بازیابی مناظر درمانی: حالت فضایی از 'جایگزین' گروه خودیاری

Since Gesler first introduced the concept in 1992, the language of ‘therapeutic landscapes’ has attained a core position in the toolkit of health/place studies. Whilst many authors using the term acknowledge that therapeutic landscapes are often also spaces of contestation, few if any have extended this to incorporate a serious critique of therapy itself. In this article, I use the case study of an ‘alternative’ psychiatric survivor (self-help) group in the north of England to attempt just this. Based on a ten month period of ethnography, I engage with the spaces – meeting places and venues – occupied by the group, focusing on the dilapidated and reputedly dangerous city park where the group hosts its most regular meetings. Three qualities of these spaces were found to be particularly embraced by the group: spaces of agency and appropriation; a space in the world; and a non-technical relation with space. The article uses these three themes to explore how the unconventional spaces of the group are not mere products of marginality but a serious aspect of mobilising the dissident and ‘anti-psychiatric’ recovery sought by its members. Through attending to what the survivors' found helpful in the park, a more sensitive rendition of ‘anti-psychiatry’ as it relates to the group is developed. The therapeutic landscapes framework as put forward by Gesler retains currency in highlighting the importance of place to the processes and identity of the group. However, it is also suggested that the ‘dissident topophilias’ of the survivors express a critique of current therapeutic landscapes thinking, challenging the supposition that it is the planned, the pleasant and the professional that provide the best backdrops for recovery.

The therapeutic landscapes perspective, first introduced by Gesler in 1992, has today become a broad collection of approaches in social science and health studies which together explore the rich connectedness between healing and place (Gesler, 1992 and Gesler, 2003; Williams, 2007). Traditional ‘therapeutic landscapes’ have included the restorative properties of spa towns, spiritual retreats and landscapes of natural beauty, yet more recently the term has also been applied to places expressly set aside for ‘cure’ or treatment such as hospitals and clinics (e.g., Curtis et al., 2007 and Kearns and Barnett, 1999). Underlying many of these approaches is an assumption that what is therapeutic in the natural context provides a good basis for clinical therapy also. Whilst authors using the therapeutic landscapes construct have long wrestled with a lack of consensus in defining what kind of place is therapeutic (Andrews and Holmes, 2007 and Curtis et al., 2009), few if any have taken seriously the contested nature of therapy itself. In particular, the many and varied critical approaches to therapy (often associated with the ‘anti-psychiatry’ movement, which has also incorporated many critiques of talking therapies) are barely represented within the therapeutic landscapes literature. In this article, I use ethnographic data from an ‘alternative’ and politicised self-help network of mental health service-users and ex-service-users in the north of England to address this lacuna. Located ideologically and geographically beyond the traditional spaces of care and service provision, the ‘survivor’ group (so-called due to its loose alignment with the ‘psychiatric survivor’ or ‘anti-psychiatry’ movement) is excellently positioned to begin the work of thinking critically about ‘therapy’ – not least because of the self-avowed ambivalence of its members towards institutionalised or professionalised forms of care and treatment. Two major threads or themes emerge in the argument which follows. The first embraces the therapeutic landscapes method (as an attentiveness to the healing qualities of place) to explore how a spatial reading of the survivor group provides a more nuanced understanding of some particular hostilities towards therapy and psychiatry. The latter works at unpicking the concept of ‘therapy’ within the therapeutic landscapes discourse. An important assertion here is, to the extent that therapy might be equated by some as a treatment or ‘cure’, members of the survivor group did not find the traditional landscapes of therapy (hospitals, clinics, therapy rooms.) therapeutic. A complementary thread tackles a second muddle; that ‘therapy’ might best be equated with what is comforting or comfortable (a potential sense of the adjective ‘therapeutic’, perhaps). Whilst this may come as no surprise to those who have undergone therapy or practiced it, both theoretical approaches to therapeutic landscapes and practical applications in designing spaces for therapy often appear to neglect this, in a point I develop throughout the article. Within this debate, links are made with the growing body of research (e.g., Davidson, 2003, Knowles, 2000 and Parr, 2008) that seeks to challenge what Faulkner and Thomas (2002) identify as an endemic bias towards top-down perspectives in mental health research. In this tradition, important strides have been taken to emphasise the lived and embodied subjectivities of people with mental health problems and to celebrate the capacity of psychiatric patients for self-determination. In cultivating this consciously ‘hopeful ontology’ (Conradson 2003, p. 521), widespread anxieties in popular culture about mental health patients and ‘self-help’ are also challenged, be these visions of malignant narcissism (see David Fincher's creation in the opening scenes of Fight Club for a parody) or fears about the unacceptable riskiness of unregulated patient-to-patient alliances such as the survivor group. Attending to the survivor group neither allays these concerns nor presents the viewpoints of its members as representative of the mental health service-user community. However, in listening to the members of the survivor group and documenting their ‘alternative’ landscapes of therapy, the ethnography gives testimony to the diversity of alternative recoveries and survivorships. In the remainder of the paper, after introducing the survivor group and research methodology, I begin by demonstrating the shared importance of space to the development of psychiatry/psychotherapy and the alternative model of the survivors. I then explore in greater detail the ‘dissident’ connections or topophilia (literally, love of place – see Tuan, 1974) that the survivor group demonstrate towards their meeting places, and the oppositional relations these assume with traditional landscapes of psychiatry and psychotherapy. I conclude with some comments aimed at reuniting the apparently ‘mad’ preferences of the survivor group with a more ‘ordinary’ understanding of emotion and place, drawing on insights from the arts and humanities. Readers will notice that the structure of the article weaves together ethnography, literature and analysis, rather than maintaining a strict arrangement of ‘theory, results, discussion’. This follows the philosophical method of those such as Collingwood (1933) and Rawls (1973), in which argument ‘is supported throughout its texture by cross-reference to experience’ ( Collingwood 1933, p. 51). In the ethical and political context of this paper, such an approach is a necessity, in order to allow the scholarly contributions from philosophy and theory and the grassroots philosophies of the survivors (what we might think of as the ‘empirical’ content) to progress dialectically together. Finally, a brief note about language should be made before progressing to the body of the article. Neither ‘therapy’ nor ‘anti-psychiatry’ form unitary or undifferentiated bodies, creating a slippery and often frustrating context in which this discussion takes place. For this reason, from here on the author will use the terms ‘therapy’ or ‘psychotherapy’ to refer generally to the range of non-medical, psychological ‘talking cures’ accessed by people in mental distress as a loosely defined set of practices and beliefs; where specific therapeutic traditions such as counselling or Freudian-derived psychoanalysis are intended, these are indicated separately. ‘Psychiatry’ by contrast refers to the hospital-based medical specialism and related community mental health services; a discussion of ‘anti-psychiatry’ as a social and intellectual movement is reserved for the body of the text. Whilst mapping the field of contention in psychotherapy/psychiatry is not the purpose of this paper (but see Crossley 2006), some typical concerns directed at both psychotherapy and psychiatry include: the ethics of compulsory treatment (Breggin, 1993 and Szasz, 1974); the reductionist framework of much psychotherapeutic/psychiatric modelling (Deleuze and Guattari, 1983 and Masson, 1993); the technicism and ‘expertism’ that may characterise certain kinds of therapeutic relationships (Smail, 1987 and Smeyers et al., 2007); and the proliferation of the psychotherapeutic template to areas previously beyond the remit of health or psychopathology (Furedi, 2004 and Sommers and Satel, 2005). Survivors supporting survivors: case study and methods To introduce the group (here named ‘Survivors Supporting Survivors’) in more detail, this is a small self-help network run by and for service-users and ex-service-users on the fringes of a deinstitutionalising psychiatric hospital in Northern England. Activities of the network include peer support, campaigning and a reading group on the philosophy of mental distress. The group currently has 23 members (15 female) aged 19–32, all of whom have experience of severe mental distress. Members generally became involved with the group after unsatisfactory experiences with mainstream services, having heard about the network through other patients during periods of in-patient care. Unlike support groups discussed more frequently in the academic literature (e.g., Karp, 1992 and Philo et al., 2005), the group has no formal links with service providers or registered patient organisations – an attribute which features rather prominently in its ‘underground’ identity. When asked about their philosophical persuasions, members describe the group as ‘anti-psychiatric’; nevertheless, it is important to note that individual members report various and conflicting personal relations with psychiatry and psychological therapies. Research methods took the form of an ethnography conducted over a ten month period in 2007, made possible due to the author's own enduring connections and friendships with the network (as such the ethnographic challenge of ‘going native’ was somewhat eased, since the researcher was already an accepted group associate). With the group's awareness and consent, the author attended weekly meetings as a participant observer for 38 weeks, recording impressions during and after contact. This was supplemented by 20 unstructured interviews in small groups or on a one-to-one basis, which were recorded and transcribed. In total, 17 group members took part in the interviews, with some individuals attending multiple sessions. Approval for all fieldwork was granted by the internal research ethics committee of the author's institution. The original purpose of the research was to address a series of questions about listening, which are not addressed in this article. Rather, the discussions about space and place that are reported here arose spontaneously and in the course of several separate moments in the research. The reanalysis of the original dataset to bring out these spatial themes was carried out in discussion with 3 of the original participants who helped to develop and give grounding to the interpretations I present here. All quotations are taken from the original interview transcripts and all names are pseudonyms. The spatiality of ‘psy’ and psychiatric survivorship As is well documented in mental health geographies, the history of institutional medical care for the mentally ‘ill’ has often centred on the development of specially circumscribed and rationalised spaces to contain and treat the unhappy and insane. From 19th century deliberations about where best to place the proliferating madhouses to contemporary restyling of post-asylum hospital architecture, the spatial organisation of psychiatry has both reflected prevailing views about mental illness and given structure to its treatments (Curtis et al., 2007 and Philo, 2004). Whilst in historical medical geography most attention has been paid to the spatiality of psychiatry (predominantly, the asylum and the mental hospital), equally interesting are the micro-spaces of psychological treatments. At the origin of psychoanalysis (at least according to conventional renditions of the profession's development), Freud developed the emblematic couch as central to therapeutic technique. By geographically locating his own chair behind and thus out of sight of the client, Freud believed he could limit undesired psychological transference and enable therapeutic regression ( Arehart-Treichel, 2004 and Freud, 1913). The couch with its multiple significations (a hospital bed, a lover's bed, the womb, a surgical table) both enacted and made possible the development of psychodynamic theory at large. In the 1960s, when what we now think of as the counselling movement emerged under the influence of Carl Rogers and others, again it was shifts in the microspatial materialities of the relationship that symbolised change. Contrasting the Freudian-derived ‘dynamic’ analysis client and therapist now sat facing each other, in chairs of equal size in order to foster the ‘core conditions’ of acceptance, empathy and genuineness that Rogers posited were both necessary and sufficient for therapeutic change ( Kahn, 1999). Departure from the couch was a means of establishing distance from psychoanalytic method. Yet to look at Rogers' writing at this time – ‘the therapist is genuine, hiding behind no defensive façade but meeting the client with the feelings which organically he is experiencing… no inner barriers keep the therapist from sensing what if feels like to be the client’ ( Rogers, 1961, p. 185) – it is clear that seating his clients face-to-face and ‘on a par’ was not just a means to create the core conditions, but actually constituted the core conditions and the new therapeutic relationship themselves. As the British Association of Counsellors put it, ‘this arrangement [comfy chairs, open angles, carefully arranged box of tissues] is so common because in many ways it is perfect’ ( Rowan, 1996, p. 351); although as I demonstrate next, support for this setup is less unanimous than Rowan appears to suggest. To shift attention now beyond the settings of psychiatry and psychotherapy, the story of the survivor group is also retold through significant spaces, although these spaces share little with the risk-assessed and planned environments of therapy and psychiatry that I have outlined above. As legend tells it, the group was born in the bathroom of a locked psychiatric ward, where patients began convening ‘in secret’ to talk about aspects of ward life which elsewhere in the hospital were censured. It should be noted here that in psychiatric ward culture, bathrooms have numerous dissident associations, such as places for purging or self-harming. Whilst early members of the group did not meet to engage in these behaviours collectively (just one of the popular anxieties about unregulated peer-to-peer support), the bathrooms remained preferable to the ‘flowery’ day rooms where other patients socialised because of the brief privacy they afforded from the surveillance elsewhere on the ward. As the group grew – in size and also in confidence – it moved out of the wards, as did many of its founding members as they were discharged or transferred to lower security units. During the course of my fieldwork, the group met in varied places: a bike shed on the hospital grounds, darkened bars, grubby fast-food restaurants and, most commonly of all, on the swings or in the burnt-out summerhouse in the city park with its unsavoury reputation as home to the city's vagrants and a popular spot for ‘dogging’, as outdoor casual sexual encounters are known to their participants. In an observation that was made jokingly by group members throughout the interviews, the most salient features of these venues were often their dubious reputations and unpleasant surroundings compared to the more comfortably furnished environments of conventional psychotherapy and psychiatry. To an extent, material circumstances necessitate these unconventional venues. The group cannot afford to hire a meeting hall. The hospital holds unhappy memories for members and besides, some of the group's unorthodox practices (harbouring the occasional ‘escapee’ who had left the hospital grounds without permission, for example) meant that support from formal mental health services was minimal. Yet, from speaking with the survivors, limited access to resources appeared only a partial explanation for the group's unusual meeting points: Becky: The park? Yeah, it's not confined like the hospital. You have some space to think. Gee: Well it would change us, wouldn't it [to meet in the hospital]? I think we'd have to agree to rules and “talk about how we feel” and become like all the other groups and we know they didn't work for us. Anna: Yeah, I don't think I'd like that at all. I like it up here [the park]. It's a bit damp and a bit dodgy but it suits us. I don't think somewhere comfy would suit us for some reason. This is sort of who we are. Without rejecting material explanations, issues such as identity and emotional attunement as expressed here by Becky and the others reveal a connectedness to space that is deeper than spatial marginalisation alone. Echoing the argument with Freud and the couch (above), to the extent that this topophilic relation both enables the group to proceed and distinguishes it from mainstream therapy, the dissidence of the park and other unusual meeting places both define the group and bring it into being. Qualities of an alternative therapeutic space Despite the obvious drawbacks and unsightliness of the survivors' meeting points, the alternative spatialities of the survivors are embraced by the group as radical and grassroots landscapes of therapy. In what follows, I discuss this ‘dissident’ connectedness of the survivors to their meeting places (and especially the park) through examination of three interpretive qualities or properties of space that appeared significant throughout the ethnography: (i) spaces of agency and appropriation; (ii) a space in the world; and (iii) an unanalysed and non-technical relation with space. These themes were selected following careful examination of fieldnotes and interview transcripts and were discussed at numerous stages in their development with individual group members – although, inevitably, what follows is only one of a multiple potential arrangements of the data.

The final paragraphs of this article are indebted to a friend and practicing counsellor who on reading an earlier draft of this paper exclaimed at some critiques of therapy, ‘whatever we do, they won't like it!’ Doubtless this will ring true for other readers who are puzzled by the ‘contrariness’ of the survivors' choices of venue (or else who attribute them only to insanity). As a final task I shall attempt to address some of these reservations. As I have discussed extensively in this paper, much social science research has sought to examine the affective connectedness between people, place and wellbeing. To recap two of the concepts I have worked with (each with a distinct theoretical heritage), these might be described variously as topophilias or therapeutic landscapes. Whilst both constructs have proved valuable in interpreting the spatiality of the survivor group, frameworks such as these render the survivor group atypical or dissident – not least because the research they proffer takes as its core examples the very landscapes which the survivor group rejected. At the heart of this is an aesthetic of space: it is too frequently assumed that a pleasant environment (a clean and planned and congenial one) is best for recovery; progressive attempts by planners to create such landscapes in clinical settings appear as ethically sound as they are commonsensical. Yet the survivor group demonstrates a different aesthetic: