Phototherapy as an Alternative Treatment in Mental Health for Malaysian Post-Pandemic Covid-19 Victims

Phototherapy as an Alternative Treatment in Mental Health for Malaysian Post-Pandemic Covid-19 Victims

Norsalina Norhasni¹, Norfadilah Kamaruddin^2*

¹College of Creative Arts, Universiti Teknologi MARA, Shah Alam, Selangor

²Creative Visual Exchange Group (CREaTE), College of Creative Arts, Universiti Teknologi MARA, Puncak Alam Campus, Selangor

*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.9020155

Received: 27 January 2025; Accepted: 03 February 2025; Published: 08 March 2025

ABSTRACT

Globally, the COVID-19 pandemic has had a significant influence on mental health and raised demand for more therapeutic approaches. This article assesses phototherapy as a substitute treatment for mental health issues among COVID-19 survivors in Malaysia. Data was gathered qualitatively via case studies, participant stories, expert and personal interviews, and firsthand observation of the seven participants’ phototherapy sessions. The study found that participants are unaware about phototherapy and feel uneasy about it by voiced differing opinions, with some being amenable to mixing phototherapy with more traditional treatment modalities like medicine and counselling. For broader acceptance and use, future research would look at the effectiveness of phototherapy in various demographic groups, in comparison to other forms of treatment, and in conjunction with digital technology.

INTRODUCTION

The world faced a pandemic at the end of 2019 due to the rapid spread of the coronavirus disease COVID-19, which resulted in over six million deaths and affected more than 223 countries and territories worldwide. (Cascella et al., 2020). The effect of all these social distancing measures and the uncertainty of returning to normal directly and indirectly impacts community members’ social life and mental well-being. For instance, MCOs or lockdowns, physical distancing, and quarantines have led to increased stress and anxiety among people worldwide. The stressors of the COVID-19 pandemic could also result in behavioral disorders in children and adolescents, which could change psychological well-being in early life and adulthood (Cascella et al., 2020).

Around 800,000 cases of suicide have been committed globally each year since 2015 (Martinez-Ales et al, 2020). However, contrary to other illness that consists of coronavirus, psychological conditions like depression and anxiety do not show any symptoms or indicators. Although both illnesses have a few noticeable symptoms, the symptoms may not be as visible as a fever or cough in viral illness. The leading cause of this condition is that they are not aware of the symptoms due to the lack of knowledge about psychiatric disorders and are unaware of treatment options for this illness, resulting in them not receiving treatment. As depression becomes the focus of mental health disorders and is classified under non-communicable diseases or mental disorders, it concludes that without proper treatment, it has a high possibility of leading to suicide (Hassan et al., 2018).

In September 2015, mental health was included in the United Nations Sustainable Development Goals (SDGs). The United Nations (UN) recognized the mental health burden in this historic movement. They made mental health a global development priority for the next 15 years (Votruba et al., 2016). This makes mental illness a major challenge for any health and mental health system, a developmental problem clear in low-, middle- and high-income countries (WHO et al., 2004). Nevertheless, especially in less developed countries, there is a large treatment gap; most people with mental disorders are not treated at all and often face isolation, discrimination, and human rights violations (Kohn et al., 2004).

However, with the advancement of technology, there are many alternative treatments for mental health, one of which is visual art. Photography has become much more accessible in this digitized world, so people no longer

need an expensive camera to receive help from practice; a cell phone camera is possible (Tourigny & Naydenova, 2020). With photography, people can easily engage with the familiar device in their hands without feeling compelled to be skilled photographers. Thus, photography has long been used to help people in their personal development. It is an alternative communication method, reducing anxiety and increasing communication rates (Goodhart et al., 2006; Krauss & Fryrear, 1983; Reynolds et al., 2008; Schudson, 1975).

Dough Stewart (1979) defines Phototherapy as the application of photography or photographic material under the guidance of a qualified therapist to lessen or alleviate unpleasant psychological symptoms and foster psychological growth and therapeutic change. David Krauss defined phototherapy in 1980 as the systematic use of photographic images and the photographic process (often in combination with visually referenced language and imagery) to positively alter a client’s thoughts, feelings, and behaviors (Krauss, Fryrears 1983).

LITERATURE REVIEW

Projective Phototherapy Technique

Projection is the process of projecting aspects of one’s internal reality onto outside objects, and the images we see usually come from within us. Imagine showing the same picture to a thousand individuals; you would discover that each one has a unique reaction. This highlights the power of perspective and the beauty of diverse interpretations. This could be a defense technique to let go of uncomfortable inner thoughts and feelings and bring them out. Weiser explains that the projective technique uses photographs to evoke emotional responses, with or without verbal description, using photographic images as triggers. This technique helps the patient open in ways that talking cannot because the therapist and patient can both focus on an image outside the patient’s defense structure. This way, even intrusive questions are much easier to deal with than if asked or challenged directly (Weiser, 1993).

Projective phototherapy techniques include active and passive projecting, decoding, and deconstructing emotional content from stimulus images. This technique is done by supporting the patient in exploring their own interpretations and associations of meanings and feelings they believe come from the photograph. This applies regardless of whether the viewer is viewing their own photos, portraits of themselves, photos from an album, photos of the therapist, or photos from printed materials. They do not have to be portraits of people. Patients can choose images of trees, flowers, animals, or anything that stands for themselves (Halkola, 2011).

Halkola (2011) state that this method uses a group of images to facilitate self-introduction. These images should include one that arouses your curiosity, one that you like, one that you do not like, one that makes you feel something, one that evokes memories of your early years, one that tells a story, and one that makes a difference when you feel present and connected. People communicate by focusing on images, which lessens their anxiety about making mistakes or looking foolish (Star & Cox, 2008). Nothing a person says when describing why he or she chose a particular photo or guessing why another person might choose a different one is disputed because it is simply their version and applies to them. Notably, the initiated emerging story is always synchronistical and more meaningful than a randomly initiated story, for working with visual and metaphorical imagery can elicit personal and emotional information from the unconscious if the process is not overly self-aware and thus guarded.

According to Star & Cox (2008) using a photo as a catalyst helps only internal thinking or imagination because it keeps the therapist and patient focused on an image that does not get too close to the patient’s defenses. So, a small quantity of intrusive questioning will be much easier for the client to deal with than being directly questioned or challenged. If something that has been pushed into the unconscious needs to come out, it will keep coming up, either emotionally or non-verbally, until it is brought to the conscious minds notice. Emotional messages originating from profound internal experiences can manifest as symbols, particularly when observing recurring patterns in life or artistic expression. This recognition often occurs only after the visual characteristics of these patterns have become sufficiently apparent.

Most project-based work begins with the client selecting one or more images from a more extensive collection that answers a question. Self-portrait in a pictorial way: Which of the images calls for you the most? Which is called by their name? Which of these pictures do you think they would have taken themselves if they could? Which ones would you like to take home or keep for a week? Which ones talk about how they feel, including in negative ways? Which photo do you like, or which photo do you want to talk about? If there are many family issues in therapy, the counselor might ask the client to choose one picture from a large stack to stand for each critical family (Halkola, 2011).

The fundamental therapeutic function is objectively watching, questioning, and listening to the patient’s responses to photographic stimuli. The therapist cannot make assumptions about a person from a few snapshots, but initial questions can be asked, and answers can be written down and stored until further observations are made. The same themes or patterns of visual imagery will crop up so often that they seem to beg for attention. Recurring symbols will also appear often enough for the therapist to start making connections and figure out what to ask next.

METHODOLOGY

This study explores how the use of phototherapy in treating people with mental health using a qualitative methodology. The selected method combines field experiments, participant and expert interviews, and case studies, all of which can provide in-depth, complex insights into the therapeutic process. Qualitative methods allowed the researcher to gather detailed information from participants by focusing on understanding human experiences, emotions, and behaviors in their natural setting.

The case study method was selected because it may provide comprehensive, in-depth understanding of a particular event in its natural environment. Furthermore, because the research was exploratory, a case study allowed for a more thorough analysis of the application and outcomes of phototherapy (Coombs, 2022). It was especially helpful in recording individual experiences, understanding the subtleties of mental health therapy, and highlighting the subtleties that might be missed in large-scale quantitative research. This methodology also facilitated the investigation of a new, little-researched therapeutic strategy.

In-depth interviews were used to learn more about the participants’ experiences, provide a way to look more closely at their behaviors, and let them share their opinions about what they watched. One way to learn about people’s beliefs, feelings, ideas, thoughts, and interpretations based on their experiences is through in-depth, one-on-one interviews. Participants with mental health concerns participated in the study. People who exhibited symptoms including persistent sorrow or poor mood, helplessness and hopelessness, low self-esteem, crying, lack of motivation or interest in things, lack of enjoyment from life, anxiety or worry, or suicidal thoughts of harming themselves. Approximately seven participants are between the ages of 20 and 30 and reside in the Selangor region.

This research endeavor involves ethical considerations because the investigation approach entailed interviewing and seeing people. The participants have been protected from danger with great care. As mentioned in this section, several factors were considered. A thorough ethical clearance was provided in this regard, and it was approved. Participants were informed in writing that their participation in the study was voluntary and that they might withdraw without risk of repercussions. All participants were asked to provide written informed consent. Before participating in data collection, each subject signed a consent letter, placed it in a separate envelope and returned it to the researcher.

The research will involve respondents with mental health issues. Those who have symptoms such as continuous low mood or sadness, feeling hopeless and helpless, having low self-esteem, feeling tearful, not being motivated or interested in things, not getting any enjoyment out of life, feeling anxious or worried, or having suicidal thoughts of harming themselves. About five to ten respondents will be chosen from those who live in the Selangor region, are 24-30 years old, and are currently studying or employed. The interview will be held in person; however, those who cannot attend can answer the questionnaire online

The interview instrument comprises two sections. The initial component collects demographic data (name, age, occupation) and examines the participants therapeutic practices, knowledge of projective phototherapy, and openness to alternative treatments. The second section employs visual stimuli (images) as triggers to investigate emotions, memories, and viewpoints regarding various temporal contexts (past, present, future, hope) and current emotional conditions following the treatment session. The purpose of all the questions was to elicit deeper responses from the participants by employing the previously mentioned technique of evoking emotion through visual imagery while also describing the potential therapeutic effect of projective therapy. This is in line with the projective aspects of phototherapy, in which the reading of pictures represents the patient’s emotional and psychological condition.

Qualitative data analysis, through interviews, is done by searching for patterns, themes, and insights with respect to the objectives of the study. Transcripts will be analyzed using a structured yet flexible methodology to comprehensively explore the depth and richness of the responses made by participants.

RESULTS AND DISCUSSION

Projective Phototherapy: An Expert Interview

A Zoom meeting was held between the researcher and Francesca, an Italian psychodynamic psychotherapist engaged in clinical practical’s in Milan, specializing in therapeutic interventions informed by psychodynamics principles. During the meeting, a question-and-answer session and a theoretical explanation of the phototherapy process will be conducted. Field experiment: Unlike laboratory experiments, which take place in a controlled environment, field experiments occur in a naturally occurring system. As a result, researchers often need more control over the measured variables.

The interview with Francesca gives insights into valuable data that closely align with the objectives of this study, especially on the use of image-based therapy to address mental health challenges. Francesca talks about photography as a medium that is non-verbal and safe for the emotional exploratory self. Her work is inspired by pioneers such as Judy Weiser and Jo Spence; she underlines the use of photography to enable emotional projection- to help clients find deeper emotions and memories by interpreting images. This is most relevant to the 20-30-year-old generation, a generation of young adults plagued by identity crises, anxiety, and depression-especially in the post-pandemic context. Francesca further sensitizes that it is important to establish a non-judgmental, safe therapeutic space for the client to establish trust and slowly share personal experiences. The practical usefulness of her image selection method as an “icebreaker” to bypass cognitive barriers in order to initiate meaningful therapeutic discussions cannot be overemphasized. Such observations heighten the importance and opportunities for image therapy to effectively pursue mental health pathology, even from such populations that tend to struggle to express themselves in classic settings. Building on these insights will help one increase the value and reach of image-based therapeutic approaches in post-pandemic Malaysia.

Projective Phototherapy: An Interview

The interview was aimed to explore participants experiences with mental health issues and their perspective on phototherapy as an intervention. This method also provides a deep, personal insight into the therapeutic process and allows the researcher to understand the participant’s emotional and cognitive responses in a natural, conversational way. Table 1 below show the summary of the respondents’ demographic, their current knowledge and willingness with the Projective Phototherapy treatment.

Table 1 Participants Details

Interviews involved 7 of participants who are currently having a problem with their mental health issues. All the participants age are range from 20 years old to 28 years old. Most of them are currently under counselling and medication treatment. In the context of knowledge towards projective phototherapy treatment, most of the respondents are not having knowledge of it but they are willing to have it as a treatment for them.

The qualitative analysis across interviews is done by searching for patterns, themes, and insights with respect to the objectives of the study. The summary as per shown in table 2 below.

Table 2 The summary of the interview results.

The further study on the potential of projective phototherapy treatment was discovered 6 themes from the interview data. There are including isolation and loneliness, optimism and metamorphosis, complexity of emotions, nostalgia and memory, interpersonal relationship and connection and searching for identity and purposes.

In the context of isolation and loneliness, 3 respondents were agreed with the feeling of lonely is commonly happened to the mental health patient as stated:

“I feel sad and lonely; I spent my time alone in bathroom,” (participant 3)

“There were times when I felt like being in adulthood could make me feel so lonely, especially regarding self-appreciation.” (participant 5)

“When I deal with a traumatic event, I will always be alone. I had to deal with the pressure on my body and

mind by myself. I am not sure how to put it into words. Since I am an only child, for this reason, I would rather keep my emotions to myself, and I feel more at ease being by myself in this situation.” (participant 6

Moreover, the participants also agreed on how most of the mental health patients are hardly facing with the lost hope situation. to them searching for identity and purposes is not something that easy when they can easily view something from a different perspective. This claimed was express by participant 3, 4 and 5 as below:

“It represents most of the word hope since it is a new day. Think that every morning light comes with a new hope. With the calm feeling, you start a new day and a new hope.” (participant 3)

“I am in a phase to eliminate negative things in my life. Regarding my workplace, the people around me and my environment push me to think negatively. I do not want to think negatively to live more calmly. Jihad to fight negative feelings. scissors and negative words” (participant 4)

“I felt the mysterious energy from it. The world is vast with mystical, magical things, and we can view it from any aspect from a different perspective.” (participant 5)

A few photos were also shown to the participant during the interview, and they were asked to select one by describing how they felt while viewing the images. Choosing a picture to represent their feelings can be done in four distinct ways: (i) their current self, (ii) their prior experiences, and (iii) their current state. Responses based on their current selves are listed here (Table 3), their prior experience (Table 4), their current state (Table 5) and their potential solutions to their problems (Table 6).

Table 3 Participants Selected Photographs and Description Representing Their Current Self

Participant	Photograph	Reason Description
1		The image has a unique and gives me a sense of being lost. Feeling like something inside me is getting all twisted up, weighing me down and making me dizzy. The subject of the man concealing himself, hiding from the world around him.
2		Something joyful when I looked at this photo The most obvious thing, I saw in this photo was the bubble
3		I feel sad and lonely The man is all alone without anyone by his side
4		I chose the picture were about my work, I have good management, but my environment does not help me at work The most obvious things noticeable in this photo are the signboard lost and hope. If I could change anything about the photo is the light, I want to see light.
5		Loneliness, Determination. The two figures.
6		Sad, angry mixed with dissatisfaction.
7		A person sits alone on the beach, tired eyes that reflect the burden of deep thoughts. Find peace in the noise of the world

Table 4 Participants Selected Photographs and Description Representing Their Past Experiences

Participant	Photograph	Description
1		This photo feels connected to my past self is lost Dead and dreary. Feeling of being left out, sadness, and lost.
2		Scared. There is a loss. Detachment, Isolation.
3		I feel like I am left all alone, sad or lonely. Feel left out and do not want to hear anything.
4		My past seems dark, in terms of my career, in terms of my life, in terms of my relationships I lost a lot.
5		I think of my past childish self not caring about the future or the world. Just wanting to have fun. Childhood memories. Nostalgic, happiness. Happy children playing with each other.
6		This picture reminds me of my past with my stepfather. Love and gratitude. Hand hold.
7		This image depicts a friendship relationship. two friends who have reached the top of the mountain. Implying a sense of achievement and togetherness in a journey full of challenges.

Table 5 Participants Selected Photograph and Description Representing Their Current State

Participant	Photograph	Description
1		The feeling of reliving.
2		Because of the view. The rain represents sadness, the rainbow represents hope.
3		The picture tells me that the world is wide, and you still have a lot to do. Looking forward to what is going to happen next, rest a while.
4		Behind the darkness, there is still colour. The blurred background for me represents the future that we still do not see. It can be dark or light.
5		It is wide angled to the fullest. I felt the mysterious energy from it. The world is vast with mystical, magical things, and we can view it from any aspect from a different perspective.
6		A hand that helps people in the dark. I feel calm. I feel safe and calm. Welcoming hands.
7		A symbol of trust in each other. Belief. Someone is always ready to support and share faith with each other. “You will be free”

Table 6 Participants Selected Photographs and Description Representing Their Potential Solutions to Their Problems

Participant	Photograph	Description
1		The hardship. The emotion that this photo evokes is hope.
2		Body posture like a free man.
3		A new hope. The calm feeling.
4		Two swans are love. Happiness, not loneliness.
5		A journey with no ending that leads to a certain goal, which is good for me. A long, calm road. Encouragement to keep going forward.
6		Holy Land. A hope I will never forget. If I go here, I hope my life will change 100%. Calm
7		A fleeting memory of beauty. Sad and lost.

In conclusion, the exploration of participants’ accounts illustrates a marked interaction between their emotional struggles and individual development. The overriding themes of loneliness and isolation tell a lot about the need for self-reliance as well as the emotional cost of rising above hardships by oneself. The strengths, hopes, and possibilities for change were the positives that the clients demonstrated, which stood out. The emotions, memories, and nostalgia make their internal world complex, where their past bears a heavy influence on their current perceptions and future desires.

Interpersonal relationships and social networks are required for emotional stability. This means that support systems enhance healing and self-development. In addition, when the participants seek meaning and identity, it means that they are trying to learn more about themselves. Most of the participants have issues with meaning in life and negativity. In general, the observations point out that human emotions are not fixed, and there is always scope for change and development, no matter how bad things are.

CONCLUSION

The study’s findings reveal the range of reactions and knowledge regarding phototherapy as a substitute treatment for mentally ill COVID-19 survivors in Malaysia. Seven individuals were questioned once the photo card selection process was completed. The findings of the qualitative investigation revealed a significant knowledge gap about the various levels of acceptance of phototherapy. The fact that most of participants are unfamiliar with phototherapy indicates the need for more thorough instruction to increase knowledge of the advantages and potential of using phototherapy therapeutically.

The second objective sought to establish the effectiveness of the phototherapy method in the local setting in managing mental illness. The study was discovered the perceptions and awareness on the participants are significant implementation challenges.  According to an assessment of phototherapy’s potential effectiveness in Malaysia’s mental health context, a common issue in the data is a lack of understanding about phototherapy, which may compromise its validity as a therapeutic strategy. Thus, there is a need for initiatives and collaboration involving various parties to provide deeper exposure to introduce phototherapy treatment methods. Phototherapy also must be used with cultural sensitivity, respect for traditional beliefs, and an unambiguous explanation of its advantages if it is to be widely accepted.

The results also demonstrate the potential of phototherapy as a mental health treatment approach in Malaysia, particularly when paired with other therapeutic modalities. Based on participants’ responses, this study established an evident that there is a need for integration or collaboration between phototherapy and existing treatments such as counseling, psychotherapy, and medication. Accordingly, more thorough study and real-world application of this approach are necessary to determine its place in the regional mental health industry.

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