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In the post-institutional era of mental health care how are we to conceptualize "community care" and "the mental patient"? There are those who look back to the institutional era with a fond, usually rose-tinted, nostalgia; for others deinstitutionalization remains an ideal rather than a reality. The literature on psychiatry and mental illness shows increasing divergence. Even mainstream services have adopted "recovery" as a motif, there are new biological discourses, and for many people with mental illness, a forensic identity as either patient or criminal. The movement to community care has had limited success in dismantling the mental patient as different and other. Hester Parr's contribution to this issue uses the conceptual tools of geography to open up debate about the social space of the person with mental health problems, and in so doing to move beyond debate about "institutional spaces and enclosed medical identities" Mental Health and Social Space. Towards Inclusionary Geographies? re-examines the identity of people with mental illness, especially the transition "from inert non-citizen to valued and relational social agent."
Two theoretical chapters provide the background against which Parr reports empirical studies of mental health in various social spaces, with a final chapter looking forward to new ways of thinking and practice. The social spaces are widely divergent, ranging from rural villages of the Scottish Highlands to the Internet. Each offers opportunities and risks in the task of forging an identity as a person with mental illness. The concept of space is central to this book, beginning with the observation that the asylum enterprise can be understood as one of segregation, and the creation of spaces of exclusion. Debate over moral and medical models of the asylum ignores their common feature of spatial and conceptual differentiation. What Parr also points out is that many of the critical histories of psychiatry have also characterized the mental patient as passive, and have ignored the agency seen in small acts of resistance, exercised even by institutionalized asylum inmates. Interestingly, Erving Goffman is cited as one whose work recognizes the operation of agency, even within the "total institution." Parr quotes from Asylums:
The patient curling up at the window, looking outside through the bars, pressing the nose of his whole body against the outside, and in this way somewhat removing himself from the ward, and somewhat freeing himself from its territorial restriction.
The second chapter explores the development of community care in the UK, leading to a discussion of how "social inclusion" of people with mental illness might lead to identities beyond those derived from mental illness or use of mental health services. Parr makes much of the disproportionate expenditure on inpatient compared to community services, and especially compared to expenditure on the large majority of people with mental illness within primary care. While this economic analysis is interesting, it tells only a partial story, and begs the question of the extent to which the mental health sector should cater for the whole spectrum of people with mental illness. Given the tendency of the mental health sector to develop silos, it seems positive that the majority of people with mental illness receive care in the primary sector. In terms of the wider historical perspective, the global emergence of mental health as a major issue in primary care is something that requires close analysis, especially as this is a new claim for resources, which arguably should not be made on a mental health budget already struggling to meet demands for new services. Parr argues that "community" is largely a rhetorical device for mental health policy, with little direct evidence that reinvestment has been substantially diverted away from institutional psychiatric care, despite the "widespread emergence of community mental health teams." (p. 38-9). I found this statement problematic. It seems hard to argue that "community" is merely a rhetorical device if there has been a widespread emergence of community mental health teams. In terms of the data Parr presents, community services account for around 25% of the mental health budget, which seems somewhat more than "mere rhetoric".
The section in Chapter Two on inclusion provides an interesting analysis of rights and citizenship, pointing out the apparent contradiction between the assertion of universal rights and the creation of exceptions embodied in mental health legislation and its inherent power of spatial sanctions. The rights based approach to citizenship is contrasted with "relational citizenship" exemplified by some of the programs sponsored by the Scottish Executive. These include media advertising to render mental illness an understandable human experience, and the work of the Scottish Recovery Network in promoting non-linear recovery narratives. Relational, or social citizenship may be more accessible to people with mental illness and it is more amenable to individual agency than rights based citizenship that depends on an explicit legal framework.
Parr next examines rural communities. Often idealized as peaceful, close-knit, with solid traditional values, these are the communities that for almost a century hosted the rural asylums, islands of confinement within an otherwise open and supportive community. This is where Parr begins to show, through accounts of lived experience, how people with mental illness resist their prescribed identity and negotiate social space on their own terms. Parr is careful to stress that she is not simply recasting rural communities as exclusionary; nor is she romanticizing the lot of the mentally ill person in a rural community. Her task is to show that taken for granted notions about person and place are more complicated than it might appear, something that has implications for the "geographies of despair" often thought to characterize the urban environment. A case study set in the Highlands shows a tenuous balance between inclusion and exclusion, with the same behavior (e.g. a simple enquiry after one's health) being interpreted as either intrusive or supportive, perhaps even both. The reality of visibility in a small community makes public space problematic as it doesn't afford the anonymity of a larger center. A public snub can be very much more obvious. Similarly, while Parr rejects the idea of the Highlands as an exemplar of a naïve Gemeinschaft, there is a very real history, social code and culture that acts as a "two-edged sword": including out of an enduring sense of belonging, but having a flashpoint of exclusion, triggered by affront to community values. The complex and unstable social context of the Highlands challenges people with mental health problems to become resourceful agents in order to negotiate the sometimes contradictory rules. Strategies of concealment, avoidance, and reaching beyond the community show that the rural citizen with a mental health problem is no passive object of pity or derision.
Turning to the natural world, Parr begins the next chapter with a discussion of the idea of "nature" in Western thought, and especially in relation to madness. Foucalt used the expression "nature mediated by morality" to refer to the farm-like environment of the early asylums. This is a truly romantic notion, incorporating the values of manual labor, observation of the seasons, rejection of the "unnatural" man made environment. Parr describes it as having organic disciplinary power. Modern gardening as a mental health intervention also serves moral and therapeutic functions. Parr cites an example in which the transformation of waste land into a manicured garden acts as a visible demonstration of the civilizing effects of work and nature. This also serves an agenda of social inclusion through proximity and development of social relationships. An intriguing aspect of this chapter is the continuity of the 19th century notion of the restorative power of "nature".
As with nature, visual art has a long history in mental health care. Parr prefaces her chapter on artistic spaces with a review of art as either representational or therapeutic, in both cases contributing to an "art of the insane". This tradition continues in psychiatric publications. The American Journal of Psychiatry runs a regular "Images in Psychiatry" column. Schizophrenia Bulletin features artwork of people with mental illness, the appreciation of which must surely be limited by accessing journals online rather than in print. Parr is less concerned with expressive art than with art as a social practice, especially one with the potential to promote social inclusion. I was intrigued to learn that the Scottish Mental Health Act mandates the provision of social and cultural activities. Parr again draws on research, in this case to show a developing use of art as a valued non-clinical activity that promotes sociability and inclusion, contributing to the reformation of identities previously dominated by patienthood. As people participate in these modern art programs, the studio becomes a transitional space, providing the opportunity of movement towards insider status. The transitional nature of the studio is reflected in a tension within the art community about whether aspiring artists have earned insider status, or are patronized by them and according their art a special space at exhibitions. What is clear from Parr's account though, is that these "patient artists" exercise their own agency in negotiating their ambiguous status.
The Internet is the focus of the final empirical chapter. Parr firstly notes the claims for democratizing of information and access to relationships. Her focus is on the opportunity the Internet provides for the rescripting of identity in virtual space. The promise of the Internet, like that of nature and art, is tempered by its limitations. Nevertheless, Parr is able to argue that the Internet offers something new, and for some people with mental illness, a unique opportunity for inclusion. Parr gives examples of the sorts of disclosures made possible in anonymous forums, and of individuals' experiences of support and validation. The danger is that "forums can become risky spaces in which the integrity of the self may be challenged or even unravelled" (p. 148). There is also the issue that those with mental illness share with other Internet users, that of whether online experiences generalize to the "real world". For some, clearly, the Internet is a refuge and a haven. Parr concludes this section with measured optimism about the Internet as a social space: neither as safe nor as different as sometimes thought, it is one more opportunity for inclusion available to people with mental illness.
While the issues raised in this book are of enormous importance to the mental health sector, many will find Mental Health and Social Space rather forbidding in terms of its language and density of argument. The book is replete with the novel terms common to the social science literature: "disrupting monolithic imaginations", "disclosive affordances of these spaces of engagement", different possibilities are "excavated". It is also theoretically rather complex in places. However there is a certain amount of intellectual spade work which must be done if mental health is to be reconceptualized in the way Parr suggests. Mental Health and Social Space invites a re-evaluation of concepts of "the mental patient" and suggests that this re-evaluation is already taking place by those to whom it matters the most: people with mental illness. In this sense people with mental illness have included themselves in. Identity is never final, and so the rescripting that Parr describes is not towards a fixed new identity. That is very much the point of Mental Health and Social Space: defining, or declaring, who one is is never finished. The key this process, common across all four of Parr's research sites, is proximity, either proximity to difference as people with mental illness and other members of the community find themselves closer together, or proximity to others with mental illness.
As with other reconceptualizations of the mental patient, Parr acknowledges that the concept of citizenship is potentially fraught. Notions of "citizenship" and "self-governance" are open to neo-liberal capture that serve State interests in rationalizing resources and in regulating citizens. The same language can be employed in pursuit of very different ends. For example, Parr questions whether, given the "powerful social ascriptions that have constituted [the mentally ill] over time" (p. 41) employment is likely to lead to social inclusion. On the other hand, for those who find independent employment difficult to attain or maintain, a State exhortation into voluntary work might have the effect of devolving to people with mental illness, responsibility for their own social exclusion. In her conclusion Parr explores the inevitable tension between the program of the liberal State which supports the development of the autonomous, self-regulating "post-patient" citizen, and simultaneously seeks to devolve responsibility to that same citizen. There is also the issue of the material circumstances of people with mental illness. Opportunities for social inclusion are limited, or at least mediated, by income and material resources, and many people with mental illness, especially those with severe and enduring mental illness, have little of either.
Mental Health and Social Space is successful in challenging the "outsiderness" assumed to characterize people with mental illness. The case studies bring substantial evidence to bear on this question, and are supported by a theoretical framework that allows us to understand why we should recognize social citizenship as practiced by people with mental illness. Parr shows that the non-medical social spaces that allow social citizenship to develop are deeply connected to the historical imagination of the insane. Twenty-first century models of mental health still talk back to the asylum. But beneath the discourse of neglect and failure which characterizes much debate about community mental health there are stories of assertion of citizenship that go against the grain. This is nicely summed up at the end of the book in an anecdote from a researcher, ready to present her findings of neglect at a conference, only to find herself sitting next to another researcher with a very different story to tell. The title of this book ends in a question mark. The question is inherent in Parr's comment that the inclusionary geographies she describes are not a panacea, and their viability is not assured. Parr has made an important contribution to the redefining of "the mental patient", a crucial undertaking if social citizenship for people with mental illness is to become an enduring reality.
© 2008 Tony O'Brien
Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, [email protected]