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The ‘three waves’ of research in mental health geography: a review and critical commentary CHRIS PHILO1 and JENNIFER WOLCH2 1

Department of Geography and Topographic Science, University of Glasgow, Glasgow, United Kingdom 2 Department of Geography, University of Southern California, Los Angeles, USA

RIASSUNTO. Scopo — Valutare la ricerca condotta nel campo della geografia della salute mentale, concentrandosi sui lavori pubblicati in lingua inglese. Metodi — L’articolo offre una lettura globale, approfondita e critica della letteratura relativa alla geografia della salute mentale, a partire dal sorgere di questo settore di ricerca nei primi anni ’70. Risultati — L’articolo identifica tre fasi di ricerca all’interno dei lavori sulla geografia della salute mentale. Queste fasi sono descritte in dettaglio; inoltre, sono interpretati punti di forza e di debolezza delle prime due fasi, che sono ben consolidate, e vengono forniti suggerimenti su importanti problemi che dovranno essere affrontati in una futura terza fase della ricerca. Conclusioni — Molte eccellenti ricerche sono state finora condotte nel campo della geografia della salute mentale, è tuttavia necessario aumentare la rilevanza di queste ricerche, mediante un ampliamento del focus ed un collegamento più diretto della ricerca con le politiche sulla salute mentale. PAROLE CHIAVE: geografia sulla salute mentale, analisi sulla localizzazione, identità e differenza, politica sulla salute mentale. SUMMARY. 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. KEY WORDS: mental health geography; 'waves' of research; locational analysis; identity and difference; mental health policy. Ricevuto il 27.09.2001 - Accettato il 1.10.2001.

Indirizzo per la corrispondenza: Prof. C. Philo, Department of Geography and Topographic Science, University of Glasgow, Glasgow G12 9AE (UK). Fax: +44-(0)141-330.4894 E-mail: [email protected]

Epidemiologia e Psichiatria Sociale, 10, 4, 2001

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

INTRODUCTION This paper reviews research in mental health geography that has examined landscapes of deinstitutionalisation, community care and everyday social life. Offering an interpretation of developments in this research sub-field, it charts three different ‘waves’ of inquiry, and concludes by suggesting further research questions needing to be addressed. The paper is an abridged and slightly updated version of a longer and more fully referenced piece (Wolch & Philo, 2000; also Gesler, 2000), and it complements the outline of developments in mental health geography provided in this issue by Jones (2001).

MENTAL HEALTH GEOGRAPHY’S ‘FIRST WAVE’ In the opening years of first wave research in mental health geography the focus was on spatial-distributional questions, tracing the shifts of people with mental health problems, historically considered ‘deviant’, from largescale asylums or hospitals into the community (We will not discuss work that began even earlier on the ‘spatial ecology’ of diagnosed mental illness: see Jones, 2001). The studies involved were mainly completed from the mid-1970s to the 1980s, although ones in a similar vein, sometimes blending with concerns that we will refer to below as second wave, have continued ever since. These studies examined numerous phenomena never previously examined by geographers, highlighting dimensions of human pain, concern and struggle never previously acknowledged by the discipline. Moreover, the research here informed the practices of mental health advocates and practitioners, and also influenced a variety of public policies and programmes. We will now elaborate these claims by taking three ‘cuts’ through this first wave of mental health geography.

Locational analysis of mental health care delivery Studies were marked by the quantitative revolution within the wider discipline of the 1960s and early-1970s. Initially its substantive focus was mental health care systems still dominated by large institutions, the asylums inherited from the nineteenth century, and studies focused on mental health care delivery from and accessibility to relatively small numbers of facilities in fixed locations. Attention was paid to mapped distributions and the spatial linkages of facilities (White, 1976; 1979), the

distance-decay patterns of facility utilisation (Davey & Giles, 1979; Joseph, 1979; Joseph & Boeckh, 1981), and the relationships between facility locations and the residential locations of both in-patients and out-patients (Beaumont & Sixsmith, 1984; Sixsmith, 1983; 1988a). These spatial-distributional issues were examined through the lenses of location theory and normative public facility location modelling, thereby extending the pioneering health care geography of scholars such as Shannon & Dever (1974) into the domain of mental health care. The nature of services provided went largely unproblematised, and the people who utilised mental health services were regarded simply as ‘service users’ who acted like ‘atoms’ obeying mechanical laws of motion or collectively constituted ‘demand surfaces’ on which the geometries of care provisions were superimposed. In the tradition of health systems planning, the goal was to inform public policy and decision-making so as to optimise facility location-allocation, the goals being couched ultimately in terms of maximising system efficiency and client accessibility (see Philo, 1997, pp.76-77, for further commentary and criticism).

From asylum to community to ghetto The changing social context of mental health care delivery systems soon prompted a shift within mental health geography. As the locus of mental health care moved increasingly during the 1970s from asylums undergoing closure to the community, geographers turned to the topic of community-based facility siting. They asked about the factors underlying this new dispersed geography of small-scale facilities, and also about what it meant for both communities and clients, and a resounding initial statement was Wolpert (1976). Overviews appeared of the deinstitutionalised mental health landscapes emerging in Britain, the USA and elsewhere (Giggs & Mather, 1976; Jones, 1996; 1999; 2000; Smith C.J., 1983; Smith C.J. & Hanham, 1981a). Attempts were made by geographers interested in deinstitutionalisation to trace its root causes, noting the fraught alliance between ‘anti-psychiatry ideologists’ who hated the asylum and ‘fiscal conservatives’ who thought it too expensive (Dear & Wittman, 1980), and claims were made about the influence of political-economic restructuring under conditions of ‘fiscal crisis’, ‘deregulation’ and ‘privatisation’ (Eyles, 1988; Joseph & Kearns, 1996; Kearns & Joseph, 1997; 2000; Laws, 1988; 1989; Smith C.J., 1987; 1989). The growing contribution of the voluntary sector, with the state rolling back some of its immediate care-giving functions,


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began to be considered as well (Wolch, 1990, pp.69-79; also Milligan, 1998; 1999a; 2000). The complexity of inquiry dramatically expanded, and it became harder to pretend that the locational patterns of mental health services could be understood as the outcome of a rational planning process undertaken by all-knowing serviceproviders. Rather, it required reference to the politicaleconomic dynamics and the sociospatial organisation of regions, as well as attention to the situated responses of community residents to their ‘new’ neighbours in the community (the new facilities and their users). The rise of community-based mental health thus revealed as inadequate the earlier and far narrower approach anchored in locational analysis (for explicit criticisms, see Dear, 1974a, b; 1978). Studies started to tackle the ‘spatial externalities’ of facilities on surrounding neighbourhoods, asking about both impacts on property values and perceived effects on local social life (Boeckh et al., 1980; Dear, 1977b, c; Dear et al., 1977; 1980; Moon, 1988). Related research charted community attitudes, largely oppositional (‘not in my backyard’ or NIMBY) in nature, toward smallscale mental health facilities and their users (Boeckh, 1980; Burnett & Moon, 1983; Dear, 1992; Hall, 1980; Hall & Taylor, 1983; Isaak, 1979; Moon, 1988; Smith C.J., 1981; Smith C.J. & Hanham, 1981b, c; Taylor, 1986; 1988; 1989; Taylor & Dear, 1981; Taylor et al., 1979; 1984). ‘Accepting’ neighbourhoods, often found in inner-city areas occupied by poorer groupings unwise to the ways of urban politics or by younger professionals, were found to be basically tolerant of their new neighbours; while ‘rejecting’ neighbourhoods, often found in more affluent, family-oriented suburban areas, were found to be suspicious of nonconformist behaviour. One implication was that the locations adopted by facilities were closely related to the geographies of both neighbourhood impacts and community attitudes. The occurrence, even just threatened, of opposition arising from well-organised suburban ‘protest groups’ possessing a knowledge of local land-use zoning legislation was a particular factor in siting decisions (e.g. Dear & Laws, 1986; Hall & Joseph, 1988; Wolpert et al., 1975). As remarked previously (Philo, 1997, pp. 77-78), such studies, debating a policy of ‘conflict avoidance’ rooted in the realms of local politics, discourse and power, comprised a very different approach within mental health geography to that conducted under the sign of locational analysis. Dear & Taylor’s (1982) influential Not on Our Street covered much of this ground, and it arguably announced the maturation of the first wave of mental health geography. This research on the spatial channelling of facilities

fused with related studies by Wolpert, Dear and others that tracked the emergence of urban ‘psychiatric ghettos’ as spatial concentrations of numerous small-scale mental health facilities and their users (Dear, 1977d; 1992; Eyles, 1986; Giggs, 1990; Gleeson et al., 1998; Hall & Joseph, 1988; Hughes, 1980; Joseph & Hall, 1985; Law et al., 1995; Moos, 1984; Wolpert & Wolpert, 1974; 1976). (For one dissenting voice, questioning the prevalence of such ‘psychiatric ghettos’, see Smith C.J., 1975b.) The evidence suggested that support facilities such as day centres, drop-ins and more informal ‘clubs’ were springing up in proximity to one another, alongside residential facilities such as ‘board-and-care’ homes, group homes and other forms of sheltered accommodation. Clients of the former and residents of the latter were coming to comprise fair-sized local populations of people with mental health problems. A positive feedback situation was created, since further facilities would locate in the same districts to serve their mentally unwell populations, while more people with poor mental health (especially discharged patients) would relocate or be assigned to housing near the services available to them in these districts. The spatial outcome of such processes was sometimes given another name, the ‘service dependent ghetto’ (Wolch, 1980), a notion then linked to that of the ‘public city’, meaning inner-city localities whose character was dominated by health and welfare services targeted at their poorest residents (theorised by Wolch, 1979; 1980; adapted with reference to mental health clients by Dear, 1980). The conjoint ‘social and spatial reproduction of the mentally ill’ occurring in such urban spaces was remarked upon by Dear (Dear, 1981; also Clark & Dear, 1984, Chap.4). Attempts were made to assess both the negative features of such clusters, such as the likelihood of many people with mental health problems being jammed into streets of substandard accommodation, and the positive features, such as the enhanced possibilities for ‘selfhelp’ and ‘advocacy’ among people able to empathise with one another’s difficulties (Dear & Wittman, 1980; Gleeson et al., 1998; Law et al., 1995; Taylor et al., 1989). Attention was also drawn to urban restructuring and its implications for the service dependent ghettos, with some researchers detecting signs of ghetto dismantling in the wake of gentrification and urban renewal (Wolch & Gabriel, 1985). Dear & Wolch’s (1987) Landscapes of Despair provided a comprehensive survey and theoretical interpretation of all of these issues and processes (also Dear & Moos, 1986; Moos, 1984). If in the early years of the first wave scant attention was paid to the human subjects of mental health systems, the later years of this wave, moving into the late-1980s


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and early-1990s, saw progress in this regard. Increasingly, therefore, researchers became interested in the micro-level of individuals interacting with treatment settings and landscapes. The older ‘spatial ecology’ tradition (Jones, 2001) was reinvigorated by looking further at spatial patterns of residential relocation as discharged patients and never-institutionalised clients move (or ‘drift’) across the city, partly in response to changes in the location of services and accommodation (Giggs, 1984; Giggs et al., 1993; Scobie, 1989; 1990; also Dean, 1984, on the ‘spatial implications’ of a mental patient’s ‘career’). Studies of how people with mental health problems, usually discharged ex-patients, cope when ‘out’ in the community put more emphasis on the grounded experiences of these people, recording their use of the urban environment and its role as a source of ‘(dis)satisfaction’ and ‘quality of life’ (Dear et al., 1989; Hall, 1980; Kearns, 1987; 1990a, b; Kearns et al., 1987; 1991; Laws & Dear, 1988). Such studies also tackled specific matters such as the effects of housing as a ‘stressor’ on people suffering serious mental ill-health (Elliott, 1987; Kearns & Smith, 1993; Kearns et al., 1992; Smith C.A. et al., 1994; Taylor et al., 1989), and considered the importance of ‘social networks’, often with other mental health sufferers, which can sustain people in the face of adverse circumstances (Hall & Nelson, 1992; Kearns, 1987; Nelson et al., 1992; Smith C.A. & Smith C.J., 1978; Smith C.A. et al., 1994). In addition, researchers addressed the fundamental normative question of service concentration versus dispersal (Dear, 1977a; Smith C.J., 1976b), and asked about the requisite qualities of spread-out ‘humane’ neighbourhoods as both sites of mental health service delivery and potential ‘therapeutic environments’ where people could repair their mental health (Daiches, 1981; Smith C.J., 1975a; 1976a; 1977; 1978a,b; 1980; 1982; 1984). Smith’s extensive early research on such matters was particularly important (also Sixsmith, 1988b, esp.pp.17-20), and this work eventually led to broader statements on ‘the management of urban distress’ (Smith C.J., 1988). The first wave of mental health geography thus took on a well-rounded shape, and the theoretical perspectives diversified as investigators drew variously upon what can be termed radical (political-economic, sometimes Marxian), humanistic and structurationist approaches, all of which surfaced in the wider discipline of geography during the 1970s and 1980s (Cloke et al., 1991). The methodological tool-kit expanded too, with research methods ranging from broad-brush reviews of ghetto formation to detailed case studies of facility siting politics and conflict (Dear & Laws, 1986), including lar-

ge-scale community/neighbourhood attitudinal surveys such as those done by Dear &Taylor (1982). Much of the work was explicitly policy-oriented, and diffused throughout organisations of mental health professionals as well as within advocacy organisations. Dear & Taylor’s work on attitudes, for example, led to a large-scale public education campaign designed to increase acceptance of community-based mental health facilities in Ontario. Many other scholars exploring the NIMBYism and facility concentration/client ghettoisation problems were also involved in shaping policy and regulations, writing reports for both government ministries and patients’ rights groups, testifying at zoning hearings, public meetings and legislative committees, and disseminating results to mental health care providers.

Street lives of the urban homeless During the 1980s and early-1990s, an increasing number of people with mental health problems slipped through the welfare and housing nets into a state of chronic homelessness (Morrissey & Gounis, 1988; Segal & Baumohl, 1988), and partly to blame was a simple mismatch between the number of old (institutional) bed spaces lost and the number of new (community) bed spaces provided. Also to blame was the difficulty for mentally unwell people in securing a steady income and in just being ‘together’ enough to pay rents to landlords, a state of ‘incipient homelessness’ according to Kearns et al. (1992). An increasing share of work by mental health geographers hence considered the urban homeless, assessing the difficult relationships between deinstitutionalisation and homelessness, and the subtitle of Dear & Wolch (1987) - ‘from deinstitutionalisation to homelessness’ - emphasised the linkage. Subsequent research (Wolch & Dear 1993) returned repeatedly to the mental health problems of many homeless people, and to the fiscal, welfare and health policy implications of mental ill health among the homeless (also Lee et al., 1998; Takahashi & Wolch, 1994; Wolch et al., 1993). Moreover, through detailed ethnographic research, these studies paid increasing attention to the experiences of mentally unwell homeless people themselves, highlighting how they manage to cope, or not, with life on the streets (Knowles, 2000a,b; O’Dwyer, 1997; Parr, 1997a, pp. 258-294; Rowe & Wolch, 1990). Other work utilised more traditional quantitative methods (Giggs & Whynes, 1988; 1992) to assess differences between mentally unwell and other homeless people in terms of their


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coping abilities (Koegel et al., 1990; Rahimian et al., 1992). Policy-related work on homelessness continued earlier traditions of activism among mental health geographers. In particular, the continuing battles over facility siting prompted geographers to refocus their attention on community attitudes to hostels and homeless shelters (Burnett & Moon, 1983; Moon, 1988), whose residents often suffer mental health problems, which reinforces the stigmatisation of the facilities in question. An element in such studies entailed finding ways to help service providers gain community acceptance of controversial facilities for the urban homeless (Dear, 1992; Takahashi, 1998a; Venness, 1994). Other studies, by Laws (1992) and Hoch (1992), documented the changing spatial patterns of homeless shelters and pointed to geographical disparities in access to emergency shelter, arguing that access should become an explicit input to shelter location policy. Analyses of homeless service facility distribution suggested to policy makers the merits of ‘service hubs’, the ‘artful colocational siting of facilities that can create, and benefit from, an array of agglomeration economies’ (Dear et al., 1994, p. 182).

MENTAL HEALTH GEOGRAPHY’S ‘SECOND WAVE’ Since the 1980s, a second wave of mental health geography has appeared. Newer research now includes few attempts to document or to understand large-scale distributions of mental health and ill health, and instead scholarship tends - continuing the concern, noted above - to focus at smaller scales of analysis where it is easier to make sense of individual human perceptions, psyches, hopes and fears. At the same time, this work shifts attention from the analysis of space, forsaking an overview of distributional patterns, to more interpretative engagements with disability, identity and place. Indeed, under the influence of both cultural and disability studies, second wave mental health geographers are turning their attention to questions of ‘identity’, and are framing their inquiries in terms of the differences between people identified by society as mentally ‘abnormal’ and those deemed ‘normal’. The dominant conception of people with mental health problems duly transfers from one centred on ‘deviance’ to one preoccupied with ‘difference’. Let us again take three ‘cuts’ through the kinds of work conducted by this wave of mental health geography.

Different minds, different bodies Second wave mental health geography reflects the influence of diverse theoretical positions such as feminism, post-colonial criticism and psychoanalysis, all of which turn on the importance of difference. Such positions and more are sometimes grouped together as constituting geography’s ‘cultural turn’ (Barnett, 1998; Philo, 2000) or as expressing a still broader poststructuralist or even postmodernist drift to seeing fragmentation and multiplicity rather than coherence and singularity (Cloke et al., 1991, Chap.6). More concretely, a key development appears to be the linkage to work on disability geography, and therefore with critical disability studies, where the prime focus has commonly been physical disability. This link has seen the importing of ideas about the role of bodily difference in the fragmentation of identity seemingly endemic to the contemporary human condition, and has begun to combine two geographical sub-fields that have for some years been pursued in curious isolation from one another. Within disability geography, prominent themes have included the historical geographies of different bodies in society, the intersubjective meanings of bodily health status, the everyday lives and lifeworlds of people dealing with embodied ‘medical’ problems, and the effects of difference in ‘socialising’ and ‘medicalising’ the body: and all of these emerging themes are likely to feature in future work on mental health geography. The dialogue between the two fields has been heralded by the inclusion of two papers discussing mental health (one directly, one more tangentially) in a Society and Space theme issue on ‘geographies of disability’ (Chouinard & Cormode, 1997: the two papers are Dear et al., 1997; Parr, 1997b), and also in the recent Mind and Body Spaces collection (Butler & Parr, 1999) where the editors (Parr & Butler, 1999, esp.pp.12-15) write about ‘bringing mental differences into the picture’ alongside the more obvious bodily focus of disability geography. To oversimplify, bodies are carriers of minds while mental states - alongside the social reactions which certain people as conscious and reflexive beings experience as a result of their ‘differences’ - are intimately bound up in the making of physical appearances, movements and capabilities. Thus mental and physical health problems often arise together, shaping in tandem a person’s transactions with wider society, as Parr and Butler explain with specific reference to Dyck’s (1995) study of women with MS. Second wave mental health geography is thereby very much attuned to the complex mesh of mental and physical difference, to both different minds and different bodies (see also Parr, 1999a).


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Underlying this work is a concern for the span of human differences. Such differences figure in how one set of people (usually regarding themselves as ‘normal’ on the mind-body continuum) think of themselves over and against other sets of people reckoned to lie beyond normal parameters on this continuum (the ‘abnormal’). The identities of the former (‘us’, ‘the same’, ‘self’) are always formed with reference to their perceptions and conceptions of the latter (‘them’, ‘the other’, ‘not-self’). Such difference becomes crucial to both the establishment of identities and the pursuit of practices, often hateful and prejudicial ones, which ‘the same’ then enacts toward ‘the other’ (Philo, 1986; Sibley, 1995). The processes identified here are often spatialised, in that, to echo Said’s (1978) famous statements about ‘imaginative geography’, the situation involves ‘us’ here (in ‘our’ patch of the world, however large or small) demonising ‘them’ there (in ‘their’ patch of the world) and seeking to ensure that ‘they’ are not allowed to come or to remain here. Thus, the imaginative geographies of the powerful frequently feed into a material landscape of social exclusion, within which those designated as other, who will tend to be relatively powerless, are banished to marginal spaces and unloved places (Sibley, 1995). While these geographies of difference and exclusion are mostly envisaged in relation to axes of class, race, ethnicity and sometimes gender, they can also be envisaged in relation to the axis of mental health and ill-health (‘rationality’ and ‘madness’, or ‘sanity’ and ‘insanity’: see Philo, 1999). In this way, the targets for negative projections and actions become those who fall outside of widely agreed if often unacknowledged parameters of what is psychologically and behaviourally rational and sane, who duly get ‘consigned to the shadows’ (Evans, 1989). Two little-known early papers in mental health geography effectively pointed the way: Fincher (1978) discussing how deinstitutionalised ex-mental patients become marked as different by a wider society unable to reintegrate them into mainstream social life, and Evans (1978) theorising how and why suburban communities fantasise themselves as ‘purified’ and ‘harmonious’ in contradistinction to an ‘objectified other’ (all manner of problem people found elsewhere, notably in the inner city). Similar themes have now returned to the agenda, forming the background of much recent work on the everyday geographies of people whose mental health problems cause them to be regarded as, and to feel, ‘out of place’ in ordinary settings such as home or work. We will consider such work presently, but it is first worth referencing a paper by Dear et al. (1997) from the above-mentioned Society and Space collection. This pa-

per explores the ‘sociospatial construction of disability’, reviewing how all manner of human differences, to do with bodies, minds, attributes, orientations and so on, become the bases on which ‘the self’ becomes spatially ‘partitioned’ off from ‘the other’. More narrowly, the authors discuss ‘hierarchies of acceptance’, the rankings of the ‘distances’ that most people would seemingly want to maintain between themselves and the embodied members of various ‘disability’ categories. It is highly revealing that ‘the unpredictability and aberrant behaviours frequently associated with mental disabilities and mental retardation have contributed to their continued ranking among the least acceptable conditions’ (Dear et al., 1997, p.466; also Takahashi, 1992; 1997; 1998a,b,c). Such findings, tied to the will of the majority to put spatial boundaries between their worlds and those of the least acceptable disabled people, throw fresh light on the ‘material expressions of NIMBYism’ (Dear et al., 1997, p.474) discussed by mental health geographers in their earlier community opposition studies (also Smith C.J. & Hanham, 1981c; cf. Smith C.J. & Hanham, 1981b). A concern for difference was present in the first wave studies, to be sure, but it was usually rooted in standard sociological and political science conceptions. For example, suburbanites were conceived as different from inner urban residents through their high ‘stakes’ in their local neighbourhoods, as fostered through large ‘investments’ of money, time and resources designed to secure their class, professional and social status, and it was argued that such stakes led them to ‘defend’ their neighbourhoods against any incursions perceived as threatening these social achievements (Dear, 1981; Clark & Dear, 1984, Chap.4). With the exceptions of Evans (1978) and Fincher (1978), there was hence little in these earlier studies which amounted to more than empirical observations about public fears of mental health clients. The second wave emphasis on difference clearly goes beyond such thinking, then, to borrow more explicitly from psychoanalytic theory wherein the ‘us’/’them’ or ‘same’/’other’ binary is viewed as the collective outworking of repressed psychic materials originating when each of ‘us’ as children learn to recognise ‘ourselves’ in contradistinction to what ‘we’ are not - chiefly, those impure bodily excretions symbolic of everything unwelcome in the environment. These excretions, and all entities that subsequently become psychically crosscoded with them, are to be controlled, the aim being to reduce sources of ‘anxiety’ in ‘the self’ through the creation of social and spatial boundaries between ‘the self’ and all such entities. This is to caricature complex theorising, as well as to neglect distinctions between com-


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peting versions of psychoanalysis, but it highlights the significance of Sibley’s (1995; also Pile, 1996) spatialising of psychoanalytic claims about ‘society and difference’. Such concepts evidently underlie Dear et al. (1997, esp.pp.458-462), and appear in a sustained fashion as the foundation for Wilton’s (1998) reflections on community opposition to unwanted neighbours like mental health facilities and AIDS hospices. In addition, Parr (2000) mobilises the Freudian notion of Unheimlich (the ‘uncanny’) to explore what is happening when members of a drop-in for people with mental health problems themselves very much victims of social exclusion - effectively impose their own exclusions, including barriers to entry, on certain individuals whose mental states and attendant conduct are even more disturbed than their own.

Identity, place and mapping ‘mad’ geographies Closely connected to the endeavours just described, a prominent focus in second wave mental health geography becomes the role of particular places in the identities, the senses of self, acquired by people with mental health problems as they navigate their daily existences. Perhaps reflecting Ley’s (1989) insistence that interpretative human geography needs to concentrate on the ‘human scale’ of people and places, several mental health geographers now narrow their attention to nameable places: a city such as Nottingham, England, for instance, or a region such as Dumfries and Galloway, Scotland. Within this limited spatial context, they probe in detail the significance of such places in the fragile identities possessed by local people suffering mental ill-health, often specific individuals with whom the researchers develop personal contact. This research has antecedents in earlier ‘coping in the community’ work that took seriously the ‘human’ side of deinstitutionalisation (Laws & Dear, 1988; Kearns, 1986; 1987; 1990a), but it shifts away from the specifics of ‘being discharged’ to embrace the overall texture of daily movements, activities and feelings integral to the worlds of the individuals under study. Methodologically, such research teases out rich layers of qualitative information in a manner that goes beyond previous survey techniques, with semi-structured indepth interviews and focus groups allowing individuals to voice at length their own ‘narratives’ of health, illness, living, working and identity (Parr, 1998b; Pinfold, 1996; 1999; 2000). Parr (1997a, b; 2000), most notably, has spent countless hours as an observer, even a participant observer, sitting in residential homes, day centres and drop-ins or hanging around particular streets, squa-

res and parks which she knows to be frequented by people with mental health problems (also Knowles, 2000a, b). Often she has encountered people through her ethnographies who she has also subsequently interviewed, thus triangulating her empirical observations with the stories told to her by the individuals concerned. (There are many ethical worries associated with being an ethnographer in mental health research, as Parr, 1998a, in press, herself acknowledges.) Despite misgiving about the mapping metaphor (Gregory, 1994: Chap.2), studies in this latter vein are in the business of mapping ‘mad’ geographies. They aim to trace in detail the grounded social geographies of how people with mental health problems negotiate the spaces and places all around them: facilities, housing, shops, streets; squares and parks; neighbourhoods, cities and regions (also Kearns, 1986; 1987; Kearns & Taylor, 1989). Some interest lies in the exterior, objective geographies of what these people do (their daily activity patterns), but the greatest interest lies in the interior, subjective senses that these people possess about the spaces and places accessed, utilised and shunned. How do they feel in these spaces and places, ‘at home’ or not, ‘in place’ or ‘out of place’? Do they experience hostility or tolerance from other people present there? What is it that renders some locations attractive, calming, supportive and the like, and what is it that renders others less appealing and even frightening? For a researcher like Pinfold (1996; 1998; 1999; 2000), the key questions revolve around the extent to which the people she interviews are, and perceive themselves to be, socially ‘isolated’ or ‘integrated’ when occupying different spaces and places. Similar questions concern Milligan (1998; 1999b esp.p.221), albeit cast more as ‘the ways in which inclusion and exclusionary practices are experienced by such individuals within the social and spatial environment [where] they are located’. Parr (1997a, b; 2000), meanwhile, reconstructs the overlapping geographies of encounter traced by people with mental health problems moving about the city of Nottingham, and she relates these geographies to the identities, often fractured and plural, which form, shatter and reform in the minds of these people. She shows too how the diverse ‘resources’ the ideas, discussions, books, pamphlets, therapies, practices and the like - which become available to them in the spaces and places encountered daily then feed into their identity formation, and here she is in effect mapping both ‘mad’ geographies and ‘mad’ identities (also Parr & Philo, 1995). Moreover, her focus is not only at the individual level, for she also explores the group identities that certain people with mental health problems de-


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velop in association with one another, particularly through advocacy groups striving to present a collective voice, a shared account of identity politics, to mental health service professionals and managers (esp. Parr, 1997b, 1999a).

Geographies of the ‘mad’ imagination There is also a hint in the second wave research of attention being drawn to what might be termed, with hesitation, the ‘mad’ imagination. The interior imaginings, fantasies and anxieties of supposedly ‘sane’ people are complicated enough, but it is likely that these interior worlds are even stranger - even more vivid, disorientating and maybe terrifying - for people experiencing episodes of serious mental disturbance. It is usually assumed that the ‘mad’ imagination is only of interest to a limited range of mental health professionals (clinical psychologists and psychotherapists), theorists of the mind (psychoanalysts and certain philosophers) and theorists of creativity (who sometimes suppose that ‘great’ artistic insights arise from the languages of ‘madness’). Yet, some geographers are now exploring the geographical references, contortions and fusings that occur in the minds of people with mental health problems. Parr (1999b; also Parr & Philo, 1995, pp.221-223), for instance, has taken seriously the often strange utterances made to her during in-depth interviews about the quite different senses of space, place, time, scale, proximity and distance experienced by people with mental health problems. (Such differences are especially evident when such individuals are in ‘manic’ stages of their condition). The result is a collection of remarkable accounts from which Parr discerns the elements of what she calls ‘delusional geographies’, although she never loses sight of the genuine terrors which these delusions and ‘voices’ often bring to the people concerned, nor to the possibility that they would prefer to replace their distorted spaces with a more ‘ordinary’ relation to fixed, tangible places in the everyday world. Another geographical take on ‘delusional minds’ is Park et al’s (1994) journey into ‘the interior landscape of a schizophrenic artist’, Adolfi Wölfi (1864-1930), a resident for much of his adult life in the Waldau Asylum near Bern, Switzerland. Through a careful appreciation of his many drawings and collages, these authors demonstrate how a host of ‘real’, symbolic and hyperbolic geographical features - undisciplined by linear perspective and vanishing points - spin together in Wölfi’s ‘landscapes ... of despair, pessimism and tension’ (Park

et al., 1994, p.207). Elsewhere Park with others (Gilbert et al., 1996; Gilbert & Park, 1995: esp.pp.146-151) draws upon literary work by the novelist Janet Frame to excavate how mentally ‘dislocated’ individuals experience, identify with and represent the material landscapes all around them, including asylums, homeplaces and public spaces. Both Parr and Park et al. (1994) are cautious about claiming that their studies signal important ‘other’ ways of perceiving and conceiving of space, place, landscape and geography, but other geographers, excited by the claims of theorists such as Deleuze & Guattari (1983; 1984), celebrate the possibilities of a ‘schizoanalysis’ which deploys the unfixity of the schizophrenic’s geographical imaginings as a source of transgressive insights for challenging the rigidities of rational thought (e.g. Doel, 1995; 1999, esp. Part II). While it is easy to see the appeal, we are hesitant about the precise status of mental ill health in this theoretical register, and would agree with Gregory (1994, p.156) that ‘there is also something cruel - at the very least insensitive about analogising schizophrenia like this’.

TOWARD ‘THIRD WAVE’ MENTAL HEALTH GEOGRAPHY? Community mental health delivery systems are being rapidly reshaped under conditions of globalisation, radical welfare reform and urban restructuring, and second wave mental health geography can clearly contribute to an understanding what is now occurring. Its alertness to the sociospatial constitution of difference and the recovery of place as a central component of identity, along with the dual foci on corporeality and subjectivity, greatly enrich our knowledge of the worldly geographies of contemporary mental health and mental health care. Research here has become increasingly sophisticated, both theoretically and methodologically, as the ‘cultural turn’, post-structuralism, feminism and other conceptual innovations have bitten, as profound problems of representation have been raised, and as new research strategies have been adopted. However, there remains a danger that much of the new work remains somewhat disengaged from real life politics or the policy-making process. This is not to imply that researchers as individuals are not politically active in grassroots or state-centred mental health policy arenas (they are). Neither is it to suggest that normative questions have been entirely sidelined (they have not, as is evident from work linking disability and difference to larger themes of social-environmental justice: Gleeson & Law, 1998; Gleeson & Memon, 1994;


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1997; Takahashi, 1992; 1998b). Yet in general, second wave mental health geography is not always that well suited to informing policy, or to articulating concrete avenues for resolving today’s social, environmental and service delivery problems facing people with mental health problems. There are perhaps several reasons for this. Firstly, as questions of representation and multi-positionality come to the fore, it becomes increasingly problematic to conduct large-scale or longitudinal research associated with mental (ill-)health, and there is indeed a risk that some researchers become paralytically self-reflexive (also Parr, 1998a, b). Secondly, as noted already, the increasing focus on difference, identity and everyday life places does lead most studies of the contemporary situation to be relatively small-scale, and to utilise qualitative methods such as in-depth interviews, focus groups and ethnography in a research design based on localised studies. Findings are typically site- or case-specific, rather than demonstrably representative of larger portions of the mentally unwell population or of national or cross-national mental health care delivery systems (c.f. Jones, 2000; 2001). Thirdly, deep-seated cynicism about the ability of academic research to do anything except support a ‘corrupt’ political and policy process means that large-scale longitudinal studies designed to trace the shifting challenges faced by people with mental health problems, studies that require large amounts of external research funding, are regarded with unease. Even so, now is perhaps the time to become more ambitious in our efforts to conduct mental health research: in short, to work toward creating a third wave in mental health geography. We need to harness a variety of theories and methods to enable us to understand nuanced ‘place-specific’ happenings as well as more structurally-determined ‘space-compressing’ processes. Indeed, we need to be able to move across scales such that - to give an example - we can conduct micro-scale (socialcultural) research into the personal transformations (and geographies) experienced by users taking certain prescribed drugs (such as Prozac), but can then supplement such an inquiry with macro-scale (political-economic) research into the wider restructuring (and geographies) of the multi-million pound pharmaceutics industry. In so doing, we must also assess the relative magnitudes of the problems confronting people with mental health problems, appreciating how these problems vary from place to place but recognising too commonalities in how such problems arise across many different spaces (regionally, nationally and even globally). Our sense of urgency arises largely out of an aware-

ness of the contemporary context, especially as it is being played out in the largest cities of North America (and elsewhere). Faced with rising rates of extreme poverty despite what had been (until very recently) a booming economy, and alert to the expanding numbers of service-dependent populations once supported by public assistance but now increasingly excluded in the wake of welfare reform and human service privatisation, urban areas appear to be developing a de facto ‘(dis)placement model’ of service delivery. This model continually churns or cycles extremely poor people, including people with mental health problems, around a number of inauspicious sites: moving them to and from the streets via temporary settings such as homeless shelters, psychiatric wards, jails and prisons, and out-of-home placement facilities (Hopper et al., 1997; Knowles, 2000a, b; Moon, 2000). Unlike earlier treatment regimes based on the asylum/hospital or community-based care, the displacement approach is not informed by any therapeutic rationale but rather by the logics of load-shedding, cost minimisation, and, most particularly, the removal of inconvenient populations from sites targeted for urban development (Mitchell, 1997; Wright, 1997; Ellickson, 1996; Kenny, 1995). Such a scenario prompts crucial research questions: 1. The (dis)placement model stands in contrast to earlier models of mental health treatment based on the asylum/hospital, and then on community-based care, both of which have been linked to larger-scale economic and policy cycles (Dear et al., 1979; Dear & Wolch, 1987). How are the broad time-space cycles in contemporary economy, policy and urbanism interacting to produce new local landscapes of ‘madness’ and geographies of mental health? 2. The idea of churning implies a series of residential settings ranging enormously in the support that they provide, their restrictions on individual liberties, and the risks to health and safety posed to the individual. Yet, where, exactly, do ‘churned’ populations go? How long are typical treatment-setting cycles, and how do both setting and periodicity influence mental health status? 3. Geographers know quite a lot about group homes, a little less about homeless shelters, much less about jails and prisons, and almost nothing about new forms of out-of-home placement facilities such as sober-living homes. Yet many people with mental health problems, many of whom resort to medicating themselves with street drugs, are now routinely sent to such small-scale facilities. Where are these new sites of mental health treatment? Who operates them and how? How are their locations linked to welfare state policy and


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funding, to urbanism under conditions of postmodernity, and to an increasingly revanchist politics of turf (Dear & Flusty, 1999; Smith N., 1996)? What, in brief, are the emerging geographies of transinsitutionalisation and reinstitutionalisation affecting many people with mental health problems (Moon, 2000; Wolch et al., 1988)? 4. Sites of resistance to current moves in mental health policy include local, state and national ‘mental health alliances’ and advocacy groups (Parr, 1997a, b), and also other consumer and family groups. Arguably these groups constitute a critical social movement, waging battle over major efforts to overturn civil rights for people with mental health problems. What are the geographies of these and other sites of resistance to the emerging mental health order? How might targeted research or the formation of strategic coalitions strengthen such sites, movements and resistances? 5. In recent years, a variety of sub-fields within human geography have returned to questions of social justice and the city, and have increasingly linked such issues to broad-based conceptions of justice (Gleeson & Low, 1998). How might this renewed emphasis on social and environmental justice inform normative perspectives in mental health geography, allowing us to reframe - and not simply to reverse the terms of - debates which have previously offered knee-jerk characterisations of both the ‘bad’ or even ‘immoral’ asylum solution and the ‘good’ and hence ‘moral’ deinstitutional solution (Gleeson & Kearns, 2001)? Answering such questions will require both large- and small-scale research efforts, cross-sectional as well as time-series or panel studies, and a mixture of theoretical perspectives and methodological tools, all of which should vary according to both levels and spatial scales of analysis, ethical considerations and the particular research purpose.

Qualifying note Due to our own limited linguistic competence, our paper does not consider work on mental health geography which may be written up in languages other than English: we would gratefully receive information about any such work. Our paper does not tackle the very small but growing corpus of geographical research on ‘intellectual disabilities’ (‘learning difficulities’ or ‘mental handicap’ in other terminologies), but see the brief summary in Wolch & Philo (2000, Footnote 3, p.138; see also Hall & Kearns, 2001). It should be noted that the vast majority

of research reported above has concentrated on urban areas, and that there is more to be done on the rural dimension of mental health geography, although see Joseph & Kearns (1996), Kearns & Joseph (1997), and Milligan (1996; 1999b). One of the present authors, Philo, together with Parr (1998c), is presently studying mental health issues in the Highlands region of Scotland, much of which is extremely rural and remote.

Acknowledgements. We would like to thank Michele Tansella and Julia Jones for encouraging us to rework our previous paper (Wolch & Philo, 2000) for publiction here. Various people who helped us with the previous paper, notably Brendan Gleeson, Graham Moon and Hester Parr, also deserve our thanks.

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