GEOG 726 – GEOGRAPHIES OF HEALTH AND PLACE

ESSAY:

Do ‘Therapeutic Landscapes’ play a pivotal role in analysing the relationships between ‘health’ and ‘place’?

Joshua Arbury

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The concept of a ‘therapeutic landscape’ is fairly new to health geography, first introduced by Gesler (1992, 1993, 1996 and 1998) to describe the ways that people have traditionally sought healing powers in certain locations. This notion has been adapted throughout the last fifteen years to include a much broader concept of both the therapy provided, and the landscape within which such therapy occurs. (Williams, 1998, 2002; Wilson, 2003; Casey, 2003; Kearns, 1993) In their broadest sense, therapeutic landscapes are “those changing places, settings, situations, locales, and milieus that encompass both the physical and psychological environments associated with treatment or healing; they are reputed to have an enduring reputation for achieving physical, mental, and spiritual healing” (Williams, 1998: 1193). As such, they bring together both ‘health’ and ‘place’, in analysing the way in which certain places influence health status – potentially either in a positive or negative manner. Although initially therapeutic landscapes were associated with particular material or symbolic aspects of places such as baths, (Gesler, 1998) places of pilgrimage, (Gesler, 1996) health camps, (Kearns and Collins, 2000) and hospitals (Kearns and Barnett, 2000), more recent research claims that more familiar places such as the home (Williams, 2002) and garden (Milligan et. al., 2004) can provide therapy as well, in an everyday context. Much of the increased diversity of what a therapeutic landscape means can be traced to the increasingly broad definitions of both ‘health’ and ‘place’, encompassing more humanistic theories. In this essay I will argue that indeed therapeutic landscapes do play a pivotal role in understanding how health and place interact, and how landscapes can affect health and wellbeing. Through using examples of therapeutic landscapes, and how they explain the diverse interrelationships between health and place, it becomes clear that “the use of therapeutic landscapes within health geography is important because it provides us with an alternative way of viewing the link between health and place. It allows us to shed the geometric and locational approaches to space and place by embracing more meaningful perspectives that view places as symbolic systems of healing” (Wilson, 2003: 84) Effectively, therapeutic landscapes provide us with a framework to analyse how health and place interact in our “reformed, post-medical geography of health” (Kearns, 1993 cited in Williams, 1999: 3)

The concept of a therapeutic landscape originally arose from observations that certain sites have obtained reputations as places of healing throughout human history. Therapeutic locations have had strong links to ‘nature’, through a perception that nature is the provider of medicinal cures, both physically and psychologically. Indeed, “there is a long tradition that healing powers may be found in the physical environment, whether this entails materials such as medicinal plants, the fresh air and pure water of the countryside, or magnificent scenery.” (Gesler, 1992: 736) In particular, water has been one aspect of the physical environment which has been a source of healing for many societies, providing curative and restorative powers since classical Greek and Roman times. (Gesler, 1992) Along with nature’s obvious physical healing capabilities, much of the focus for therapeutic locations has been on how ‘nature’ can improve psychological health and wellbeing. This is particularly the case for people living in urban environments – characterised by pollution, overcrowding and a high-stress lifestyle – and many traditional therapeutic locations were designed as places where people could escape their everyday lives. (Conradson, 2003) There were many spas located outside major U.S. cities in the nineteenth century that clearly catered to this demand, and were associated with the perception of pastoral cleanliness and social neutrality; in direct contrast to the pollution and class consciousness of urban society (Gesler, 1992). Whilst the use of spas has lessened over time, “the perception that urban places are relatively unhealthy and rural areas relatively healthy has persisted throughout the modern period of rapid urbanisation”. (Gesler, 1992: 737) Therefore, settings such as wilderness areas and even urban parks maintain popularity with those living in urban areas, by providing opportunities of solitude, contact with nature, and the viewing of scenery, (Hartig et. al., 2003) which contribute to the therapy of those people in that location.

Environmental psychologists have also used notions of ‘therapeutic landscapes’ to understand how and why people react differently to different landscapes. Empirical evidence indicates “that environments differ in how well they support cognitive restoration, as measured by improvements in self-reported positive and negative mood states, and psychological indicators such as reduced blood pressures and lower levels of stress hormones” (van den Burg et. al., 2003: 136); while Hartig and Staats (2003: 103) go further to say “…how restoration proceeds owes not only to the characteristics of the demands faced and the individual who faced them, but also to the sociophysical and temporal characteristics of the environment subsequently available for restoration.” Moreover, “moderate depth, moderate complexity, the presence of a focal point, gross structural qualities, and natural contents such as vegetation and water can evoke positive emotions, sustain non-vigilant attention, restrict negative thoughts, and so aid a return of autonomic arousal to more moderate levels.” (Hartig et. al., 2003) These studies show that ‘places’, whether physically, socially or culturally defined, can have clear, quantitative, effects upon not only the ability of people to recover from a disease or injury, but also their ability to maintain health within such environments.

However, many of the therapeutic benefits of natural locations not only arise from their physical characteristics, but also through their particular meaning to those seeking therapy. In effect, there is ‘more’ to these locations than simply the vegetation, water and clean air that is most obviously present. Therefore, it is necessary to look at a ‘landscape’ as being more than simply a ‘location’ – and at how ‘place’ is different to ‘space’. Such distinctions reflect a more humanistic view of landscape and place, and can provide incredibly valuable insights into how therapeutic landscapes can link the two concepts of ‘health’ and ‘place’. Firstly, a broader definition of ‘landscape’ is needed, to encompass many of the broader meanings that can be associated with places. Gesler (1992: 743) proposes that landscapes should not only be defined as the result of interaction between human activity and the environment, but should be seen as “the product of the human mind, and of material circumstance” encompassing the relationships among people, as well as between people and societal structures. Therefore, the reasons for “rural places being frequently constructed as therapeutic in opposition to urban places as sites of physical and moral decay” (Kearns and Collins, 2000: 1049) are just as related to the symbolic nature of both rural and urban landscapes as they are to the actual physical nature of these two contrasting locations. Natural landscapes often have positive symbolic meanings to people, and associations of peacefulness, relaxation, restorations and rejuvenation. Frequently, there are individual relationships with these particular places that can be used to either communicate qualities of the self to others, or how they symbolise emotional ties between the individual and that ‘place’. (Williams, 2002)

Clearly, such a broad definition of landscape reflects the broad geographic concept of ‘place’, and can be applied to the many spaces from which people’s lives are constructed, rather than just natural environments away from daily life. The concept of place is quite distinct from ‘space’, as places are subjective and can be shaped by each individual who encounters that particular ‘place’. Indeed, Relph (1976: 43) succinctly describes this subjectivity of ‘place’ through saying that “the essence of place lies in the largely unselfconscious intentionality that defines places as centres of human existence. There is for virtually everyone a deep association with and consciousness of the places where we were born and grew up, where we live now, or where we have had particularly moving experiences. This association seems to constitute a vital source of both individual and cultural identity and security.” As a result, all places can theoretically become therapeutic landscapes if they have the right set of circumstances that can create a therapeutic ‘sense of place’. A ‘sense of place’ ascribes particular values to certain spaces, which can be shaped and reshaped by the individuals who encounter that particular place. “It is through lived experience that moral, value, and aesthetic judgements are transferred to particular sites which, as a result, acquire a spirit or personality. It is this subjective knowledge that give subjective places significance, meaning and felt value for those experiencing them.” (Williams, 1998: 1197) Thus, therapeutic landscapes clearly have a ‘sense of place’ associated with them that is either health promoting or restorative. However, such associations are not necessarily dependant upon any particular environmental attribute, and are more closely link to the individual or group that is constructing that place in their own minds. Subsequently, the concept of therapeutic landscapes can link health and place in a way beyond traditional ‘therapeutic spaces’ in the natural environment. This evolution of therapeutic landscapes is also clearly linked to changes in the way that ‘health’ and ‘therapy’ are defined, and the broadening of health from the biomedical model of disease, to one focused on the psychological, social and cultural aspects of ‘wellbeing’. Indeed, through analysing how a complex network of factors come together in the creating of health – defined broadly by the World Health Organisation as “a state of complete physical, social and mental wellbeing and not merely the absence of disease or infirmity” (Lee, 1982: 24) – as well as healing places, we can best understand what can be done to create therapeutic landscapes, in their most diverse sense. One example, of how the link between health and place has adapted over time to meet the evolution of the ‘therapeutic landscape’, can be seen in New Zealand children’s health camps – as explored by Kearns and Collins (2000).

New Zealand children’s health camps were initially associated with improving health through the therapeutic qualities associated with routine, instruction and rural tranquillity. “In the middle of the [twentieth] century it was widely accepted that the camps were national treasures whose existence symbolised New Zealand’s commitment to the well-being of children and helped to ‘maintain its supposed position as world leader in health and welfare’” (Kearns and Collins, 2000: 1048). Health camps were established in New Zealand in 1919 by Dr Elizabeth Gunn, as a way to improve the health of New Zealand’s children through offering them large meals, fresh air, sunshine and gentle exercise – in response to worries that there were a high percentage of unfit people in the country that could lead to ‘racial deterioration’. (Kearns and Collins, 2000) Furthermore, health camps were seen as ways to combat diseases such as tuberculosis, which was “widely regarded as a disease of civilisation, and its treatment was deemed to require a ‘return to nature’.” (Kearns and Collins, 2000: 1051) However, in recent years funding cutbacks have placed the future of health camps in jeopardy, and the camps have had to expand their focus to providing social as well as physical wellbeing – often through ‘taking in’ disadvantaged children. Camp managers now re-assert the therapeutic qualities of the health camps, not only at a physical level through the engagement with nature, but by claiming that all aspects of camp life are therapeutic, particularly providing children with ‘time out’ from stressful situations and family problems. Indeed, camp users including both children and their caregivers, state that “…the very process of removing the child from their environment has been reported to be one of the programme’s strengths” (Dumble, 1999: 14, cited in Kearns and Collins, 2000) Thus, health camps use the concept of therapeutic landscapes to clearly illustrate how particular places can have positive effects upon health status among children, not only physically through their interaction with nature, but also psychologically by removing them from a stressful environment. Placing them in an environment with a much more positive ‘sense of place’ resulted in benefits not only for the children involved in the camp, but also for their caregivers.

A positive ‘sense of place’ can also create therapeutic landscapes in other locations, most obviously the home, which “without exception… is considered to be the ‘place’ of greatest personal significance in one’s life – ‘the central reference point of human existence’” (Williams, 2002: 145) Although hardly thought of as a ‘therapeutic landscape’ in its traditional guise, the home appears as the most logical landscape which can provide therapy. Many patients recovering from hospitalisation consider that the real healing only begins once they are back in familiar surroundings. “In the case of palliative care, research suggests that families, similar to patients, prefer the home environment to the hospital environment”. (McWhinney et. al., 1995; Seamark et. al., 1995) This preference is generally based upon the notion that the home facilitates normalcy, self-direction, sustenance relationships and reciprocity, important aspects of the healing process. (Williams, 2002) “Such an environment is understood to be an individual’s ‘personal home’, providing an integrative network of physical, spiritual and psychological factors merging together to promote the creation of a healing and/or healthy place” (Williams, 1998: 1198). These include caring family members, as well as the home’s associated symbolism of security, privacy and familiarity – which can vary subjectively according to individuals – can prove to be an important factor not only in the healing process, but also in health and wellbeing maintenance. The decision of some mothers to have a home-birth can be seen as directly related to this concept of the home as a ‘safe’ place, which can be experienced without deliberate and self-conscious reflection, yet is full of significance. “Because planned home-birthing allows for personal control and individual decision-making, it also contributes to strengthening the sense of place inherent in the home” (Williams, 1998: 1198), which combined with the strong relationship between a midwife and the mother can create a therapeutic environment characterised by familiar surroundings and a friendly sense of place as well as strong networks of interpersonal concern among those present. Through the creation of this ‘therapeutic landscape’ the birthing process can be less stressful for the mother, further showing how deeply connected the concepts of ‘health’ and ‘place’ can be, as positive ‘senses of place’ can create better health outcomes. Conversely, if the home has a negative ‘sense of place’, which could be the result of a low standard of housing, overcrowding or domestic abuse, then there is likely to be a link between such an ‘unauthentic landscape’ and poor health. (Williams, 1998: 1198)

Unauthentic landscapes, or those that exhibit a negative ‘sense of place’, clearly have a negative effect upon health status, and can be seen as the opposite of ‘therapeutic landscapes’. These landscapes incarcerate, quarantine and exclude people, and are perceived as unfriendly, hostile or sterile. Somewhat ironically, hospitals – the basis of healthcare provision in most developed nations – are often perceived as being unauthentic landscapes. “From a users’ perspective, hospitals are often understood to be unauthentic because they are perceived to be hostile environments which reduce and individual’s locus of control.” (Williams, 1998: 1198) Indeed, the symbolism associated with hospitals creates the ‘sense of place’ – whether positive or negative – which surround these institutions, creating meanings and emotions attached to mere ‘bricks and mortar’. “As a result, what would otherwise be a mere hospital space could be considered as a place with its own abiding history and idiosyncratic layout. A room would no longer be a mere space for speedy convalescence but a place with a distinctive ambience in which the experiences of previous patients were somehow inscribed – subtly infused into the very appearance of the place.” (Casey, 2003: 2245) As the creation of caring environments can be seen as very important in facilitating health and restoration, making traditional healthcare centres, such as hospitals, have a friendlier and more ‘authentic’ environment could lead to significant improvements in the therapy and recovery of those in hospitals. One famous study by Urlich (1984) showed how the view from a hospital room, to either a brick wall or a group of trees, could have a significant impact upon therapy and recovery. “In comparison with the wall-view group, the patients with the tree view had shorter postoperative stays, had fewer negative evaluative comments from nurses, far fewer moderate and strong analgesic doses, and had slightly lower scores for minor post surgical complications” (Urlich, 1984: 421).

There have been attempts by some medical institutions to create environments that are friendlier and more ‘authentic’. One example is the Sioux Lookout Zone Hospital, which serves the aboriginal population living in the northern reaches of the Canadian province of Ontario. This hospital allows family and friends to reside in the hospital so that they can spend prolonged periods of time with the patient in an attempt to create interpersonal positive interpersonal relationships with family, friends and practitioners that can lead to the provision of continuous social support. (Williams, 1998) The rise of alternative birthing environments, either in the case of birthing centres or in-hospital birthing rooms that attempt to replicate the home environment, is another way in which networks of interpersonal concern as well as creating a familiar built environment are being used in medical institutions to improve the wellbeing of those within the institution. Surveys show that women regard a home-like environment in the delivery suite as important. “Similar to home-birthing, the presence of family and friends contributes greatly to the authenticity of such environments, which is also achieved through incorporating general home furnishings, such as comfortable chairs, windows, and soft lighting.” (Williams, 1998: 1199) Yet another example is Auckland’s Starship Children’s Hospital, which was designed specifically to create a space-efficient yet child-friendly building that tries to remove traditional ‘hospital’ symbols such a long, straight corridors and sterile, white walls. (Kearns and Barnett, 2000) Indeed, “the award winning design of the Starship is characterised by pastel colours, the use of all-wool carpets throughout the wards and waiting areas, and space for children’s artwork on the walls” (Kearns and Barnett, 2000: 84). Such features mark a radical departure from the efficient, sterile environment traditionally associated with hospitals, and attempts to create a landscape which is therapeutic to children, complete with rocket-like lifts, as well as green astroturf and wooden benches in the atrium – reminiscent of a city park, and even a McDonald’s restaurant. Even the name ‘Starship’ deliberately attempts to de-emphasise the institution’s medical purposes, instead creating a ‘landscape of excitement and curiosity’ in the place of traditional ‘landscapes of fear’ that children associated with hospitals. (Kearns and Barnett, 2000) These attempts to modify either the built environment of the hospital or the interpersonal relationships that occur within the hospital are clear indicators of the way in which the creation of a ‘therapeutic landscape’ in such institutions has been deemed a useful way to encourage the recovery of patients.

With medical institutions giving credibility to notions of therapeutic landscapes, it is important to question whether resources invested in the creation of ‘authentic’ environments is worthwhile and effective. On a merely physical basis, changes to the built environment that create something more ‘friendly’, such as the Starship, are not likely to lead to shorter hospital stays and faster recovery for child-patients; perhaps spending that money on extra staff or equipment would be a more effective use of public money. However, as “the concept of a therapeutic landscape is concerned with a holistic, socio-ecological model of health that focuses on those complex interactions that include the physical, mental, emotions, spiritual, societal and environmental” (Milligan et. al., 2004: 1783) the concept of therapeutic landscapes potentially fulfils many of the wider aspects of health, related to the WHO definition. Especially when one considers the humanistic aspects of creating a therapeutic landscape – giving a central role to active human awareness and creating a positive ‘sense of place’ attached to the medical institution – the likeliness of people returning to that same institution in the future could be affected. If there is a strongly negative ‘sense of place’ attached to a hospital, or other healthcare centre, as is quite possibly the case at many under-funded public hospitals around the world, then people may decide not to go to these places in emergencies, creating the potential for disaster. On a personal note, recent experiences with both the maternity and emergency departments at North Shore Hospital – maternity having been recently redeveloped to incorporate many of the ideas associated with ‘therapeutic landscape’; while the emergency department remained a traditionally sterile and forbidding environment – brought home what a difference at both a psychological and physical level a positive ‘sense of place’ can have. Therefore, as the concept of a ‘therapeutic landscape’ can effectively highlight the links between place and health status, it can be a useful tool for those constructing health promotion activities.

Health geography, as distinct from medical geography, is concerned with moving beyond the medical model to provide insights into the links between health and place. (Williams, 1999) The concept of therapeutic landscapes clearly plays a pivotal role in any understanding of this relationship between health and place, most obviously as ‘therapy’ is both a process of health restoration and a process of health maintenance, while ‘landscapes’ referred to in the literature have a direct correlation to ideas about ‘place’, whether through people’s ‘sense of place’, symbolic landscapes, or notions of authentic, and inauthentic places. In effect, the term ‘therapeutic landscapes’ could theoretically be replaced by ‘healthy places’, with no great change to its meaning. Thus, “although the growing interest in the metaphorical notion of therapeutic landscapes may be related to the reclamation of health as a quality rather than a commodity, it may have more to do with the rejection of the biomedical model, and a simultaneous acceptance of the socio-ecological model of health and/or holistic health paradigm, which views the inclusion of diverse causal agents in disease and health – a complex interaction of physical, mental, emotional, spiritual, environmental and societal factors.” (Williams, 2002: 149) Through incorporating wider perspectives of both health: as a state of complete physical, psychological and social wellbeing (Lee, 1982), and place: as constructed not only by the interaction between people and nature, but also as a result of the conflict between human agency and societal structure, health geography can use the concept of therapeutic landscapes to reveal an enhanced understanding of both the meaning and nature of place with respect to health and healthcare. (Gesler, 1993; Jones and Moon, 1993; Kearns, 1995; Kearns and Joseph, 1997) Therefore, it is impossible to separate ‘therapeutic landscapes’ from any attempt to analyse health and place, in respect to modern health geography, meaning that it definitely does play a pivotal role in the relationship between the two concepts.

List of References:

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