‘I am in my Own territory, when I’m at home’: Shifting Meanings of Geographies of Care

1. ‘I am in my Own territory, when I’m at home’: Shifting Meanings of Geographies of Care Rubina Jasani, Laura Griffith, Sarah Pemberton, Martin Commander, Hannah Bradby, Sashi Sashidharan and Scott Weich

2. Why Place? • Sizeable number of people were homeless. • Interviews conducted in respite homes and temporary housing. • Most of the Service Users, we saw ended up in hospital. • After hospitalisation, service users spent time at home, till they were ready to re-integrate into the community. • Question - How is place experienced and lived when you are unwell? What role does place play in recovery?

3. Literature • Research from geography, epidemiology and public health shows, where people live significantly affects their health outcomes. (Macintyre et.al 1993, 1997; Ecob et. Al 2000 and Picket and Pearl, 2001). • Homelessness and High levels of mental illness (Gill et al., 1996; Hodder et al., 1998; Commander et al., 2002; Griffiths, 2002) • Research has shown, how people with mental health illnesses are more likely to experience housing problems and that those who experience housing problems, such as homelessness, become more vulnerable to stress related illnesses (Pleasence and Balmer, 2007) • Despite the shift of acute care from in-patient wards to people’s homes (Williams: 1999, 2002; MHA:2007), relatively little is known about the role of place in recovery from acute mental illness (Gessler: 2005). • This paper builds on William’s (1999, 2001) and Gessler and Parr’s (1996, 1999) work on therapeutic geographies.

4. Context • Part of a larger study, looking at service users experiences of care within Heart of Birmingham (HOB) area of the city (November 2006 - July 2007) • HOB - Recruited from three home treatment teams (Sparkhill and Sparkbrook, Handsworth Ladywood and Smallheath) • Covered eight wards in the City. • 79% of the population from ethnic minority background, as compared to 29.6% of Birmingham.

5. Method • Mainly Qualitative. • Semi- Structured interviews, using topic guides. • Aim - To understand Service Users explanations of their illness and their perceptions of the care they were receiving. • A section on everyday lives, daily routines and activities around the area and time in hospital. • These discussions led to chats about community and context. • Supplemented with detailed fieldnotes taken by the researchers. • 110 Service Users contacted; 40 interviews conducted and 12 carer interviews conducted at settings of their choice.

6. Analysis • Nvivo 2.0 • The broad coding categories - Construction of the Community, Housing, Local Environment, Childhood Environment and Time Spent in-patient care. • Responses classified into - positive and negative and neutral to their local area. • Simple coding, was then grouped into four categories - everyday spaces, therapeutic spaces, time in inpatient care and what constituted a place. • Ethnicity is not seperated out, but allowed to emerge as a category in the way narratives have been put together. • General Observations based on emerging patterns, quotations were selected, from the text of the interviews, which were believed to be representative of the data.

7. Results • Lived and therapeutic landscapes of the service users got radically altered during a psychotic episode. With the focus of acute care changing, from in-patient units to home treatment, home emerged as a therapeutic space in ways that it has not been analysed in literatures on public health, disability and social geography. • Housing related problems - living in temporary accommodation or being declared homeless after a psychotic episode affected the recovery of service users’. These served as additional pressures to their recovery and re-integration back to the community.

8. Results, continued • Service user’s experiences of place were mediated by their experiences of migration, social class, childhood and family experiences, age, gender, physical location, ethnicity as well as experience of illness  (what stage of recovery the service user was on).  • There were differences in the ways in which participants born in the UK, related to place and community in comparison to the migrants. Participants born in the UK had a better sense of entitlement when it came to services.

9. Lived Everyday Spaces - Neighborhood • Moral and material deterioration of their surroundings. • Descriptions of certain neighborhoods as ‘bad places’. • Despite the problems, familiarity with a particular locale - having grown up in a particular place, having lived in a particular place or having re-created a particular context made it endearing for its residents. • During periods of illness, sense of insecurity heightened because of worries about the insecurities of living in ‘bad places’. • It was observed that there were differences in the ways in which participants born in the UK related to place and community as compared to those who had migrated at different points in time

10. Therapeutic Landscapes - Home • In some cases, place/ home became the primary irritant in the spiralling of the illness, and in some others, it became a huge component of their recovery after the illness. • Having housing problems, living in temporary accommodation or being declared homeless after a psychotic episode emerged as a key theme. • Home acquired new meaning after the episode because of the immobility imposed after the illness. • Not only the physical aspects of one’s space, but also the complicated living settings and the external environment (community and pressures of performing specific cultural gendered roles, have an impact on health).  

11. Time in Inpatient Care – ‘Inevitable Hell’ • Hospitalisation inevitable. • Resistance to medication – Wanting control over their lives. • Use of force – ‘manhandled by two beefy blokes’; ‘prison style camps, that they have got’ • Hospitalisation necessary, but not sectioning. • Negative hospital experience; happy with Home Treatment (HT). But, instances, where Service users complained about HT, not being taken seriously.

12. Time in inpatient care • I2: You were in the hospital for less than six months? • R: Yes and then I was manhandled by someone from the hospital. Like I was manhandled and then they took me to a… They took me downstairs. Two people grabbed hold of me and they gripped me they took a hold of my arms. They tugged them and really funny like, you know…stretched them and bending them and everything like that and then they took me downstairs and then…that’s because… I don’t know why they took me downstairs like that, like…you know…manhandled me and everything and I tried getting a solicitor to sort it out but the solicitor didn’t know anything and then they took me downstairs and they put me away downstairs like…and then they kept me downstairs for a little while and then they took me back upstairs again. • I1: Yes. • R: But it’s still there – still lingering on. It’s [in my] mind…controlling my whole mind, like. • (British Pakistani, Male)

13. What constitutes a place? • Nicholas : Just somewhere where I can live totally independently. I am not bothered by race, creed, colour, or anything like that. Just somewhere where people can leave me alone and I can get on with my own thing. • Having things to do on a regular basis and easy transport access to services. • Weatherspoon pubs, as the new day centres. • Stigma, Gender and Culture mediate understandings of place. • Ethnicity and ethnic diversity, an important component of place – Eastern European, prefers Handsworth because Aston is ‘mono-cultural’.

14. Implications for Policy • Homelessness and irritants related to the built environment could be avoided by providing co-ordinated and continuous care that is integrated into the existing social lives and networks of the service users. • The need for understanding ‘home’, as a therapeutic space. • Stigma, community structures and gendered constructions of social roles should be kept into account while dealing with housing needs of service users. • The need to further unpack concepts like ‘community engagement’ and the use of ‘social capital’ as heavy handed policy tools, in the light of the isolation experienced by service users and complicated relationships with the community experienced after a psychotic episode.

15. Limitations • Heavily relies on narratives, which made the connection between place and health. • Silences, not to be ignored because in their engagement with services, lived environment was not a part of the medical narrative, they had learnt to tell. • Recruitment through HT; researchers, an extension of the biomedical model. • Power Dynamic – Impacted upon the responses we got. • Carer perspective missing.