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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.37 no.2 Porto Alegre  2016  Epub May 31, 2016 

Original Article

Representations of nurses and individuals in psychological distress in the photographic exhibit USAnatomy, by Steven Klein

Evanilda Souza de Santana Carvalhoa 

Edna Maria de Araújoa 

Silvone Santa Bárbara da Silva Santosa 

Alexandro Gesner Gomes dos Santosb 

a Universidade Estadual de Feira de Santana, Programa de Mestrado Profissional em Enfermagem, Departamento de Saúde. Feira de Santana, Bahia, Brasil.

b Secretaria Municipal da Saúde do Salvador, Coordenação da Atenção Primária à Saúde. Salvador, Bahia, Brasil.



To analyze the representations of the nurse and individual in mental suffering portrayed in the photographic work by Steven Klein, in the USAnatomy exhibit held at the Museum of Sculpture (Museu da escultura) in São Paulo, in 2011.


Qualitative study carried out in 2012. Three photographs were submitted to iconographic analysis. The interpretation of the findings was based on theoretical frameworks of Foucault and Bourdieu on power relations.


The nurse is represented as a sensual, insensitive person, with the power to control and torture while the person in psychological distress is represented as dirty, imprisoned and subjected to an asymmetrical relationship of power with the nurse.

Final considerations

Relationships of submission and symbolic dominance, in which the person in psychological distress has their body molded by discipline imposed by the nurse. Stereotypes of the image of the nurse oppose the ideology of the profession, which is to ensure the integrity of those being cared for.

Key words: Nursing; Audiovisual media; Power (psychology); Mental health



Analisar as representações da enfermeira e da pessoa em sofrimento psíquico retratadas na obra fotográfica de Steven Klein, na mostra USAnatomy realizada no Museu da Escultura em São Paulo, no ano de 2011.


Estudo qualitativo realizado no ano de 2012. Três fotografias foram submetidas à análise iconográfica. A interpretação dos achados baseou-se no referencial teórico filosófico de Foucault e Bourdieu sobre as relações de poder.


A enfermeira é representada como sensual, insensível, com poder de controlar e torturar, enquanto a pessoa em sofrimento psíquico é representada como suja, prisioneira e sujeitada à relação assimétrica de poder com a enfermeira.

Considerações finais

Foram evidenciadas relações de sujeição e de dominação simbólica nas quais a pessoa em sofrimento psíquico tem seu corpo moldado por uma disciplina imposta pela enfermeira. Estereótipos sobre a imagem da enfermeira se opõem ao ideário da profissão que é zelar pela integridade dos seres cuidados.

Palavras-Chave: Enfermagem; Mídia audiovisual; Poder (Psicologia); Saúde Mental



Analizar las representaciones de la enfermera y el paciente, en la obra fotográfica de Steven Klein en USAnatomy muestra celebrada en el Museo de Escultura en São Paulo, en 2011.


Estudio cualitativo realizado en 2012. Tres fotografías fueron sometidas al análisis iconográfico. La interpretación de los datos se fundamentó en el referencial teórico filosófico de Foucault e Bourdieu sobre las relaciones de poder.


La enfermera es representada como sensual, insensible, con poder para controlar, someter y torturar. Mientras la persona en sufrimiento psíquico se representa como sucia, prisionera y sometida en la relación asimétrica de poder con la enfermera.

Consideraciones finales

Relaciones de dominación simbólica en que la persona bajo sufrimiento psíquico tiene su cuerpo sometido a la disciplina impuesta por la enfermera fueron representadas. Los estereotipos sobre la enfermera se oponen a los ideales de la profesión que es garantizar la integridad de los seres cuidados.

Palabras-clave: Enfermería; Medios audiovisuales; Poder (Psicología); Salud Mental


This article examines photographs from a fashion advertising campaign in which the models portrayed the characters of a nurse and an individual in psychological distress. On August 10, 2011, Steven Klein presented the photo shoot at an exhibit entitled “USAnatomy”, at the Brazilian Museum of Sculpture in São Paulo(1).

Steven Klein is currently one of the most influential photographers in the fashion world. Born in New York in the 60’s, after studying painting at the Rhode Island School of Design, he opted for photography. He became famous for creating controversial campaigns in which bodies are displayed in a realistic perspective, in unconventional environments for fashion advertising campaigns.

The work of Steven Klein shows conceptual images that are sexually charged, evoking the dark side of pop culture. His work lies at the boundaries between art and fashion. His images permeate the pages of the most acclaimed fashion magazines in the world, achieving a balance between transgression and trade(2).

Steven Klein’s exhibit at the Museum of São Paulo, part of an effort to present to the public a picture that goes beyond journalistic witnessing, the iconographic register of classic photography, but that is also a means for contemporary cultural expression(1-2).

The interpretation of a photograph has a historical character, as there is always something to say about the image it presents. One also refers to the idea of “what has been” from Barthes to give the picture a documentary function of registering reality. However, it should be emphasized that the eye of the photographer is already a relevant detail in transforming historic reality, even if a social scientist is the author of the image. “His gaze – which ends up being the camera itself – is full of idiosyncrasies, knowledge and judgment”(3-4). From this statement, it is worth considering that contemporary photography, in such works as those by Steven Klein, does not base itself on reality captured by the camera, but a represented reality, stored in memory, that is then planned, architected, assembled for subsequently registration. It should be noted that there is still more of the photographer’s subjectivity than in historical photography.

When Steven Klein represents the characters of a nurse and the individual in psychological distress through a work of art, he reveals what lurks in his imagination, something that happened in a particular historical context. To the extent that the artist exhibits his work, this representation will be shared with the public that, when viewing the images, will evoke the information from this universe, thus interpreting what is seen and building theories to explain the behavior represented.

A visual image has the potential to contain meaning, to communicate various issues simultaneously and reach the general public at the same time. It is also able to silently articulate a complex theme in an impressively way, just as verbal language would(5).

Studies with photographs and images of Nursing and Mental Health are justified because they contribute to the knowledge of the icons, symbols, meanings and representations that circulate in the artistic and media communities, and that diffuse common sense knowledge on the profession and a certain practice. In addition to being a methodological alternative for social research in health, it allows you to analyze hidden elements of what moves in the field of subjectivity.

It is considered that Foucault(6) and Bourdieu(7) have different theories about power, but are not contradictory. According to Foucault, power as a social practice, seeks to discipline the bodies and minds of individuals and groups. Bourdieu emphasizes the existence of a symbolic domination system from collective actions resulting from individual actions(7). Therefore, the symbolic dominance also takes place in a microphysical and microlocated scope, which is why the authors base the analysis of photographs by Steven Klein in which the bodies of characters are presented in clear asymmetrical relationship of power.

Observing the nurse’s image in media and photographs produced by Steven Klein, the following question emerged: How are the nurse and the person in psychological distress represented in the photographs presented in US Anatomy? To answer this question, a qualitative study was performed with the intention of analyzing how the artist depicted the attitude of nurses in relation to the ill person.


Three images published on the website of Interview Magazine(8), in a report entitled Institutional White, referring to the disclosure of USAnatomy exhibit in São Paulo, both with free access and opened to the public, in the period from June to August 2012. These images were subjected to iconographic analysis, defined as an analysis of the visual record, i.e., the set of visual information comprising the content of the document(9). To explore this information, ancillary questions were formulated: Who are the subjects shown in the photograph? Where are they? What are they doing? How do they interact? Thus, the environmental characteristics of the characters and their interactions were observed. With regard to the bodies, postures were analyzed, as were actions, facial expressions, presentation and clothing.

The analysis occurred in three steps. I the first step, there was the observation of photographs, guided by questions directed to seizing image content, such as: (1) Who are the people and what places and things are depicted in these images, and how can they be recognized? (2) What ideas and values are associated with these places, people and things represented, and how is this association is allowed?(9). During this step, notes were taken and from the denotative inventory, a mental map was built, consiting in drafting a diagram representing the synthesis of fragmented and diffuse information in order to illustrate ideas and concepts, thus making them comprehensible(10).

To the extent that the questions were answered based on the experiences of the authors, other issues arose requiring further analysis. Thus, in the second stage, they expanded the readings from other sources that allowed new analyzes about the implicit contents and the meanings shown in the images(11). In the third step, there was the synthesis and preparation of the report.

The first stage is characterized by being more exploratory and descriptive, by which the investigators attempt to recognize the elements and record everything they see. In the second stage, the authors intend to show what the findings and descriptions mean, being it a more analytical step. Interpreting a photograph is related to what it presents and the analysis of it is related to what it is and means(3).

The process of image analysis never exhausts itself, it is never complete, because on the same image will always be the possibility of applying a new reading. Therefore, the analyst must be aware of the time to stop and declare the completion of the analysis(4). Based on this assumption, the analysis was completed after construction of mental maps around the denotative inventory and examination of the relationships between the elements “nurse” and “individual in psychological distress.” For each image a file was built, which contained the following questions: Who? When? Where? How/what?(3).

The analysis and interpretation of the findings were based on theoretical frameworks of Michel Foucault(6) and Pierre Bourdieu(7), both discuss power relationships, specifically when these relationships are configured as a dominance strategy and the subjection of bodies correlated with a particular field of knowledge.


In the three images(8, slides 1,5,9) analyzed in the composition of this article, the scenarios simulate the environment of a psychological hospital. The walls have become dark, images in low light, unstructured spaces, broken equipment and furniture, long corridors, only a few doors, as if there were no exits, small windows as if it were a prison where small beams of light let you see the protagonists.

The model that embodies the nurse uses different costumes in each photo, as observed in the images published by Interview Magazine on March 9, 2012(8, slides 1-9). She wears what can be interpreted as a lab coat, a usual uniform in care scenarios. Through this garment is a transparency that that enables one to see that she uses a short dress for the standards of the the profession. The body of the nurse is erect, elegant, expressionless and meticulously cared for. The model that represents the person with mental illness is more disorganized, scruffy, contracted, constrained and naked, and in this sense, less censored.

Both walk down a corridor, seeming to enter the institution. Thus the image analyzed in Chart 1(8, slide1) represents the moment of admission of the patient in the institution, moment at which that person’s body seemed to refuse the inventions performed by the nurse. Part of the patient’s belongings are still with the patient when high heels are seen, while in the following photos, the patient is shown barefoot and sometimes completely naked.

Source: (8, slide 1).

Chart 1 – Denotative and connotative content of photo 1 by Steven Klein 

In all photographs, the nurse is shown wearing long clothes, ajar. Regarding slide 5(8, slide 5), Chart 2 shows that it is possible to observe that the dress has long sleeves and a long skirt, and the garment also includes boots. A body with arms and legs that are well covered, but that reveal the neck and chest and a slot that allows the observer to visualize the laced under garments and naval. This photograph nurtures the imagination of a body that is sacralized, dressed and well hidden, sensual, insinuating and desiring to be touched, all at the same time. The image portrayed by the model is that where she carries the insitution keys, she has the power to deprive or offer the freedom to come and go in the spaces. The key represents an instrument of control, clearly stating who dominates the relationship that happens between the profissional and a person in psychological distress.

Source: (8, slide 5).

Chart 2 – Denotative and connotative content of photo 5 by Steven Klein 

The nurse rests while the person in psychological distress is contained and controlled, looking at a window with the hope of being freed from their prison(8, slide 9) (Chart 3). The image of a nurse resting on the stretcher refers to several meanings: the indifference, the serenity of someone that feels that this attitude is not irregular at all and serenely waits for time to pass. The neatly aligned clothes recalls that nothing gets out of control, nothing disrupts her mood.

Source: (8, slide 9)

Chart 3 – Denotative and connotative content of photo 9 by Steven Klein 

Observing the body of the person in psychological distress, one can notice the expressiveness in that person’s eyes, there are moments when tention can be noticed, which can be observed through the contracted hands. The image, then of the person in psychological distress, is antagonistic to the nurse’s image, always deadpan, distant, cold and relaxed (Chart 3).

Another important aspect seen in images produced by Steven Klein refers to the environment. This is depicted with through the broken, dark, seemingly dirty, damp walls, broken bathroom fixtures, little or no light, small windows, and reflects a grim status. So, the question is: what can be therapeutic in this place? The context is similar to basements, hidden common spaces used for torture in war environments, these spaces in which punishments are given, is out of sight from others in society.

In this sense, the environment portrayed allows us to infer that, such as prison, a psychological hospital is a place devoid of color without favorable conditions for the development of a healthy mental physical condition, meaning it is a space capable of aggravating or adding new forms of illness.


The set of analyzed images allows you to build an itinerary of the person in psychological distress within the psychological institution, which begins with admission, followed by submission to violent control procedures and isolation, and also describes the role of the nurse in this context.

The spread of representations of the person with mental illness as aggressive, unproductive and excluded has been a constant in both written and televised media. Although the quality of knowledge about mental illness has improved the image of the ill person is associated with the idea of dangerousness and there is a growing tendency to avoid contact with them, which is, at present, a great difficulty in establishing a new care model, as such representations spread fear and undermine the rehabilitation process of the patient(12).

In this sense, together with a whole range of changes in care, it is necessary to bring about changes in the representations of the mentally ill, spreading more realistic and less stigmatizing images(12).

Psychological reform in Brazil, which began in the 70’s, but legally evidence was only found from the 90’s, has just proposed alternative models of care and advocated the inclusion of people in society, seeking to overcome the hospital-centered model, since it has been proven that this model reinforces stigma and exclusion and favors the mortification of the subject.

This process begins with patient admission, at which the person is subtracted of their material possessions, to enter an institution where individuality is denied. The withdrawal of belongings is a form of depersonalization of the subject, in this sense the subtraction of goods is also set in the deconstruction of a personal and individual history of those who enter the hospital.

Institutions such as the psychological hospital act on the patients so that their “I” undergoes dramatic transformation from a personal point of view and its social role(13). When the patient reaches the hospital, they undergo a process of “mortification of the self” that suppresses the “conception of one’s self” and the “apparent culture” that they bring with them, which are formed in family and civil life and are not accepted by society. These “attacks on the I” stem from “stripping” the patients of their role in civil life by imposing barriers in the contact with the outside world(13-14).

In psychological institutions, the treatment provided by the doctor and accepted by society comes in the form of “regimentation” (dormitory, isolation cell, impulse control, medicine, tasks, rewards and punishments). Such measures are considered by both medical professionals and by society as a repair mechanism of “sick self”. However, it is noteworthy that such treatments are not applied by the doctor, who only prescribes them, but the nurse and his assistants, staff members who spend more time with the interns, constantly subjecting them to standards that attempt to shape their behavior(6.14).

A study on the production of knowledge in the field of psychological nursing in Brazil between 1933-1955, showed that, although the nurses were concerned with the welfare and needs of patients and the quality of care that was offered to them, the medical discourse at the time emphasized that the psychological nursing objectives were to perform the doctor ‘s orders, keep the routine of the pavilion, prepare the patient for the treatments, promote a healthy hospital environment that is peaceful and harmonious, and facilitate the doctor’s work(15).

According to Foucault, the disciplinary procedure carries principles that assign functions to each individual, determining for each their place. When setting bodies in space and time, a dynamic relationship network is established, which simultaneously acts as a power technique and a process of knowing(6.15).

It is through body subjugation, whether physical, psychological or moral, through the discipline applied – spatial, time, body discipline – that the body sets the mind, disciplining and standardizing behaviors and thoughts, which makes dominance easier by those in power(6.15). Thus, the practices in the context represented bring body torture into evidence as a means of control and dominance over the mind, sould, wishes and attitudes of the subject through the painful manipulation of the body. manipulation of his body.

Attempts to subdue the subject through the body have varied according to time and the system in place, traditions, drawing on tactics, strategies and different techniques, all treated in hospital for said insane subjects: the more or less violent (the torture), more or less “manly” (imprisonment), more or less refined (the separation, isolation). These measures infringe punishment to those considered deviant from the norm, and in psychiatry, such methods were justified as a search to treat the different until they surrender and eventually become equal(6,14,16).

The images in question show the nurse as the main operating character of this discipline, in the extent that it is she who carries out the function to apply the rules, routines and control bodies, seeking to make them docile(6).

In this sense, torture in the hospital context, in modern times, is no longer characterized by the application of physical torture, but the subjectivity of the subject, the soul, subjecting them to strict routines like bath time, meal, waking time, sleeping time, time to see family, time to watch TV, to undergo tests(12). All this without negotiation with the subject that is receiving care, imposing the power to decide on the fate of the ill person unilaterally.

The images analyzed reveal the imposition of rules and measures by the nurse. We observe the control of the individual ‘s life, including the most intimate, on behalf of the welfare of the community(6.16 to 17). The way the (lack of) care for people in psychological distress is represented in the analyzed images reveals that this person should not only fit into a number of provisions that relate to disease, but also the general forms of existence and behavior.

In this sense, Bourdieu(7) states that symbolic systems have the function of imposing and legitimating domination of one class over another, well represented here in the photographs.

Making an analogy with the image represented by the nurse, it is observed that the power knowledge is directly related, as Foucault supposes, since there is no power relationship without correlation with a field of knowledge, and no knowledge that will not be accompanied by power(6.16). The absence of evidence to suggest communication between the characters shows the retention, by the nurse, of information about what is happening.

An imposed and police like action is observed in the pictures, revealing a practice that is also coercive and aimed at imposing discipline to the diseased(6). Thus, the nurse’s body is portrayed as an instrument for the exercise of power.

Although nursing has established strong professional training programs, in which university education includes the practice of research in the social imagination, there are still stereotypes of nurses that are portrayed as an angel and/or the doctor’s right arm(18), executor of their mandates. External barriers to building a positive identity of nurses are found in mainstream media through the dissemination of continuous superficial and demeaning images(19). The negative public image induces feelings of inferiority and powerlessness of nurses, this because the image of nursing that is widespread is opposed to the nursing performed(18).

Such myths and stereotypes shape and constrain the social practice, particularly in relation to class and gender(19). Nursing remains an action field of the working class and a job for women, despite the historical evidence that the middle class and men were involved in nursing for centuries(20). Being it a career linked to an inherit female figure with all the historical burden of the devaluation of work performed by women as charitable, domestic, secondary and devoid of economic value.

The negative effect of stereotypes in nursing impacts not only on nurses, but also the users themselves. To the extent that the public does not understand the importance and complexity of the work of nurses, they cannot claim social and financial resources that enable these workers to provide skilled care. On the other hand, the low professional self-esteem discourages nurses to mobilize to achieve respect, recognition and adequate compensation, thus the unfavorable conditions at work tend to persist indefinitely(19-20). The persistence of old stereotypes makes nursing less attractive as a career option for younger people and prevents professionals from building a satisfying career in the long term(20).


The representations of the nurse and the person in psychological distress, portrayed in the photographic work of Steven Klein show that the bodies of the subjects involved in the hospital scene have different connotations that reveal an asymmetry of power. The body of the nurse represents the one who exercises control over the body of the subject in distress, seeking to discipline that individual and make them docile.

The iconographic analysis identified that the body signals emit meanings that unfold in a complex network of images whose interpretation can be shared and lead to the development of common sense knowledge. This is shared and disseminated in museums as well as in magazines and web pages.

Although the psychological reform and new ways of caring for the mentally ill have been introduced around the world, there is the strong image of the psychological hospital as a place of torture, denial of autonomy and depersonalization of the subjects from the practice of subjection and disciplining of bodies. The images constructed from these realities overexploited by cinema, fiction and the visual arts consolidated representations about common subjects in these spaces (the nurse and the sick person).

Deconstructing an alienating practice of hospitalized subjects in health contexts, especially psychological, it has been configured as a space of disputes, conflicts and negotiation in the political and assistance fields in defense of human rights. The advances made with the new therapeutic communities, the Psychosocial Care Centers and the Back Home program have been shown to be possible avenues for a new model of care for people with mental ailment order.

The images analyzed bring out the negative figure of the health professional, the antagonistic nurse with the ideals of the profession which aim to ensure the integrity of those in care. However, it is noteworthy that these same images can be useful to discuss stereotypes, the construction of the professional identity of the nurse, the psychological care models reproduced in the last centuries and the likely changes.

This study has implications for the care, teaching and research in that it can support discussions of issues that cross-cut the curriculum components of mental health, the history of nursing and the power relations in the contexts of care practices. It also contributes to reflection and recognition of the persistence of prejudices and stereotypes in the profession, inviting professionals to create strategies to give greater visibility to the role of the nurse in the health team, favoring the construction of a humanized model of mental health care through media means.


We would like to thank the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for financial support.


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Received: March 30, 2015; Accepted: January 27, 2016

Corresponding author: Evanilda Souza de Santana Carvalho. E-mail:

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