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The geography of mental healthJULIA JONES

INTRODUCTION

This Editorial takes a social science perspective of thegeography of mental health, drawing upon the work ofprofessional geographers with an interest in mental healthand mental health care service provision. The academicdiscipline of Geography is broadly defined as "the studyof the earth's surface as the space within which the hu-man population lives" (Haggett, 1990). This all-inclusi-ve definition, which basically includes everything thatoccurs both in the natural and human world, often re-sults in the allegation that professional geographers arebasically 'jack of all trades, and master of none!' Howe-ver, in this Editorial I aim to demonstrate that geographersactually have much to offer to mental health research,both in terms of their social science research expertiseand their particular 'geographical' view of the world. Ihope to illustrate the benefits of including a geographi-cal perspective in mental health services research to as-sist us in studying both the spatial patterns of mental ill-health, and the geographical distribution of mental healthservices and facflities at different spatial scales (local,regional, national, global).

Geographers (myself included) believe that 'Geo-graphy matters' when we ask research questions such as

Indirizzo per la corrispondenza: Dr. J. Jones, Mental HealthProgramme. The Royal College of Nursing Institute, The RadcliffeInfirmary, Woodstock Road, Oxford 0X2 6HE (UK).

Fax: +44-(0)1865-246.787E-mail: [email protected]

'Why is there a concentration of people with mental healthproblems living in this district of City A'? or 'Why doesClient A living in City A have access to services X, Yand Z, but Client B living in City B only has access toservice Z'? Rather than simply observing spatial patterns,geographers seek to explore and interrelate the epide-miological, demographic, social, economic, political andspatial relationships which underpin phenomenon suchas changing patterns of psychiatric service use or the va-riations in service provision in different places. This skillis derived from our 'jack of all trades' quality - we ha-ve been trained in all the above mentioned spheres, andthus can think very broadly about complex and interre-lated factors when we focus upon a particular topic su-ch as mental health.

Firstly I will briefly outline the development of men-tal health geography. I will then focus upon the resear-ch area of the geography of mental health care provi-sion, using the findings of a doctoral research study (Jo-nes, 1999) to demonstrate the huge potential of studyingmental health service provision through a 'geographicallens'.

THE GEOGRAPHY OF MENTAL HEALTH

Within the discipline of geography, research on thegeography of mental health constitutes a small sub-field,crossing the interests of a number of the sub-disciplines,most notably social and medical geography. For purpo-ses of definition, social geography is concerned withstudying social relations in space, and the spatial struc-

Epidemiologia e Psichiatria Sociale, 10, 4, 2001

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J. Jones

tures that underpin those relations. For example, this in-volves an interest in the location of social groups in dif-ferent places, such as the residential concentration of eth-nic minority populations, low income families, or peo-ple with mental health problems within particular urbansettings. Social geography is also concerned with map-ping and interpreting the spatial incidence of social pro-blems, for example: the geographies of crime; housing;health; education provision; drug and alcohol abuse; ho-melessness; and suicide (Jackson, 1994).

Traditionally, medical geography has had two broadareas of research concern. The research area with a lon-ger tradition concerns the spatial ecology of disease andgeographical aspects of health and ill-health. Some ofthe earliest studies in medical geography studied mor-bidity and mortality by examining their distribution inspace, often by mapping them and comparing their oc-currence in different geographical areas (Curtis, 1994).This ecological strand of medical geography is closelyassociated to studies in epidemiology, and has develo-ped over the years to analyse the spatial distribution ofillness and disease and associated environmental factors,for example the relationship between nuclear power sta-tions and childhood leukaemia (Openshaw et al, 1988).

The initial interest in mental health by geographerswas through an ecological approach, drawing upon thework of Faris & Dunham (1939) who examined the di-stribution of patients admitted to mental hospitals in Chi-cago in the 1930s. Early geographical studies of the di-stribution of mental illness have included work by Giggs(1973; 1986; 1988) conducted in Nottingham, Taylor(1974, cited by Scobie, 1989) in Southampton, and Dean& James (1981; 1984) in Plymouth (all cities in England).These studies focused upon the relationship between men-tal illness and the urban environment, with particular at-tention to the spatial distribution of mental illness in dif-ferent social areas of these cities. Some consistent fin-dings of these studies have included: a concentration ofpeople with schizophrenia in inner-city areas (Giggs, 1973;1986; 1988; Dean & James, 1981); a more random di-stribution of people with manic depression (Dean & Ja-mes, 1984; Taylor, 1974); and a correlation of inciden-ce of particular disorders with social factors such as sui-cide and delinquency (Bagley et al., 1973; Bagley & Ja-cobson, 1976). These examples of ecological studies ofmental illness demonstrate the spatial variability of men-tal illness, particularly within an individual city.

However, as noted by Scobie (1989), there are a num-ber of limitations of these types of ecological studies. Amajor difficulty is the fact that most research of this kindrelies on data relating to service use, frequently inpatient

statistics. Consequently such studies are not specifical-ly studies of morbidity, but of service use. These studiesalso focus upon more severe psychiatric disorders andthus little is known about the geographical distributionof more minor (but still significant) disorders. Ne-vertheless, the ecological approach does provide resear-chers with a greater awareness of where people with mo-re serious mental health problems live, and where localservice provision needs to be targeted. This informationis a crucial 'starting point' to then examine mental healthpolicy issues such as accessibility to services and the pro-vision of a 'needs-based' mental health service.

The geographical approach to studying incidences ofmental illness has been built upon by more recent stu-dies which have incorporated the significance of socialand spatial processes to both the position of people withmental health problems within the urban environment andthe facilities which serve them. The implementation ofmental health reforms in Europe and North America sin-ce the late 1950s has created new areas of geographicalinterest, with people and services being transferred frominstitutional to community-based care. Geographers ha-ve an academic interest in the social and spatial proces-ses involved with deinstitutionalisation, and this intere-st has provided the impetus for the emergence of a se-cond strand of the geography of mental health - the studyof mental health care provision.

GEOGRAPHICAL STUDIES OF MENTALHEALTH CARE PROVISION

Since the 1980s the changing social context of mentalhealth care provision, with the closure of long-stay psychiatrichospitals and transfer of people and services into commu-nity settings, has shifted the attention of many geographersto the impact of this significant social and spatial change.The first geographical studies regarding the geographicalimpact of deinstitutionalisation were conducted in NorthAmerica. The pace of deinstitutionalisation has been quickerin North America than elsewhere and this is a contributoryfactor to why North American studies have dominated thissub-field. A key finding of these studies is the tendency formental health facilities to become geographically concen-trated in low income, inner city communities in major ci-ties, for example in Toronto, San Francisco and Winnipeg(Dear & Taylor, 1982; Dear & Wolch, 1987; Currie et al.,1989). These studies suggest that a ghettoisation of the men-tally ill has developed in these places and that the isolationof the asylum is in danger of being replaced by an 'asylumwithout walls' (Wolpert et al, 1975).


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Until recently very few studies of mental health ser-vice provision have been conducted outside North Ame-rica. In Britain, three studies were conducted at the endof the 1980s and early 1990s. Eyles (1986) investigatedthe provision and location of mental health facilities inNorthampton and Giggs (1990) conducted research witha similar focus in Nottingham. Moon (1988) publisheda study which examined local community reactions to amental health facility in Portsmouth. These three studiesall substantiated the findings of North American resear-ch, finding a geographical concentration of mental healthcare facilities within less affluent areas of the respecti-ve cities.

In the 1990s, it has been researchers from mainly out-side North America who have taken the lead in the ex-ploration of different geographies of mental health careprovision. A renewed interest in the concepts of spaceand place in human geography (Johnston, 1991) has beenan important influence upon this new work, resulting inan emphasis upon the influence of the local context onthe geographies of community-based mental health pro-vision. Research studies conducted in New Zealand (Jo-seph & Kearns, 1996; Gleeson et al, 1998; Kearns, 1998;Kearns & Joseph, 2000) and Britain (Milligan, 1996;2000) focus upon the relationship between mental healthcare service provision and place. A key theme runningthrough these studies is that the characteristics of parti-cular places play an important role in shaping the localexperience of deinstitutionalisation, both in terms of thelocal service delivery infrastructure and the experiencesof the service users/clients of those services.

An important finding from the work of Milligan (1996;2000) is that that the North American experience of theghettoisation of people with mental health problems ininner cities is not necessarily a universal experience ofdeinstitutionalisation. Milligan found that the process ofdeinstitutionalisation in the localities of Dumfries andGalloway (Scotland), was not resulting in a major driftof people with mental health problems and mental healthcare facilities towards the inner city locations. Althou-gh she did find that many people travelled on a daily ba-

-sis to these locations in search of social support.Despite a renewed attention to the geography of men-

tal health in the 1990s, there remains a deficit of studieswhich focus upon geographies of mental health servicesand facilities (Philo, 1997), and also which give atten-tion to the experience of deinstitutionalisation in Euro-pe. A recently completed doctoral research study (Jones,1999) has aimed to address these two issues and also totake the research one step further by comparing the ex-periences of deinstitutionalisation in two different Eu-

ropean countries in the form of a cross-national compa-rison. This study will now be briefly discussed.

COMMUNITY-BASED MENTAL HEALTH CAREPROVISION IN BRITAIN AND ITALY - A CROSS-NATIONAL COMPARATIVE STUDY

This doctoral research study sought to explore the tem-poral and spatial developments of the geographies of dein-stitutionalisation in Britain and Italy since 1950, with par-ticular attention given to the outcomes of national men-tal health reforms at the local scale. The geographical'outcomes' investigated by this research were the extentto which psychiatric hospitals had closed and alternati-ve community-based facilities had been established, asalternative service provision for people with mentalhealth problems. Working within a cross-national fra-mework, the research adopted a sensitivity to the role ofplace by exploring the social and spatial restructuring ofmental health care service provision in two localities -Sheffield (Britain) and Verona (Italy). (For an explana-tion of why these two cities were selected as case studylocalities see Jones (1999; 2000). The purpose of focu-sing attention on these two cities, one from each coun-try, was to explore the contention that to examine a lo-cality provides a 'lens' through which one can explorethe extent of implementation of national policies at thelocal scale.

The research was conducted at two spatial levels ofanalysis, with the fieldwork component carried out in1994. At the national level, the formulation and imple-mentation of national social policy and mental health le-gislation in Britain and Italy between 1950 and 1994 wasexamined to provide the contextual detail to the imple-mentation of the respective national reform programmes(see Jones, 1999; 2000). The second level of analysisexamined the spatial patterns of mental health servicedelivery in the cities of Sheffield and Verona. In consi-dering the temporal and spatial impacts of deinstitutio-nalisation in the two localities, service provision maps,which showed the locations of community-based men-tal health care facilities, were compiled. The purpose ofthe service provision maps was to display the 'objecti-ve' geographical outcomes of deinstitutionalisation, i.e.the locations of former long-stay psychiatric hospitalsand the locations of new community-based mental healthfacilities. To explore the decision-making process behindthe locations of new community-based mental health ca-re facilities, semi-structured interviews with mental healthprofessionals and professional planners were conducted


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(fifteen interviews in Sheffield and seventeen in Vero-na). The interview material provided explanations of exi-sting spatial patterns of static mental health care facili-ties in the two localities, and also revealed how nationalpolicy was impacting upon local strategies for the plan-ning and development of further facilities and services.

It is not possible in this Editorial to discuss all the re-search findings from this study, and interested readerscan consult a more detailed publication (Jones, 2000). Afinding of relevance to this Editorial is the huge diver-sity in the local geographies of mental health servicesand facilities that were found in Sheffield and Verona.A diversity exists despite the fact that both Britain andItaly have introduced broadly similar mental health ca-re reforms: closing psychiatric hospitals and introducingcommunity-based mental health care provision. In addi-tion to international variations, there also existed intra-regional and intra-city differences, which were particu-larly pronounced in Italy.

The geographical variations in the provision of com-munity-based mental health care in different parts of Italyare well documented (Tansella et al., 1987; Donnelly,1992; De Salvia & Barbato, 1993; Burti & Benson,1996). An important finding from the research conduc-ted in Verona was the wide variation in models of ser-vice delivery provided by the three different mentalhealth services which operated within the city at the ti-me of the research (1994). For mental health provision,the administrative district of Verona was divided into th-ree geographical sectors in 1978 (when a new NationalHealth Service was established and new mental healthlegislation (Law 180) was passed), according to the ad-ministrative boundaries of the city. Three new, separatemental health services were established and given re-sponsibility for each of the three sectors.

In 1994 all services had an acute inpatient and out-patient service provided at two general hospitals. Howe-ver, the community-based services and facilities beingprovided varied considerably across the city. Service A(in the south of the city) had developed a range of inte-grated services with a Community Mental Health Cen-tre, which was open six days a week, and three multidi-sciplinary teams of mental health professionals whoworked in the community, visiting people in their ho-mes. There were also two community-based residentialfacilities. In Service B (in the north of the city) and Ser-vice C (in the centre and east) there were fewer 'static'mental health facilities. In Service B there was one re-sidential facility. In Service C there were no residentialfacilities at all, although there were two co-operative work-shops. Services B and C shared a day centre, located in

the centre of Verona, which served only young people.There was no day care provision for older people withmental health problems in these two sectors. Instead the-se two services provide ambulatories (a type of day sur-gery) in each local area, often in the local health centre,which people had to attend.

The implications of this wide variation in mentalhealth service provision in the city Verona are clear: whe-re people lived in the city determined the type of men-tal health care that was available to them. At the time ofthis research in 1994, Services B and C had not develo-ped such a comprehensive range of community servicesas Service A. There seemed to be three main interrela-ted reasons for this situation. Firstly, the lack of co-or-dination between the three different services at this ti-me; secondly, the role of the local University's Depart-ment of Psychiatry in Service A; and thirdly, the role ofparticular mental health professionals in the developmentand management of the three local mental health careservices. The roles played by these key professionals hadbeen very influential in shaping the type of mental healthprovision available within the three geographical sectorsbetween 1978 and 1994 (see Jones 1999; 2000 for a mo-re detailed account).

The geographical variations in the mental health ser-vice provision within Verona are all the more strikingwhen compared to the geography of mental health ser-vice provision in Sheffield. Unlike in Italy, where theNational Health Service is responsible for providingmental health care services, in Britain the responsibilityfor mental health care service provision is split betweenthe British National Health Service (NHS) and social ser-vices departments of local authorities. Although there aremany complexities in this system, with different statu-tory and non-statutory agencies funding and providingmental health services in individual localities (see Wi-stow et al., 1992; Mohan, 1996), there is a general prin-ciple that these different agencies will work collabora-tively to provide services for a specific local population.

In Sheffield, the local health authority and social ser-vices department are responsible for co-ordinating men-tal health service provision across the whole city. In 1986there was a spatial division of the city into five geo-graphical sectors for mental health service provision, ba-sed upon administrative boundaries. However, this pro-cess of spatial sectorisation had a very different geo-graphical outcome in Sheffield compared to Verona. Fir-stly, the same city-wide agencies had responsibility forservice provision across the five sectors. Secondly, thespatial restructuring of the city had actually resulted ina greater spatial dispersion of mental health facilities


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across the city between 1986 and 1994. This outcome isviewed as a result of a city-wide strategy to provide aspectrum of services within each geographical sector -inpatient, outpatient, residential and day provision andsector-based community mental health teams - reflectingthe principles of national mental health policy. In the citythere were also specialist mental health services that we-re available to people irrespective of which sector theylived in.

From the Verona case study, it may be asserted thatthe development of three quite distinct mental health ser-vices in the city was enabled by the considerable auto-nomy experienced by the mental health professionals ma-naging the services. A freedom from externally imposedpolicy specifications or guidelines provided an opportu-nity for mental health professionals to implement theirown interpretation of Law 180 within their respectivesector. This level of autonomy at the local level of men-tal health care provision was quite different to the si-tuation experienced by local service providers in Shef-field, where there was far greater centralised control fromnational and local policy requirements. At first sight, itcould be perceived that the existence of sector-based ser-vices in both Sheffield and Verona is a similarity, botharising as a result of a decentralisation of service provi-sion. However, in reality this represents an outcome ofdifferent political and organisational approaches to lo-cality-based service provision, a consequence of diffe-rent national-local power relations within the respectivenational political and administrative systems. This is animportant finding which is only uncovered when one ex-plores the process of implementation at the local scale.

From a cross-national perspective, comparing the lo-cal geographies of mental health provision in Sheffieldand Verona has unravelled the 'detail' of variation anddifference in the respective service delivery systems thatmight not have appeared so obvious in a single-nationstudy. This research has highlighted the fact that thereare many insights to be gained by comparing mental healthcare reforms at different spatial scales - international, na-tional and local. Such a research strategy can provide aunique opportunity to identify and illuminate similari-ties and differences between national experiences ofmental health care reform. Research findings can be ofparticular value to policy makers, providing examplesand ideas of innovative practices from different coun-tries that may be transferable. There are also lessons tobe learnt from aspects of different reform movementsthat have been less successful (Jones, 1996). For exam-ple, there are aspects of the Italian reforms that have im-plications for the organisation of community psychiatry

everywhere. An absence of political and administrativecommitment to policy reform clearly hinders the effec-tive nation-wide implementation of community-basedmental health care. However, there are also examples ofreal innovation from the 'Italian experience' which canbe adopted from one country to another (Tansella, 1991).It is considered that the possibilities, both in terms of re-search and policy, derived from adopting a cross-natio-nal perspective are considerable and worthy of furtherattention.

CONCLUSION

Huxley (2001) has commented that social scientistshave much to offer to mental health services researchand development. In this Editorial I have attempted todemonstrate that one particular group of social scienti-sts, professional geographers, have a range of researchinterests and expertise that can make a significant con-tribution to mental health research. Geographers, withtheir broadness of knowledge about the world in whichwe live, as well as their expertise in 'thinking geo-graphically' about research problems, have much to of-fer to the mental health research and policy arenas. It issuggested that Geographers' contribution to this field canbe maximised through greater collaboration betweenmental health professionals, researchers and other socialscientists, with all the disciplines bringing their specificexpertise to the 'research table'.

Acknowledgements. I would like to thank Professor Michele Tan-sella for inviting me to write this Editorial. I acknowledge the finan-cial support for my doctoral research from the Economic and SocialResearch Council (Award No. R0029234155).

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