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.

The safe journeys of an enterprising school: negotiating landscapes of opportunity and risk.

In this paper, we discuss recent efforts to improve the safety of children travelling to and from New Zealand's largest primary school. The results of a travel survey completed by parents and pupils are reported, together with our recommendations for reducing congestion at the school gate and promoting healthy alternatives to car travel. Reflecting on this research, we find that market-oriented education reforms have provided schools with strong incentives for increasing their rolls--a course of action which may endanger pupils' well-being. At the same time, they have provided some schools with opportunities for resisting the present urban (dis)order and promoting community health.

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.

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

In New Zealand, the process of deinstitutionalization is continuing to unfold as a specific manifestation of welfare state restructuring rather than as a discrete process within the health care sector. In this paper we consider the geography of mental health care in Auckland, New Zealand's only metropolitan city. Here, a highly fluid and competitive housing market has profoundly (re)shaped the opportunities for community care. We report on findings from a survey of representatives of the key agencies providing mental health care in central Auckland. We argue that the re-placing of mental health care into the community has often involved the separation of residential and treatment issues, to the detriment of the communities, institutions and (especially) individuals involved. We trace this fragmentation back to the primacy of the ideology of restructuring over the philosophy of deinstitutionalization. We build our argument around a discussion of the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the apparent subordination of the Act to the emerging of a 'contract state' and broader legislation, such as the Resource Management Act 1991, the Privacy Act 1992 and the Commerce Act 1986, which underpins the re-regulation of New Zealand society.

"Happy Meals" in the Starship Enterprise: interpreting a moral geography of health care consumption.

This paper extends earlier explorations of the use of metaphor in the marketing of the Starship Children's Hospital in Auckland, New Zealand, by examining controversy surrounding the opening of an in-hospital McDonalds fast-food outlet. The golden arches have become a key element of many children's urban geographies and a potent symbol of the corporate colonisation of the New Zealand landscape. In 1997 a minor moral panic ensued when a proposal was unveiled to open a McDonald's restaurant within the Starship. Data collected from media coverage, advertising and interviews with hospital management are analysed to interpret competing discourses around the issue of fast food within a health care setting. We contend that the introduction of a McDonald's franchise has become the hospital's ultimate placial icon, adding ambivalence to the moral geography of health care consumption. We conclude that arguments concerning the unhealthy nature of McDonald's food obscure deeper discourses surrounding the unpalatable character of the health reforms, and a perceived 'Americanisation' of health care in New Zealand.

Unhealthy Acts: interpreting narratives of community mental health care in Waikato, New Zealand.

This paper provides a regional commentary on the progress of deinstitutionalization in an era of restructuring in New Zealand. The commentary focuses on the Waikato region, where the transition to community-based psychiatric care has been underway since the announcement of the closure of Tokanui Hospital in 1993. We use media reports to construct a narrative illuminating the distinctive threads of alternative discourse on the re-placing of people with mental health problems and sites of treatment 'into the community'. Our interpretation of this local narrative is cast against a series of backdrops: firstly, we provide an abbreviated history of deinstitutionalization in New Zealand; secondly, we examine mental health care as a sector within a rapidly evolving health system; and, thirdly, we reflect on the implementation of community mental health care in a re-regulated civil society. We argue that the effective implementation of community care has been hampered by the lack of concerted policy in the mental health care sector, by a fiscal squeeze on the health care system and by the impingement of non-health care legislation (the Commerce Act, the Privacy Act and the Resource Management Act) on the local expression and management of community care. In the Waikato narrative, we also identify administrative practices that have recast people with mental health problems as criminals and re-established prisons as the site of treatment. We conclude that the media in New Zealand have a role that extends beyond simply reporting on events. Indeed, the media act as a reflexive conduit; journalists interpret issues and through their 'stories' help to shape the course of events.

Declining professional dominance?: trends in the proletarianisation of primary care in New Zealand.

This paper explores the relevance of the proletarianisation thesis to the emergence of new forms of managed primary care in New Zealand. This concern is of particular interest because of primary care sector has persisted virtually unchanged, since the birth of the welfare state in 1938, despite numerous past state attempts at reform. Since 1993 collective action on the part of general practitioners has resulted in the formation of Independent Practice Associations (IPAs). In terms of Light's (1993) idea of countervailing trends to proletarianisation, IPA development represents a pre-emptive strategy designed to prevent the introduction of the kind of managerialism imposed on the secondary sector where some loss of autonomy has been sustained by health care professionals. At the macro-level, therefore, there has been little change in GP autonomy although at the micro-scale there has been some loss of freedom as the development of IPAs ironically has meant that the degree of control by GPs over the content of their work has changed. The results suggest that the notion of the profession acting as a countervailing force has been borne out. Furthermore, the proposition inherent in modern organisation-environment relations literature, that organisations not only adapt to their environment but may actively seek to change it receives some support.

Consumerist ideology and the symbolic landscapes of private medicine.

The consumption of health care has generally been examined by geographers in terms of patterns of service utilization by patients. The sites of service provision have been viewed as locations rather than as contributors to, and constituents of, urban landscapes. In this paper we argue that perspectives of the so-called "new" cultural geography can assist in interpreting the urban landscapes of health care. The case of accident and medical clinics in New Zealand is examined and used to argue that the underlying ideologies of private provision and consumerism is reflected in the symbols used in both the built environment and in advertising.

Housing stressors, social support and psychological distress.

This paper explores the links between housing stressors, social supports and psychological distress. It was hypothesised that exposure to housing stressors would be significantly related to psychological distress, but that the adverse effects of housing stressors would be moderated by perceptions of social support resources. In other words, the stress/symptom relationship would be attenuated for individuals who believe that they have active and supportive social relationships. The results of a study conducted in the two New Zealand cities of Auckland and Christchurch partially confirmed this hypothesis, indicating that social support plays a role in mitigating the adverse effects of housing stressors. However, this relationship depends on the severity of the housing stressors. Among our respondents, the presence of social support was indeed associated with reduced symptom levels for those exposed to moderate housing stressors. However, among respondents subjected to high levels of housing stressors, social support was not associated with reduced psychological distress, indicating the need for a more specific policy response to the issue of seriously deficient housing.

Space in its place: developing the link in medical geography.

This paper argues that a re-examination of the interrelationship between constructs of place and space is crucial to geography's involvement in the broader endeavour of health research. Place has re-emerged as nexus of ascribed meaning within contemporary social theory. Places, however, are related in space, by distance or proximity. The distinction needs to be made between this orthodox (geometric) view of space and two types of social space: the (experienced) space described by humanist geographers; and the more recent (socio-spatial) conceptualization which is both experienced and (re)produced by societal structures and advocated by social theorists in geography. We argue that advancing a recursive understanding of space and place is an appropriate direction in medical geography. This direction will include both an understanding of the ways in which space shapes the character of places and how the particularities of places resist or set in motion (orthodox) spatial processes. Illustrations are drawn from studies of mental illness and mental health care and primary health care in a remote area of New Zealand.

Ethnicity, morbidity and health service utilization in two Labrador communities.

This paper compares total outpatient health care utilization of residents of the Labrador community of Sheshatshit, a predominantly native Innu settlement, with those for the adjacent and predominantly caucasian community of Northwest River for 1986. In lieu of a community survey, these data provide an approximation of the morbidity patterns within the populations. Findings indicate that the native population experiences proportionately more infectious diseases (39.3% of all visits compared to 12.5% of all visits for the non-native community). While residents of the Innu community utilize health services primarily for curative care, residents of Northwest River sought services for both curative and preventive care. It is concluded that inequalities in material wellbeing may underlie the morbidity in Sheshatshit. While desirable in light of the WHO Ottawa Charter, any modification of the health services on account of these morbidity patterns will have only modest effect until policy-based initiatives to reduce material inequalities are implemented.

Another day in paradise? Life on the margins in urban New Zealand.

This paper examines the relationships between housing and health with respect to a sample of New Zealand public housing applicants. In the first part of the paper, the notion of incipient homelessness is reviewed, the production of this population in advanced capitalist societies is considered and the social geography of the inadequately housed in New Zealand is surveyed. The second part of the paper presents some of the data collected in a survey of the inadequately housed in Auckland and Christchurch (n = 213 households). The results suggest that housing is an important determinant of the health and well-being of this population, but that rehousing the poor should be seen as only one step in addressing inequalities in contemporary urban New Zealand.

The place of health in the health of place: the case of the Hokianga special medical area.

Contemporary models of health have broadened the concept so that health includes, but is not exclusively, biomedical wellness. One concern arising from this widened perspective is the degree to which health service provision promotes healthier, more convivial communities. This paper examines the contribution of health services to the experience of place in the Hokianga, an isolated and predominantly Maori area of New Zealand. While other public services are being increasingly privatised, charged to users and restructured to central nodes of provision, health care in the Hokianga remains free and delivered within a network of community clinics. It is argued that the taking of health care into communities both enhances the wellness of the population and positively enhances the experience of place for local residents.

Birth places: a geographical perspective on planned home birth in New Zealand.

In New Zealand until the 1920s, most births occurred at home or in small maternity hospitals under the care of a midwife. Births subsequently came under the control of the medical profession and the prevalent medical ideology continues to support hospitalised birth in the interests of safety for mother and child. Despite resistance from the medical profession, recent (1990) legislation has reinstated the autonomy of midwives and this has come at a time when the demand for home births is increasing. This paper locates these changes within the geographical context of home as a primary place within human experience. It is argued that the medical profession has been an agent of an essentially patriarchal society in engendering particular experiences of time and place for women in labour. Narrative data indicate that the choice of home as a birth place is related to three dimensions of experience unavailable in a hospital context: control, continuity and the familiarity of home.

Housing satisfaction, preference and need among the chronically mentally disabled in Hamilton, Ontario.

This paper examines housing satisfaction, preference and need among a sample of the CMD in Hamilton, Ontario. The research goes beyond simply documenting the gap in housing supply by examining issues of housing quality as expressed by clients themselves. Survey data were obtained in two rounds of interviews from 66 clients attached to three aftercare programmes. Various indicators were consistent in showing a relatively high level of satisfaction with the current living situation. At the same time, clients reported major housing difficulties due to lack of appropriate and affordable accommodation, unacceptable conditions and financial constraints. Housing satisfaction was a significant correlate of scores of coping indices. There was considerable variability in satisfaction within groups of the sample defined in terms of type of housing, location and living arrangement. Data on preferences and expressed needs correspond quite closely with normative prescriptions for a continuum of housing options ranging from restricted congregate care to autonomous individual living situations. These findings underline the heterogeneity of the CMD and their needs.

Spatial patterns of attendance at general practitioner services.

Geographical theory suggests that consumers will travel to the centre nearest to their residence which offers a particular service. This is a weak indicator of surgery attendance patterns in Gisborne, New Zealand. Nearby surgeries were attended, rather than the nearest available. Various attributes of the practices and the patients were examined to discover their influence on attendance patterns. The distribution of the practices themselves had a significant effect upon relative surgery attendance. Prior knowledge of services was particularly important in determining surgery selection and continued attendance. This accounted for the spatially unconstrained attendance of many Maori. Greater personal mobility enabled higher income households to travel further to attend. Conversely, the less mobile were spatially bounded.

Daily life experience of people with chronic mental disabilities in Hamilton, Ontario.

A study of the daily life experiences of people with chronic mental disabilities who were associated with three mental health services in Hamilton, Ontario, yielded both quantifiable data and narrative accounts of life in the community. In this article, the narrative accounts are reported and interpreted under the proposition that insider perspectives reveal useful insights for all involved in community mental health. The article highlights the fact that limited social opportunities and material poverty combine to give mentally disabled people the distinctive experience of having relatively unconstrained time but a highly constrained set of places in the city available to them.