Heterotopias of Mental Health Care: the Role of Space in Experiences of Distress, Madness and Mental Health Service Use

Open Research Online The Open University’s repository of research publications and other research outputs Heterotopias of mental health care: The role of space in experiences of distress, madness and mental health service use. Thesis How to cite: Mcgrath, Laura (2012). Heterotopias of mental health care: The role of space in experiences of distress, madness and mental health service use. PhD thesis London South Bank University. For guidance on citations see FAQs. c 2012 The Author https://creativecommons.org/licenses/by-nc-nd/4.0/ Version: Version of Record Copyright and Moral Rights for the articles on this site are retained by the individual authors and/or other copyright owners. For more information on Open Research Online’s data policy on reuse of materials please consult the policies page. oro.open.ac.uk Heterotopias of mental health care: the role of space in experiences of distress, madness, and mental health service use. Laura McGrath A thesis submitted in partial fulfilment of the requirements of London South Bank University for the degree of Doctor of Philosophy 5th April 2012 1 Dedicated to Caroline McGrath 2 Acknowledgments Firstly, I am very grateful to all those who took the time to participate in this research and were willing to discuss their experiences with me. Two people in particular have been instrumental in the production of this thesis. First of all, I would like to express my gratitude to my supervisor, Paula Reavey, for her inspiring teaching in the area of mental health, as well as initially stirring my interest in space and materiality, and then for providing invaluable guidance, inspiration and friendship, over the course of this research. Secondly, I am extremely grateful to my brother, Edward Lockhart, for providing me with the financial means to enable me to pursue this particular avenue of research, at the place I wanted to study. I would also like to thank my second supervisor, Phillip Kemp, for his guidance and support. My colleagues at both London South Bank University, and latterly the University of East London were invaluable in helping to provide a supportive, friendly and fruitful working environment over the course of my PhD; I would particularly like to thank, for their advice, helpful discussions, and friendship: Dan Carney, Allan Tyler, Carly Guest, and Anamika Majumdar. 3 Dissemination of findings Conference papers McGrath, L. (2010). Service user spaces: considering a role for material space in service user experiences of community mental health care. Paper presented at the Self in Mental Health Care Conference, organised by the International Network For Philosophy and Psychiatry, June. McGrath, L. (2009). Spaces of recovery? Mapping community mental health care. Paper presented at the European Congress for Community Psychology, October. McGrath, L. (2009). The role of space in service users’ experiences of community mental health care. Paper presented at the PsyPAG conference, July. 4 Abstract The change from an institutional to community care model of mental health services can be seen as a fundamental spatial change in the lives of service users (Payne, 1999; Symonds & Kelly, 1998; Wolch & Philo, 2000). It has been argued that little attention has been paid to the experience of the specific sites of mental health care, due to a utopic (idealised and placeless) idea of ‘community’ present in ‘community care’ (Symonds, 1998). This project hence explored the role of space in service users’ experiences, both of mental health care, and community living. Seventeen ‘spatial interviews’ with service users, utilising participatory mapping techniques (Gould & White, 1974; Herlihy & Knapp, 2003; Pain & Francis, 2003), plus seven, already published first person narratives of distress (Hornstein, 2009), were analysed using thematic analysis (Braun & Clarke, 2006). Mental health service sites are argued to have been described as heterotopias (Foucault, 1986a) of a ‘control society’ (Deleuze, 1992), dominated by observation and the administration of risk (Rose, 1998a), which can in turn be seen to make visible (Hetherington, 2011) to service users a passive and stigmatised subject position (Scheff, 1974; 1999). Such visible positioning can be seen to ‘modulate’ (Deleuze, 1992) participants’ experiences in mainstream space. The management of space has hence been argued to be a central issue in the production and management of distress and madness in the community, both in terms of a differential experience of spaces as ‘concordant’ or ‘discordant’ with distress, and with movement through space being described as a key mediator of experiences of distress. It is argued that this consideration of space has profound implications for the ‘social inclusion’ agenda (Spandler, 2007; Wallcraft, 2001). 5 Table of Contents Preface 9 Chapter One 12 Space, distress and mental health services 12 1.1 Community care, space and distress. 12 1.2 Terminology 15 1.2.1 Defining the experience 16 1.2.2 Defining the person 19 1.3 Spaces of mental health care: from the asylum to the community 20 1.3.1 The asylum 21 1.3.2 Community care 24 1.3.3 Experiences of community space, and community mental health care 29 1.4 Evidence for a relationship between space and distress 35 1.4.1 Toxic spaces: the development of distress 35 1.4.2 Inner city built environments and mental distress 38 1.4.3 Therapeutic spaces: the facilitation of recovery 44 Chapter Two 52 Space, experience, and subjectivity 52 2.1. Space: definitions and debates 52 2.1.1 Geographical approaches to space and place 53 2.1.2 Space as socially produced and socially productive 55 2.1.3 Space and time to space-time 57 2.1.4 Space and place 60 2.2 Social constructionist psychology 61 2.2.1 Michel Foucault: power, knowledge and discourse 63 2.2.2 Foucault and the material 67 2.2.3 Integrating discourse, materiality and embodiment 70 2.2.4 Finding a role for materiality 73 2.2.4 Space and subjectivity: the art of living 78 2.3 Theorising mental health care spaces 82 2.3.1 Societies of control 82 2.3.2 Heterotopias 88 2.4 Conclusions 94 Chapter Three 97 Methodology 97 3.1 Service user voices 98 3.1.1 Power: service user and professional knowledge 101 3.2 Research Design 103 3.2.1 Research Questions 104 3.3 First Person Narratives 105 3.3.1 Descriptions of the narratives 108 3.4 ‘Spatial Interviews’ 114 3.4.1 Visual methods 117 6 3.4.2 Participatory mapping 121 3.4.3 Spatial Interviews 124 3.4.4 Participants 126 3.4.5 Procedure and ethics 127 3.5 Analysing Materiality. 134 3.5.1 Thematic Analysis 135 3.5.2 Coding and analysis procedure 141 Chapter Four 146 Heterotopias of control: space and subjectivity in community mental health care 146 4.1 Utopias and heterotopias of community care 146 4.2 Heterotopias of the ‘control society’ 149 4.2.1 Making heterotopia visible: materiality on the ward 152 4.2.2 Community mental health buildings as distributed heterotopias of control 156 4.2.3 Moral management: material positioning of dangerousness 160 4.2.4 Modulated subjectivity in the community 164 4.3 Heterochronicity 170 4.3.1 Heterochronicity of community services 174 4.4 Conclusions 182 Chapter Five 184 Concordant and discordant experiences: finding a place for distress in community and service use spaces 184 5.1 Discordant distress: experiencing distress in public space 185 5.1.2 Visible discordance: attracting control practices 189 5.2 Concordant distress: home as a ‘safe haven’ 193 5.2.1 Managing a distressed self: the material ordering of home 195 5.2.2 Contingencies of home as a “safe haven” 200 5.2.3 Spatial modification: using space to mediate experiences of the home 202 5.3 Disclosure: concordance and discordance in mental health service buildings 207 5.3 Concordance, discordance and disclosure in community spaces 212 5.4 Conclusions 217 Chapter Six 219 Displacement and Movement 219 6.1 Movement and community care 219 6.2 Self-confinement: retreat into private spaces 220 6.2.1 Production of a rational self in the workplace 222 6.3 The drive to be outside: movement as a modulation of distress. 225 6.3.1 Displacement: problematic encounters in public space 231 6.4 Constrained movement in the psychiatric ward 238 6.4.1 Patterns of movement on the ward 241 6.4.2 Movement off the ward: compliance and conformity 246 6.5 Conclusions 249 7 Chapter Seven 251 Discussion and Conclusions 251 7.1 Summary of findings 251 7.1.1 Research questions and key insights 255 7.2 Reflexivity and validity 261 7.2.1 Participant group: gendered and classed management of distress 263 7.2.3 Diagnosis and the categorisation of experience 272 7.3 Critiquing the social inclusion agenda 274 7.1.4 Conclusions and future directions 282 References 286 Appendices 326 Appendix One: Advert 326 Appendix Two: Participant Information Sheet 327 Appendix Three: Consent Form 328 Appendix Four: Interview Schedule 329 8 Preface Like many students, I chose to study Psychology due to an ambition to be a Clinical Psychologist. Having studied English Literature at undergraduate level, I wanted to do something more ‘concrete’, imagining I would learn ‘facts’ discovered by ‘science’, which would enable me to be able to ‘cure’ people of their problems. Of course, I quickly realised that Psychology, and the field of mental health more generally, is a far more complex, contested (and interesting) enterprise than I had envisaged. Where I had expected to find ‘facts’ there were instead competing, often incompatible theories, supported by varying amounts and kinds of evidence. With no small thanks to some inspiring mental health teaching, I learned that nearly every widely accepted ‘truth’ I had come into my degree ‘knowing’ (such as ‘schizophrenia is incurable’ and ‘depression is caused by a lack of serotonin’) turned out to be based on little evidence, more a matter of ideology than ‘science’.

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