Contracting opportunities: interpreting post-asylum geographies of mental health care in Auckland, New Zealand

From scary places to therapeutic landscapes: Voices from the community of people living with schizophrenia

This article discusses how people living with schizophrenia experience, understand, and respond to their urban environment. Our study relies on experiential photo-voice data gathered with a sample of six people diagnosed with schizophrenia and living in non-institutional settings in Montréal, Canada, to identify how individuals in this community perceive the urban landscape. We adopt a therapeutic landscapes' framework that explores the urban fabric at three levels: physical, social, and symbolic. Research participants identified both health-denying and health-enhancing places within ordinary urban landscapes. Landscapes identified as health-denying are characterized by environmental stressors and loss of control, with construction sites an example highlighted by participants. Healing and restorative landscapes, as identified by participants, were physically attractive or quiet, socially safe and welcoming, and symbolically affirmative of one's identity, all factors worthy of further study. The findings are also policy-relevant: they suggest that people living with schizophrenia and their clinicians can develop strategies to make health-enhancing uses of urban landscapes; and that urban policies and practices can foster urban environments conducive to enhanced health and well-being, both for the community of people living with schizophrenia and the wider population of urban dwellers.

Studies regarding supported housing and the built environment for people with mental health problems: A mixed-methods literature review

Places where people live are important for their personal and social lives. This is also the case for people with mental health problems living in supported housing. To summarise the existing knowledge, we conducted a systematic review of 13 studies with different methodologies regarding the built environment in supported housing and examined their findings in a thematic analysis. The built environment of supported housing involves three important and interrelated themes: well-being, social identity and privacy. If overregulated by professionals or located in problematic neighbourhoods or buildings, the settings could be an obstacle to recovery. If understood as meaningful places with scope for control by the tenants or with amenities nearby, the settings could aid recovery.

Towards a General Explanation for the Survival of the Private Asylum

Taken together, the ascendancy of community care and the dominant role of the state as a funder of services have meant that private sector residential care for people with mental health problems is now a rarity in most countries. Yet private asylums have persisted in some places. The authors propose an analytical framework for understanding such ‘institutional survivals’. This framework problematises the public—private and community—asylum boundaries that have hitherto been taken for granted. The framework is applied to case studies in Canada and New Zealand. Survival of these institutions is found to be centrally associated with accommodations with legislative environments, proactive innovation, and the availability of markets.

Creating 'therapeutic landscapes' for mental health carers in inpatient settings: a dynamic perspective on permeability and inclusivity

Although there has been a shift toward treatment in the home and the community, in the UK, inpatient facilities are still important in modern mental health care. 'Informal carers', including family members, often play an essential role, not only in providing care in the community but also in care of patients during periods of hospitalisation. UK National Health Service policies increasingly consider the position of these carers as 'partners' in the care process, but relatively little attention has been paid to their position within the hospital settings where treatment is provided for inpatients. This paper contributes to geographical work on carers experiences, by reporting how this issue emerged through a study focused on perceptions of a newly built hospital, compared with the inpatient facilities it replaced. We draw on qualitative research findings from discussion groups and interviews with informal carers. The material considered here focused especially on carers' views of aspects of the hospital environment that were important for wellbeing of carers and the people they look after. The carers' views were supplemented by relevant material drawn from other interviews from our wider study, which included service users and members of hospital staff. These accounts revealed how informal carers experienced the hospital environment; we interpret our findings through a conceptual framework that emphasises carers' experiences of a 'journey' along a 'caring pathway' to and through the hospital space. This perspective allows us to make a connection between three bodies of literature. The first relates to phenomenological interpretations of one's environmental perception, formed as one moves through the world. The second derives from the literature concerning 'permeability' of hospital institutions. Bringing these ideas together provides an innovative, dynamic perspective on a third strand of literature from health geography that examines hospitals as 'therapeutic landscapes'. The analysis helps to explore the extent to which carers in this study were positioned as 'outsiders' in the hospital space.

Using autoethnography to reclaim the 'place of healing' in mental health care

Geographies of mental health in the era of deinstitutionalisation have examined a range of places, policy processes and people's experiences associated with community care. However, such assessments have tended, given their community focus, to necessarily be silent on the character of inpatient spaces of care. There is silence too on the potential of such spaces to assist in the healing journey. While there have been a few investigations of hospital design, there has been little consideration of users' experiences of hospital spaces as critical sites and spaces of transition on the illness journey. In this paper, we critically reflect on a project that seeks, two decades after the closure of the last major institution in New Zealand, to investigate the acute care environment with an emphasis on its capacity for healing. The vehicle facilitating this investigation is a novel approach to understanding the inpatient journey: autoethnography. This methodology allows the first author (JL) to critically reflect on her multiple roles as compassionate observer, service-user and mental health professional, and developing transdisciplinary insights that, in conversation with the other authors' geographical (RK) and psychological (PA) vantage points, assist in the reconsideration of the place of the inpatient unit as a place of healing. The paper reveals how voice, experience and theory become mutually entwined concerns in an investigation which potentially stretches the therapeutic landscape idea through critical attention to the redemptive qualities of place by means of attentiveness to both the world within and the world without.

Socio-economic status and geographies of psychiatric inpatient service use. Places, provision, power and wellbeing

This editorial briefly summarises some aspects of research on socio-economic status and use of mental health services that have particular relevance for the theme of this issue of Epidemiologia e Psichiatria Sociale. This discussion takes a view from the perspective of health geography, which examines how the relationships between individuals and their social and physical environment result in variations in health and health care use. Three particular issues are considered here. First, the geographical distribution and organisation of psychiatric services may interact with social and economic factors in ways that are important for service use. Second, increasingly sophisticated ecological modelling strategies have elucidated the associations between socio-economic factors and service use at the population level. Third, more intensive, qualitative research complements these statistical analyses and encouraged reflection on the socio-economic processes, within psychiatric care settings, as well as in wider society, which influence service use.

Recycling former psychiatric hospitals in New Zealand: echoes of deinstitutionalisation and restructuring

This paper addresses a gap in the understanding of the geography of deinstitutionalisation: the fate of closed asylums. We contend that the closure process was an exercise in both deinstitutionalisation and welfare state restructuring, and examine discourses surrounding the re-use of two former psychiatric hospitals in New Zealand-Seaview in Hokitika and Kingseat near Auckland. Drawing on an analysis of media coverage and field observation, we consider former asylums as sites of celebrity. We find the shadow of stigma to be prominent, manifested directly in suggestions that the former hospitals be used as prisons and in the partial redevelopment of one as a 'horror theme park'. Indirectly, we see stigma reflected in the physical deterioration of the asylums prior to closure. While this stigmatising is attributable in the first instance to deinstitutionalisation, the evidence suggests strongly that it was co-opted and exploited by the forces of restructuring.

Smoke-free spaces over time: a policy diffusion study of bylaw development in Alberta and Ontario, Canada

Policy diffusion is a process whereby political bodies 'learn' policy solutions to public health problems by imitating policy from similar jurisdictions. This suggests that diffusion is a critical element in the policy development process, and that its role must be recognised in any examination of policy development. Yet, to date, no systematic work on the diffusion of smoke-free spaces bylaws has been reported. We examined the diffusion of municipal smoke-free bylaws over a 30-year period in the provinces of Alberta and Ontario, Canada, to begin to address this gap and to determine whether spatial patterns could be identified to help explain the nature of policy development. Bylaw adoption and change were analysed within local, regional, and provincial contexts. Geographical models of hierarchical and expansion diffusion in conjunction with the diffusion of innovations framework conceptually guided the analyses. Study findings contribute to a broader understanding of how and why health policies diffuse across time and place. Policy development can be a powerful mechanism for creating environments that support healthy decisions; hence, an understanding of policy diffusion is critical for those interested in policy interventions aimed at improving population health in any jurisdiction.

The changing face of voluntary welfare provision in New Zealand

This paper contributes a micro-level analysis of voluntary welfare providers, an under explored avenue of geographical research. It analyses the localised social impacts of the macroeconomic restructuring of the Welfare State in New Zealand in the 1980s and 1990s on the work of voluntary service organisations (VSOs) and drop-in centres (DICs) as spaces of care in Dunedin, a small South Island city. We document differences among VSOs and DICs in terms of funding, clientele, and adjustments to service provision to satisfy increasing numbers of patrons and the changing composition of demand. Our findings suggest policy recommendations which, we believe, would do much to enhance the ability of both DICs and smaller VSOs to meet client needs.

Writing place: a comparison of nursing research and health geography

The concept of 'place', and general references to 'geographies of ...' are making gradual incursions into nursing literature. Although the idea of place in nursing is not new, this recent spatial turn seems to be influenced by the increasing profile of the discipline of health geography, and the broadening of its scope to incorporate smaller and more intimate spatial scales. A wider emphasis within the social sciences on place from a social and cultural perspective, and a wider turn to 'place' across disciplines are probably equally important factors. This trend is raising some interesting questions for nurses, but at the same time contributes some confusion with regard to imputed meanings of 'place'. While it is clear that most nurse clinicians and researchers certainly understand that place of care matters to their practices and patients, many diverse uses of 'place' are found within nursing literature, and contemporary understandings of the term 'place' within nursing are not immediately clear. It is in this context that this article plans to advance the discussion of place. More specifically, the aims of this paper are threefold: to critique 'place' as it appears in nursing literature, to explore the use of 'place' within health geography, whence notions of place and 'geographies of' have originated and, finally, to compare and contrast the use of 'place' in both disciplines. This critique intends to address a deficit in the literature, in this era of growing spatialization in nursing research. The specific questions of interest here are: 'what is "place" in nursing?' and 'how do concepts of place in nursing compare to concepts of place in health geography?'

Governmentality, discourse and space in the New Zealand health care system, 1991–2003

This paper considers recent health care reform in New Zealand in the context of the continuing evolution of the 'neoliberal project'. It advocates the adoption of a Foucauldian governmentality approach to analysis as a productive way to extricate the changing understandings of space within evolving New Zealand health discourses. We analyse two policy documents released 9 years apart which, when examined together, encapsulate the changing discourses of the health care system in the 1990s. We note that through the 1990s the central governing rationality has shifted from competition towards cooperation in health care delivery. While place was held to be subservient to the market at the beginning of the decade, health care has been increasingly re-territorialised through 'community' and its associated constructions.

The geography of mental health: an established field?

PURPOSE OF REVIEW

The purpose of this review is to offer an outline introduction to a field of inquiry known as the geography of mental health (or mental health geographies). Since this is the first time the field has been reviewed in this journal, attention will be paid to the history of the field, not just recent findings.

RECENT FINDINGS

Research has chiefly, but not exclusively, tackled (i) the spatial epidemiology of mental ill-health and (ii) the changing locational associations of mental health care.

SUMMARY

This review has concentrated chiefly on contributions to this field of inquiry made by researchers with a background in the academic discipline of geography. While there are 'geographical' contributions made by workers from other disciplinary backgrounds, there is arguably something distinctive, particularly in the most recent scholarship, arising from a theorized sensitivity to the entangled relations of mental health, society, space and environment.

Contracting for health services in a public health system: the New Zealand experience

This paper reports on the process and outcomes of contracting for health services in New Zealand between 1993 and 2000 when a purchaser-provider split was in place. Key factors that shaped the contracting environment were the legal framework, funding constraints, and the cultural and professional norms of contracting personnel. A lack of good information-especially on costs, volumes and quality-increased the costs of contracting and made monitoring and accountability difficult. Over time, however, the contracting process became simpler and less costly. Overall, the introduction of contracting generally improved the focus of providers on costs and volumes; led to greater clarity through specification of services; encouraged providers to focus on methods to improve quality; and enabled new styles of service provision from providers that had not traditionally received public funds for health services. Good relationships between purchasers and providers were seen as the key to successful contracting.

The geography of complementary medicine: perspectives and prospects

While complementary and alternative medicine (CAM) research has benefited from a range of social scientific perspectives, geographical contributions have been only slowly forthcoming. In this context, this paper illuminates the possibilities for CAM researchers to develop dedicated geographical perspectives. Some fundamental changes in the empirical and theoretical foci of medical/health geography are outlined, from a concern with mapping services and diseases in macro-space to investigating the dynamic between health and place. Highlighted are some important relational dynamics among CAM providers, patients/consumers and places of treatment and some general issues that could benefit from a geographical analysis. The concurrent research agenda is located across the sub-disciplinary strata of human geography.

The 'three waves' of research in mental health geography: a review and critical commentary

OBJECTIVE

To consider research conducted in the sub-field of mental health geography, concentrating on work published in English.

METHODS

The paper offers an comprehensive, in-depth and critical reading of the relevant literature on mental health geography since the inception of this subfield of inquiry in the early-1970s.

RESULTS

The paper identifies three 'waves' of research within work on mental health geography. It describes these 'waves' in detail, interprets certain strengths and weaknesses of the first two 'waves', which are well-established, and provides suggestions about important questions to be addressed in a future third 'wave'.

CONCLUSION

Much excellent research has so far been undertaken within mental health geography, but there is scope to increase the relevance of this research through widening the focus of research and by being prepared to connect research more directly to mental health policy and politics.

Making space for the 'intellectual' in geographies of disability

There is a growing body of work on geographies of deinstitutionalisation and its consequences, but the weight of this scholarship has focussed on people with mental health problems and physically disabled people. With only few exceptions, the 'post asylum geographies' of intellectually disabled people remain neglected by geographers. We advocate a redressing of this imbalance. First, we assess reasons for the relative absence of 'intellectual' considerations in geographies of disability. We then consider ways in which the full spectrum of those with mental differences might be included in geographical research. We conclude that Wolpert's call 25 years ago to 'open closed spaces' is just as applicable to our efforts to conceptually link health, place, and disability, as it is to the material welfare of vulnerable groups in society.

New Zealand children's health camps: therapeutic landscapes meet the contract state

This paper surveys the history and current status of children's health camps in New Zealand, and places these sites within the theoretical context of therapeutic landscapes. The first health camp was established in 1919, and the seven current camps provide respite, education and health care for approximately 4000 children each year. We analyse the health-place relations inherent in the health camp concept and suggest that the 'therapeutic landscape' idea developed by Gesler provides a useful framework to explain the development of camps as sites for enhancing child and family welfare. Specifically, we contend that changing understandings of health and children have been closely linked with changing perceptions of what is therapeutic about the camps. Survey data demonstrate that contemporary restructuring of the welfare state has recast the role of health camps and placed them in a precarious position in terms of both financial viability and public acceptability. We conclude that the current status of health camps is ambiguous given the pressures of deinstitutionalisation philosophies and the regulatory environment of formal contracts between funders and providers.