Mental health geography?

By Chris Philo

Obviously of relevance to this blogsite is the parameters of what had variously been called ‘mental health geography’, ‘the geography of mental health’ and related phrases. I will briefly reflect on these parameters, acknowledging limitations and partiality in what I now describe (and acknowledging the absence of cross-referencing to work in psychoanalytic and psychotherapeutic geographies: perhaps a good topic for a later post). I also include a few useful references below.

Informed by broader orientations from the parent discipline of Geography, chiefly concerning meta-level concepts of space, place, environment, landscape and location, mental health geography has gained impetus and critical mass since the early-1970s. The main focus of this geographical work has been mental ill-health, with some researchers borrowing from conventional medical-psychiatric framings of the condition, while others remain agnostic about the deeper causes behind the alternative ‘states of being’ experienced by people with mental health problems. Indeed, the theoretical frames adopted have also included insights from ‘anti-psychiatry’ and ‘post-psychiatry’, as well as ranging across the conceptual vocabularies of psychoanalysis, phenomenology, political economy and critical social theory. There have been two broad streams of research clustering under this umbrella, the latter of which is most pertinent for inquiries into ‘asylum and post-asylum spaces’.

Spatial epidemiology of mental ill-health

Writers have long commented on mental health contrasts between ‘civilised’ and ‘backward’ regions, a concern being that ‘madness’ is a pathology associated with the march of civilisation. In the 1930s, the sociologists R.E. Faris and H.W. Dunham produced their famous map of schizophrenia in Chicago, showing a clear distance-decay in prevalence with increasing distance from the city centre. This study prompted numerous geographers (from the early-1960s) to begin investigating ‘psychiatric geography’, the general finding being that the more ‘stressful’ a local socio-economic environment – usually associated with the most poverty-ridden and run-down of neighbourhoods – the more likely it is to ‘generate’ large numbers of residents with diagnosed mental ill-health. Exact spatial patterns remain inconclusive, however, and even distinctions between urban and rural areas remain subject to dispute. The imagery of the ‘rural idyll’ suggests that mental ill-health will be more an urban than a rural phenomena, but there is evidence that serious mental health problems, albeit more the depressions than the schizophrenias, can prevail in rural districts. Collectively, these works of ‘spatial epidemiology’ have underlined that explanations for mental ill-health should not be lodged solely in an individual’s own personal problems and biography, but must always recognise ‘contextual’ factors characterising peoples’ local situations of living and working.

One of the strengths of this research is its quantitative rigour, but an over-reliance on quantification may also be a weakness, offering elaborate ways of describing spatial patterns and cross-correlations but not necessarily explaining causal connections. Moreover, the more qualitative, interpretative aspects of the original Faris and Dunham study have arguably been overlooked, neglecting their original claims about mental ill-health being prompted by the ‘social isolation’ of transitory, unattached, unanchored inner-city urban living. To tackle such claims requires a methodology ‘getting closer’ to the individuals involved through in-depth reading of case notes, interviewing, focus groups or participative ethnographies. Only once it is realised exactly how different local situations are implicated in the mental health states of ‘vulnerable’ individuals, from inception through onset into possible recidivism, can it be inferred what lies beneath the revealed spatial patterns of incidence. Such a perspective suggests that some places are indeed integral to the in situ production of mental ill-health, but it also signals how people’s deteriorating mental health may be paralleled by their ‘spatial drift’ from place to place.

Changing locational associations of mental health care

Geographical attention has been given to the ‘lunatic asylums’ appearing across the landscapes of Western Europe, North America and some ‘colonial possessions’ during the eighteenth and nineteenth centuries. Set within a longer story of conjoint social and spatial separation between the supposedly ‘sane’ and the allegedly ‘insane’, researchers have reconstructed the locations of the asylums, hospitals and ‘madhouses’ variously run by the state, charities and entrepreneurs. Typically sited in rural or ex-urban seclusion, questions have been asked about how such locations were favoured by medical, moral, economic and ‘police’ discourses (getting troublesome people ‘out of sight, out of mind’). Significant continuities can be traced from asylum geographies, as laid down in past centuries, through to the closure of the old asylums under the post-1960s drive to community care, and issues emerge as stigmatised old asylum sites become reoccupied by other land uses, groupings and communities.

The shift in mental health care policy from institutional to deinstitutional solutions has entailed a move from large ‘closed spaces’ to a maze of small-scale facilities – day care centres, drop-ins, group homes, sheltered homes, networks of ‘mobile crisis teams’, diverse primary care support mechanisms – dispersed across the spaces of everyday communities. This transition has effectively reintroduced into local settings a cohort previously spatially removed in both reality and popular imagination. The pressures of deregulation, a switch from the state to voluntary and even private sectors, together with the overarching creep of neo-liberalism have all most played out in these changing geographies of ‘care’, with some identifying a fundamental rolling back of the ‘psychiatric state’ but others seeing an intensifying web of ‘psychiatric influence’ reaching out into a multitude of spaces beyond the asylum. Some have emphasised problems arising because many communities, notably middle-class suburbs fantasising themselves as ‘purified spaces’ and fearful of threats to property values, adopt a NIMBYist (‘not-in-my-backyard’) attitude towards mental health facilities and their clients. Other have worried about small-scale mental health facilities tending to cluster in specific parts of cities, creating what some have termed the ‘asylum without walls’, ‘psychiatric ghettos’ or ‘service-dependent ghettos’ saturated with mental health ‘clients’. Others again have critiqued a trend towards deinstitutionalised ex-patients slipping through the care net into new spaces of homelessness, poverty, drug dependency and even reinstitutionalisation through the penal system.

Another group of studies has examined how post-asylum geographies have been experienced ‘from below’ by ex- or never-institutionalised mental patients. The extent to which everyday communities have proved to be ‘caring’ places has been considered, calling into question the ongoing stigmatisation of people with mental health problems as a grouping regarded as too different, by and large, for ready social inclusion. More positively, research has uncovered the ‘self-help’, ‘advocacy’ and ‘arts for mental health’ networks materialising among people with mental ill-health, alongside exploring how friendships fostered in more informal spaces – cafés, soup kitchens, food counters, bus shelters and other often ‘hidden’ spaces – comprise a largely invisible, fragile yet vital immediate layer of caring practices. With this focus upon the ‘mad’ geographies of everyday survival on the streets, the core issues arguably become routine ‘care of the self’ as individuals struggle to eat and drink, keep warm, clothe themselves, find places to sleep and, if possible, secure snatched moments of love and companionship. This research has embraced matters of identity, pertaining to how the people concerned conceive of themselves, their bodies and their ‘place’ in the world, and it has also began to consider the role here not only of physical spaces in the world but also of virtual spaces (and the rise of on-line mental health collectives).

Further Readings

Curtis, Sarah. Space, Place and Mental Health. Aldershot, UK: Ashgate, 2010.

Dear, Michael and Jennifer Wolch. Landscapes of Despair: From Deinstitutionalisation to Homelessness. Oxford: Polity Press, 1987.

Dear, Michael and S. Martin Taylor. Not on Our Street: Community Attitudes to Mental Health Care. London: Pion, 1982.

Faris, R.E. and H.W. Dunham. Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses. Chicago: University of Chicago Press, 1939.

Parr, Hester. Mental Health and Social Space. Oxford: Blackwell, 2008.

Philo, Chris. ‘Across the water: reviewing geographical studies of asylums and other mental health facilities’, Health and Place, 1997, Vol.3, pp.73-89

Philo, Chris. ‘The geography of mental health: an established field?’, Current Opinion in Psychiatry, 2005, Vol.18, pp.585-591.

Smith Chris and John Giggs (eds.) Location and Stigma: Contemporary Perspectives on Mental Health and Mental Health Care. London: Unwin Hyman, 1988.

Wolch, Jennifer and Chris Philo. ‘From distributions of deviance to definitions of difference: past and future mental health geographies’, Health and Place, 2000, Vol.6, pp.137-157.

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One thought on “Mental health geography?

  1. Pingback: Whewell’s Gazette: Vol: #36 | Whewell's Ghost

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