently emphasized as factors contributing to a psychological crisis. It is also noteworthy that students in this field often understood psychological crisis in a very literal manner, equating it with isolated stressful events such as a minor car collision or a wheel clamp applied due to improper parking. Although such incidents undoubtedly generate significant stress, they do not meet the criteria of a psychological crisis. Both nursing and national security students frequently perceived a crisis as a deterioration of health or death resulting from illness, accidents, addictions, or natural forces. This understanding may stem from the nature and specificity of their respective fields of study – nursing focuses on health protection and patient care, whereas national security emphasizes the prevention of military, economic, and environmental threats. Consequently, students in both programs tend to associate psychological crisis with a direct threat to life or health, reflecting their practical, profession-oriented perspective.

The photos allowed participants to develop strategies and learn how to cope more effectively with crisis situations. During the course, they learned how to work with people in crisis and better understand their behaviors, but also gave them the opportunity to reflect on their own reactions, mental health, and resources in the face of difficult situations. This means that the Photovoice activity demonstrates personal attitudes and offers the potential for self-reflection as a path to self-understanding, as well as empathy for themselves and those experiencing psychological crisis. Interestingly, there are a few narratives in which participants focused directly on patients. Thanks to Photovoice, participants were given the opportunity to gain insight, reflect on themselves, and share their stories, but in a safe way and to a degree that was comfortable for them. In this context, Photovoice can be an interesting strategy for introducing psychologically challenging topics, such as domestic violence or addiction.

From a scientific perspective, Photovoice can be an effective method for analyzing nurses’ perceptions and attitudes, and may be more effective in this regard than questionnaire methods. In particular, it allows for greater insight into their own, sometimes unconscious, attitudes. As Randal et al. suggest, Photovoice can also be an effective tool for teaching healthcare professionals about the social determinants of health and can serve as an educational tool for nursing students [22]. Perhaps Photovoice gave not only participants but also researchers the opportunity to expand our understanding of what a psychological crisis is and its possible consequences.

Creative tasks such as Photovoice offer the opportunity to shape one’s engagement freely. This type of task fosters a sense of agency and free will. Participants decide what and how much they want to reveal about themselves. In psychology, this process is called “disclosure” [23]. On the other hand, participants may downplay the task, completing it without deeper engagement in the process. This is a risk of using creative methods, and in this study, it was related to the lack of assessment for taking the photos. Some of the photos focused on participants’ personal experiences with horizontal aggression. Research indicates that this problem also affects students during clinical placements [24]. Photovoice allows for the easy expression of emotions and thoughts. It is also an interesting method for participants. Photos can be seen as a way to release emotions and cope with stress. In this case, the group analysis session can be important, as participants can discuss this in a very safe way with others who have been in the same situation and have shared their experiences.

Previous research has highlighted the role of therapeutic photography as a method for counteracting stress [25]. Photovoice can serve this role indirectly. It can also be a way to share one’s experiences, as in Badanta et al.’s study, in which medical personnel used photographs and their descriptions to describe their experiences during the COVID-19 pandemic [26]. The effectiveness of photography has also been demonstrated in the general population [27, 28]. This suggests that photovoice can be an effective anti-stress technique. In addition, integrating ethical reversibility, the option for participants to delete their images had an impact on the research environment. This ethical safeguard not only protected participants but also enhanced data quality and reinforced ethical discourse around visual research in academic environments.

In Photovoice, not only the process of taking photos is important, but so too is the moment of creating captions and descriptions [29]. Captions provide an opportunity to understand the photographer’s intentions, which may not be immediately apparent. Participants focused primarily on themselves rather than on their patients, suggesting that their own experiences were more important than their patients’. It is difficult to determine whether this is related to generational change, education (the biomedical model), or to other social changes. On the other hand, there is a lack of tools for analyzing how medical staff perceive patients’ psychological crises. Most studies rely on interviews and analysis of statements [30]. For this reason, self-report questionnaires may not yield accurate results if completed incorrectly. This can also lead to a tendency to answer questions based on social expectations rather than reflecting on one’s own reactions. Through Photovoice, we provide participants with a safe way to share their experiences. The lack of direct questions allows them to feel safe, as it lets them adjust the level of disclosure of their thoughts and experiences.

Despite its pedagogical utility, this study has several limitations. First, the use of a convenience sample from a single institution (Jagiellonian Univeristy) limits the generalizability of findings to the broader population of graduate students. Qualitative research values depth over numerical representativeness, focusing on the “here and now” within a participant’s experience, and lacks insight into other factors that may influence the process of taking photographs, such as personality traits or prior crisis experience. The lack of grading for the assignment, while intended to encourage openness and creativity, could have contributed to varying degrees of engagement or motivation among participants, with some students participating only superficially. It is also important to acknowledge the gender imbalance between the study groups, particularly the higher proportion of men in the national security group and the exclusively female composition of the nursing group. Such differences reflect the typical gender distribution within these academic disciplines. However, little is currently known about the extent to which Photovoice findings may be influenced by participants’ gender.

We recognize the advantages and possible disadvantages of the “short-term pedagogical adaptation” of Photovoice, requiring only a single photo, diverging from traditional multi-week cycles. This adaptation may not have allowed for the full iterative process of “conscientization” advocated by Freirean principles. Additionally, reliance on student-selected images introduces variables related to digital literacy and self-censorship that could influence the “voice” expressed in the analysis. In addition, we acknowledge that the interpretation of subjective visual data is susceptible to researcher bias. Although data triangulation was achieved through independent coding, the final narrative synthesis remains an interpretative act.

A potential future direction for this research would be to compare other groups of helping professionals, such as physicians or paramedics. Additionally, longitudinal studies could examine how perceptions of psychological crisis evolve over time and whether increasing clinical experience influences the ways in which professionals recognize, interpret, and respond to crisis-related phenomena.

Disclosures

This research received no external funding.

The study was approved by the Bioethics Committee of the Jagiellonian University Medical College, Krakow, Poland (Approval No. 118.6120.126.2023).

The authors declare no conflict of interest.