Coping Among Canadian Youth Living With Anxiety: A Phenomenological Photovoice Study

Design and Framework

This research follows Max van Manen’s (1990) approach to hermeneutic phenomenology, which aims to understand human experience as it is lived. Hermeneutic phenomenology is both a descriptive method (phenomenological) that seeks to describe phenomena as they are, and interpretive (hermeneutic) as it is based on the position that phenomena can be meaningfully interpreted (van Manen, 1997). In hermeneutic phenomenology, the goal is to capture the personal meaning of a person’s experience including what was experienced and how it was experienced (van Manen, 1990, 1997).

To understand a person’s lived experience or “lived meaning,” van Manen (1997) highlights the importance of reflecting on the four lifeworld existentials of (a) embodiment, (b) temporality, (c) spatiality, and (d) relationality. According to the work by van Manen (1990), “lived meaning” prioritizes subjectivity and refers to “the way that a person experiences and understands their world as real and meaningful” (p. 183) while “lifeworlds” refer to “the lived world as experienced in everyday situations and meanings” (p. 101). Embodiment (lived body) refers to bodily experience in everyday life including how we feel, reveal, conceal, and share (Husserl, 1925; van Manen, 1997). The notion of spatiality (lived space) refers to individuals’ subjective experience of the spaces they find themselves in and includes the ways in which space affects one’s subjectivity and how one’s subjectivity can affect the way spaces are experienced (van Manen, 1997). Relationality (lived relations) refers to the subjective experience of relations made and maintained with others in our lifeworld (van Manen, 1997). Finally, temporality (lived time) can be understood as the subjective (rather than “factual”) experience of time or the way in which individuals temporally experience their lifeworld (van Manen, 1997).

Phenomenological research often involves interviews and artistic data sources, such as photographs (van Manen, 1990). To extend and enhance the understanding of youth’s lived experience of coping and to empower youth, we used photovoice, a participatory visual methodology where participants use cameras to reflexively explore their experiences through taking photographs and describing them (Wang & Burris, 1997; Woodgate et al., 2017a). Thus, we used a youth-as-expert approach where youth were viewed as experts in their own experiences and research methods that help youth speak about their experiences were used (Darbyshire et al., 2005).

Participants

Participants included in this study were 58 Canadian youth living in Winnipeg, Manitoba who had a primary diagnosis of one or more anxiety disorders. This included separation anxiety, specific phobias, panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder. For this study, “youth” included early to late adolescents (10–18 years) and emerging adults (19–25 years). We adopted an inclusive age of 10–25 years to capture diverse experiences and developmental differences (Patton et al., 2016). The majority of youth self-identified as female (n = 44). Of the female youth, the majority (n = 31) reported being White. Other ethnicities reported by female youth include African (n = 1), Filipino (n = 2), Indigenous (n = 9), and Spanish (n = 1). All female youth were between the ages of 10 and 22 (M = 14.7) years. Of the youth who self-identified as male (n = 14), 9 were White, 4 were Indigenous, and 1 was African American. All male youth were between 10 and 18 years of age (M = 13.8). For additional information about the study sample, see the work by Woodgate et al. (2020) and Woodgate et al. (2023).

To capture a wide range of experiences, we used the maximum variation technique of purposive sampling (Sandelowski, 1995). Youth were recruited via (a) invitation letters from hospital-based programs that specialize in the treatment of anxiety disorders, (b) posters located at youth centers, teen clinics, and schools, and (c) sharing the study flyer through social media (e.g., twitter).

Data Collection

Data collection took place more than a period of 4 years from 2012 to 2016. Each youth first participated in an open-ended, face-to-face interview. The open-ended interview method helped to elicit detailed responses deemed relevant to the study aim and afforded youth the opportunity to use their own words to discuss what mattered to them, allowing interviewers to remain close to the youth’s experience. (Morse & Field, 1995). Participants were treated as “experts,” or knowledgeable persons (Darbyshire et al., 2005) about the phenomenon of anxiety. The interview began with the question, “Please tell me what it is like to be a youth living with anxiety?” An interview guide that included questions related to how anxiety shaped their day-to-day lives, the type of challenges faced by the youth, how the youth coped with their anxiety, and the types of support that helped them to cope was developed. However, questions were only asked when necessary to facilitate youth’s descriptions.

An important aspect of hermeneutic phenomenology is repeated interviews as they allow for follow-up questions that add to the descriptions revealed in the initial interview. Accordingly, two phases of interviews were conducted. The second interview was conducted 6 weeks following the first interview (to ensure the first interview was fresh in youth’s minds), with photovoice supplementing the second interview. Youth were given a digital camera and asked to take pictures that represented their experience of living with anxiety and to provide a description of the photographs (Keller et al., 2008). The SHOWeD method was used to guide the photovoice interviews by asking youth to describe the image and reflect on what it meant to them (Dahan et al., 2007). All interviews were digitally recorded and transcribed, and field notes were recorded after each interview detailing the interview context. Interview length ranged from 1.5 to 3 hr.

Data Analysis

Guided by the hermeneutic phenomenological approach, the data analysis process was both descriptive and interpretive. Data analysis occurred concurrently with data collection resulting in an iterative process that allowed young people to have ongoing input into theme development. Both text (i.e., interviews, field notes) and visual data (i.e., photographs) were used to inform the analysis. The process involved delineating units of meaning from the data, clustering units of meaning to form thematic statements, and extracting themes.

The analysis involved five steps: (a) prolonged engagement with the data and line-by-line reading of interview data and field notes to identify significant sentences or sentence clusters representative of youth’s lived experience of coping, (b) grouping the significant sentences and sentence clusters into categories through analytic discussions, (c) reducing the phrases and sentence clusters until themes emerged from the analysis, (d) viewing each photo and accompanying caption, developing youth’s interpretations of the photos by adding researchers’ perspectives, reflecting on all the photos as a whole and identifying associations to the corresponding data (Woodgate et al., 2017b; Woodgate & Skarlato, 2015), and (e) further analyzing and positioning the findings within van Manen’s (1997) four lifeworld existentials. By engaging in the circular process of reading, interpreting, and reflecting on the emerging themes, a narrative description of the essence of youth’s experiences emerged. Engaging in a circular process, which has been described as the hermeneutic circle and characterizes the act of interpretation by understanding the whole text by understanding its parts (Heidegger, 1996), involved a circular movement between the part and whole of the texts, the words and sentences, and the research interviews and photos. Data were analyzed using the highlighting and comments function in Microsoft Word and organized into a table of contents. Analysis was undertaken by the first author (study’s principal investigator and distinguished professor known internationally for youth engagement in research, integrated knowledge translation, and qualitative arts-based research methods), second author (psychologist and psychotherapist), and third author (doctoral researcher with a focus on human rights and qualitative research). All authors discussed the analysis and interpretation of the data.

Youth Engagement in This Study

A Youth Advisory Committee (YAC) was established prior to study commencement and consisted of 14 youth with lived experience of anxiety. The majority of the youth were female (2 male youth), White (1 was Indigenous), with a median age of 16 years (age range of 10–22 years). The youth were recruited through the first author. The YAC was actively engaged and contributed during each phase of the project: preparatory phase (e.g., feedback on interview guide), data collection (e.g., ideas about how and where to recruit, such as social media), data analysis and interpretation (e.g., feedback on interpretation and themes), evidence dissemination (e.g., participated in the creation of a photovoice book [https://www.ingauge.ca/article/youth-voices-of-their-lives-and-experiences-of-living-with-an-anxiety-disorder] and vignettes [https://www.ingauge.ca/article/metaphors-of-youth-experiences-of-living-with-anxiety] depicting a day in the life of youth living with anxiety; participated as youth panelists at an event displaying ABM created through this project). Youth also attended team meetings throughout the length of the project.

Ethical Considerations

The study was approved by the Education/Nursing Review Ethical Board at the University of Manitoba (approval no. E2011:094). Written informed consent was received for participants above 18 years of age, and parental written consent and assent for youth below 18 years of age prior to enrollment in the study. An ongoing process of verbal consent was also part of the project and youth received an honorarium in appreciation of their time and expertise.

Youth’s Lived Experience (Lived Meaning) of Coping With Anxiety

This overarching theme refers to how youth experienced coping (e.g., challenging) and to the intentions, purposes, and meanings of the coping strategies they used (e.g., coping gives them a break from anxious thoughts, gives them a sense of ease, creates time for their anxiety to pass, and helps them make sense of their condition). Youth experienced coping with anxiety as difficult. Their everyday life was characterized by anxious feelings and thoughts that were difficult to control. Although youth found it challenging to deal with their anxiety on a daily basis, they reluctantly accepted their condition. One youth shared:

My life isn’t excellent. I don’t have a bad life, only a challenged life. My anxiety has improved over the years, but it still impacts my life in different ways, every day. (13 years old)

The coping strategies youth reported using to deal with their anxiety gave them a “break” or release from their anxious thoughts and feelings. One youth shared:

I feel anxiety is very much rooted in your mind. It’s rooted in how you’re thinking at least for me. So, not focusing on the negative or not focusing on what’s going wrong or anything like that and you focus on something that can be solely entertaining, relaxing, calming. Yeah, and it gets your mind focused onto something else enough for the anxiety to pass. (18 years old)

Viewing their condition and experience differently, or adopting a new perspective, helped youth make sense of their anxiety. In the words of one youth:

It depends on your experience you know. If you have OCD you’re going to be way better at design and stuff and how things look. You’re going to be really, I don’t know, really good at knowing where things should go and how to make things look nice. And sometimes you’re not. Sometimes things look nice to your brain and to other people they look messy, but to you they’re like beautiful and sometimes it works, sometimes it doesn’t. (11 years old)

Contemplating both the vastness and subtleties of life around them also allowed youth to experience some degree of ease within and adopt a new perspective. For instance, youth could see the significance or insignificance of their anxiety (and of themselves) as they encountered the larger world. A photovoice submission (see Figure 1. Just Breathe Screenshots) shows two screenshots from the internet of nature scenery and someone looking out into a lake. Reflecting on the screenshots (Figure 1) she submitted, the youth shared:

[This photo], it’s just like the idea of how sweet that would be to stop and be at this view and be on the water and have those views. To just breath and be able to appreciate the little things. Your problems will seem so irrelevant and minute in an environment like that. . .like this vast huge space that’s encompassing me. (18 years old)

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Figure 1.

Just Breathe Screenshots.

Embodiment (Lived Body)

Youth reflected on their anxiety and their lived bodily experiences. Life with anxiety was characterized by anxious thoughts and feeling, excessive worry, overthinking, feeling stressed and depleted of energy, and experiencing emotional outbursts (e.g., crying, anger) when things on the inside became too much to bear. One youth shared:

Sometimes I just can’t handle what’s going on in the inside and I’m just like, I just can’t deal with it and, most of the time I can. I have those bursts and I think it’s when things just go all at once. (19 years old)

Expressing emotions and naming anxiety emerged as an important coping strategy. Youth indicated this allowed them to move heavy emotions outside of their body and into the world. One youth shared: “When I’m at home, crying, helps. I can just cry for hours. I think it changes my perspective” (16 years old). As participants discussed the expression of feelings, anger was reported frequently and emerged as intimately connected to and inseparable from anxiety. Youth reported that expressing anger eased their anxiety. One youth described:

Sometimes I can’t control it [anger] so much that I, I just freak out. . . But I don’t hurt anybody. I just freak out, throw stuff around and I punch walls. . .I yell my loudest until my throat hurst. It calms me down a little bit. (16 years old)

Youth also reported that “talking about it” to release feelings and thoughts was helpful. As one youth described it:

Sometimes you just need to talk about it [anxious feelings and thoughts] and it doesn’t mean that I need to go back to therapy. It doesn’t mean that I need to see a doctor. It doesn’t mean that I’m going to do anything extreme. It’s just, I need to talk about it. (18 years old)

Talking about their anxiety helped youth release anxious thoughts and feelings. One youth reflected on how “talking about it” was helpful:

I don’t know. It might be the fact that I feel like I’m being listened to. Or it could be just to get kind of the words out and just not have them kind of trapped inside my body anymore. (13 years old)

Journaling also helped youth move anxious feelings and thoughts out of their system. Youth noted that journaling was a good way to vent and that they wrote about anything that was bothering them (e.g., a conversation that made them anxious, their illness: why they were anxious, why the anxiety kept coming back). One youth shared: “It’s just a good way to vent. It’s okay if there’s no action after. Sometimes it feels better when there’s no action after” (18 years old). One photovoice submission shows a journal (Figure 2). The youth noted that if she experienced anxiety on a given day, she would write about what happened and would note the positives and the negatives of what had happened.

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Figure 2.

Journaling.

Youth also spoke about strategies they currently used or had used in the past to get relief from painful feelings. These included avoiding those feelings by “blocking it out,” cutting behavior, and physical violence:

Another youth shared:

It helps me if somebody’s being mean to me because I don’t even have to move. It’s just my brain takes care of it and then somehow, they’re lying on the ground with a bleeding nose. It just happens which scares me. (11 years old)

Youth were aware that while helping them in the moment, these were not constructive coping strategies that could become addictive and only made things worse.

As noted by these two youth:

Some people scratch themselves or they may cut themselves with knives. They nearly just injure themselves and it’s like you’re trying to control anger. You just throw everything around. You try to punish yourself so that you’d stop doing that but then when you’re done you realize that it’s just creating everything worse. . .. But you don’t realize that when you’re in the phase. (10 years old)

Yeah, I think self-harm feels like it, like its short-term positive but really, it’s not at all, but another thing could be just kind of hiding the feelings away, like it would be positive for just this little while but afterwards you’re going to be like a raging monster! (19 years old)

Spatiality (Lived Space)

Youth in this study reported that places with lots of people and instances where they found themselves alone were anxiety-provoking. One youth shared:

When I’m home alone I’m so paranoid that someone’s going to break in. Like every time my dog barks I freak out and I grab the, what’s it called? I close all the blinds, the drapes, turn the lights off so it looks like no one’s home. (11 years old)

When coping with anxiety, space mattered. Youth reported needing space when experiencing anxious thoughts and feelings.

Youth engaged with their lived space in several ways to reduce their anxiety and increase the feelings of comfort. Confining themselves to a familiar space was described as useful for “calming their nerves” or “collecting their thoughts.” Youth also reported removing themselves from certain spaces to reduce anxiety, such as taking bathroom breaks to excuse themselves from stressful situations. Going outdoors to be out in nature was also helpful. Youth noted that the elements of nature nourished their physical and spiritual selves. The intimacy of youth’s relationship to nature is poignantly described in one youth’s account of industrialization and its effects on nature (Figure 3):

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Figure 3

The Industrialization of Nature.

Some youth also reported using objects in their lived space to reduce anxiety. One youth shared:

The only times I walk through crowds on my own is if it’s in school hallways and everyone’s moving. So, we’re all going in the same direction but what I have to do is while I’m walking through a crowd, I have to find someone who is walking in the same direction as me and walk directly behind them. . .. I can’t just be a part in the crowd. I have to follow someone specifically and if they move, I have to find someone else to follow and I keep my head down. (14 years old)

Relationality (Lived Relations)

Youth reported that certain people (e.g., best friend, family members) offered a presence that proved invaluable as they contended with feelings of anxiety. Those who could “be there” for youth allowed them to experience a greater sense of ease within. “Being there” included listening to their worries with compassion, without judgment, and without trying to problem-solve or offer solutions. Youth reached out to these individuals and noted how important these individuals were to them:

They matter so much. They’re probably at the center of your recovery or whatever you’re going through. I feel like they’re the symbol of hope. And so, the way I do cope is for my family, is for my friends, the people who look you in the eye and say I’m here to help you, I’m here for you. . .. Yeah, they’re here. They do care about me and they’re my hope. (22 years old)

Reaching out to others who could “be there” for them also offered youth important opportunities for learning to cope with their anxiety. Youth articulated how encounters with these individuals positively influenced their lives, whether it was through normalizing their experience, providing gentle reminders to breathe, or putting up a mirror so they could reflect on underlying influences:

I think it’s [relationship with mother] probably better on a day that I’m anxious because I’ll just feel like I need to talk to her about everything that’s going on. Cause sometimes I’ll just have a panic attack about something, and I just don’t even know what it is and so she’ll be like: “Oh what did you do at school today? Is there anything that you think might be the root of the problem?” And so, I’ll just kind of tell her a whole bunch of stuff. (13 years old)

Youth also described how petting, speaking to, or cuddling an animal (e.g., pets) was very soothing and helpful. Youth noted that pets were great listeners, offered love, and never criticized. One youth shared: “I would talk [with pet] about family issues. I would talk about anything and everything that was bothering me.” (16 years old). A photovoice submission shows a cat sitting on a bed (Figure 4). The youth explained that when she felt anxious, the only thing that would help her calm down was snuggling her cat.

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Figure 4

Pet.

Youth also used social media (e.g., Facebook, Instagram) and social networking sites (e.g., Tumblr, blogs) to interact with others and cope with their anxiety. These platforms provided an anonymous forum for discussing emotional difficulties and concerns, accessing others experiencing similar challenges and providing advice to those struggling in similar ways. One youth shared his thoughts about Tumblr:

And then there’s like websites, Tumblr in my opinion is great cause you can have an ask box where people ask you questions. And so, they’ll say, if you ever need advice feel free to talk to me, you can go on anonymous or not, you can come and talk to me, and I will not judge you for anything. So that’s one of the reasons I really like Tumblr. There’s a bunch of blogs that help people that have problems with cutting and that want to stop. And so, if you feel like you’re going to cut, you can go and message them and be like: “Hey I feel like I’m going to cut, please help.” And then they’ll respond to you, and they’ll be like “Okay, well, you can do this and there’s this, and they give you like a bunch of options.” So, Tumblr’s really helpful. (14 years old)

Although internet communities offered opportunities for interaction and getting help, youth noted challenges associated with online communities, such as bullying and becoming dissatisfied with their own life when compared to others in social media. One youth shared:

I play a lot of video games [virtual community]. When I do really badly, I don’t know the best way to the community of people I play with that it’s toxic [the environment]. If you do badly, they’re really rude about it. (17 years old)

Temporality (Lived Time)

Time was central to youth’s experience of anxiety as many worried about the past and the future, with forward and backward shifts in temporality serving to exacerbate their anxious state. Life with anxiety was characterized by excessive worry and coping entailed learning to manage this worry. Some youth reported bringing their attention to the present moment which was effective in easing their anxious state:

I feel like also having anxiety you worry about the next day a lot. Like when my boyfriend left my house, I’d say, well when am I going to see you next? which is absolutely just freaky. I mean, that’s judgment but you worry about the next day and now I don’t. I don’t, I just kind of let it be. What you have to do is kind of just realize, okay this is this day. Don’t worry about the next day, like don’t. (19 years old)

Youth further described the experience of worry as a tendency to become fixed in a mind-set characterized by circular and repetitive thinking. They reported distracting themselves from worry by drawing on mediums, such as video games, reading, and the arts (e.g., music, dance, drawing) which created some time for their “anxiety to pass” so they could regain focus. A photovoice submission shows a piano (Figure 5). The youth explained that playing the piano helps her relax and that she would play the piano for 5 min to calm down.

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Figure 5.

Playing the Piano to help “Anxiety Pass”.

However, youth were aware that distraction was a temporary solution for managing their anxiety:

Sometimes music, you know, you can listen to a certain song, and it makes you forget and feel good at the moment. But a song’s like three minutes, four minutes long and then that’s it. All of a sudden, it’s like, it’s kind of like seeping back again. It’s like a mist coming back. (22 years old)

Given that distraction provided short-term relief from their anxiety, youth noted how important it was to be weary of the easy way out (e.g., distraction). They reported using other strategies, such as acknowledging their dilemmas, confronting their challenges, and adopting a new perspective of their condition and experience. One youth noted the importance of facing fears:

Just face your fears in order to get rid of them. . . “cause like my friend she hates avocados,” but we were making something with avocados “cause we did French cooking class.” And then we were making an avocado wrap thing. And she hates avocados and she’s like: “Oh get it away from me,” but actually when she ended up trying her wrap with avocado, she’s like: “Oh my goodness, this is great.” And then so you know, she kind of like faced it sort of like hating avocados to actually liking them more. So, you got to face it. (11 years old)

Some youth noted the utility of adopting a new perspective (e.g., “anxiety as a challenge to overcome”) in coping with anxiety. Adopting a new perspective helped youth make sense of their anxiety. One youth shared:

You can go through hard times, and you’ll take things away from it and the things you did take away from it they never go away. They’ll they help you, kind of make you into who you’re going to be, things like that. (17 years old)

Implications

Our findings have implications for anxiety intervention and prevention programs. It is important to learn from youth about the coping strategies they use and find helpful to manage their anxiety before integrating these strategies into existing programs. The strategies used by youth in this study suggest that youth may benefit from programs that employ more than one strategy. These may include mindfulness (bringing youth’s attention to the present moment), frequent soothing places (e.g., being outdoors), the arts (e.g., music, art, dance), making meaning of their condition and experience, and reaching out for support to those who can “be there” for them (in-person or online). In terms of theoretical implications, Van Manen’s (1997) Lifeworld Existentials Framework proved useful in understanding youth’s lived experiences of coping with anxiety. This framework allowed us to explore the multidimensionality of youth’s lived experience of coping (lived body, lived time, lived space, and lived human relations) and the meaning they assigned to the experience (lived meaning). Thus, this framework can be used when the goal is to attain a rich and nuanced understanding of lived experience.

Our findings also have implications for those who work with youth. In this study, youth reported that expressing anger eased their anxiety. It is important for clinicians to listen closely for anger in youth’s stories, identify the causes of anger, encourage youth to honor their feelings, and assist youth to safely and constructively experience, express, and manage their anger. Time was central to youth’s experiences of anxiety as many worried about the past and the future. Paying attention to temporality in youth’s stories and shifts in time (past, present, future) and their association to expressed anxiety levels can help individuals who work with youth better understand youth’s experiences and inform strategies and skills that might be most helpful for youth. Youth in this study were aware that some strategies that they used (e.g., cutting), although helpful in the moment, were harmful in the long run. This reinforces the need to work with youth to use strategies that have no negative consequences. Youth also reported that reaching out to individuals who could “be there” for them was helpful. This highlights the importance of offering one’s presence to youth living with anxiety through listening and an attitude of openness and nonjudgement.

Strengths, Limitations, and Future Research

A youth-as-expert approach was a useful medium for accessing the coping strategies used by youth. To ensure trustworthiness, we used methodological triangulation (used interviews, field notes, photographs), allowed for member checking (youth provided feedback on data interpretation), and ensured two researchers engaged with the data and other team members were available to verify interpretation and resolve discrepancies. Our sample was largely White, middle-class, and included a higher proportion of female participants. Documenting the lived experiences of youth who are male and from diverse sociodemographic backgrounds is warranted. Youth in this study had a diagnosis of one or more anxiety disorders. Documenting the coping experiences of youth from community samples (have not received a diagnosis) and examining the relationship between coping strategies used and changes in anxiety symptoms would be informative. Finally, given comorbidity is the characteristic of youth diagnosed with an anxiety disorder, future research should consider the co-occurrence of mental disorders to capture the complex and dynamic nature of how youth cope with mental illness.