Title

Othering Boundaries: Rural Geography and Mental Illness

Author Details
Christina Martens

Correct Reference
Martens (2002)  Othering Boundaries: Rural Geography and Mental Illness, International Journal Journal of Rural Psychology, Vol. 3, No. 12, URL http://www.ruralpsych.com/PracticeForum/PF-Martens.html

This tour is meant as a study trip. An exploration into how ideas of mental illness and rurality come together. We will see who the major tour designers are and what their promotional material looks like. As with any tour, there can be surprises along the way and also questions that remain unanswered. Hopefully, you will find a location that you like and choose to spend a while there. This is a difficult trip. The vistas challenge us, as visitors, to look past the glossy promotional material to the reality of life underneath.  To fully expose the intricacies of rural geography and mental illness, we need to appreciate the tour as presented by the guides but to also ask what is being left out. 

I prepared for this trip like any other. I packed my bags full of the literature, prepared my itinerary (outline), and proceeded to travel as a tourist through the geography of mental illness. Being a tourist, I needed no attachment to the landscape, only a sense of wonder and willingness to be led by the tour guide. The guides each have their own interpretation of the particular highlights of the tour. I am willing to be led, like most tourists, and am comfortable that the tour guides will not allow me to come to any harm. I am, after all, a paying customer.

Day 1 – Itinerary

Today, we will travel through the clean regions of the medical views of mental illness. We will consider the diagnosis of deviancy and spend some of our time at schizophrenia, as it provides an interesting vista. For this journey we will use as our guide the photocopied information from the Diagnostic and Statistical Manual Vol. IV that was sent to you. There are also many web sites that you can peruse at your leisure. We chose these as defining guidebooks because, although not written for lay people, they are more easily available for the general populace and the information is quick. Today’s tour is sponsored by the American Psychiatric Association, the publishers that bring you the DSM-IV.

**Note: As today’s tour is sponsored and led by the medical establishment, Doctors and Psychiatrists are the main guides. The tour is designed for the mass populace after having been approved by the medical establishment. A requirement of the tour is to follow wherever the guide leads.  Unfortunately today, we will not be venturing outside their boundaries, as this tour does not often consider location in relation to illness. Our focus will only be on the illness. Our goal is not to educate but to indoctrinate tourists into the landscape. The medical tour guides exert the most influence on what we expect to encounter in our travels through mental illness. The predominant packager of information, medicine covets its premier roll in our cultural understanding of this landscape and yet it is really not a tour designed for amateurs. 

Today’s tour is entirely focused on our relationship to deviance. A system of “normal” and  “other” is required in order to make sense of this social construction. Pfohl (1995) explains that “deviants never exist except in relation to those who attempt to control them” and this idea of control is evident in the medical paradigm surrounding mental illness. The highlight of this control is found in the naming, the categorizing of deviance through the imposition of diagnostic categories that then define the person, their actions, and subsequently their lives. These categories also determine the type and amount of stigmatization the person experiences when released back into the non-deviant society.  

“The practicalities of contesting psychiatric medication [and diagnosis] are immensely complex and difficult” (Parr 1999, 195). It is more socially acceptable to acquiesce to the power of the medical establishment than to seek out alternatives. At an even more profound level, Frank argues that it not merely acquiescence that occurs but colonization by the medical power. For him, it occurs when a person experiences incoherence in their experience and the medical establishment, with its façade of legitimacy and saviour-like publicity, readily steps in to create a version of coherence out of this chaos (Frank, 1999).  His diagnosis, his categorization into medical terminology “was a medical flag, planted as a claim on the territory of my body” (Frank 1999, 52). And this process remains unchallenged by our society and by individuals. Even Frank acknowledge “if the treatment works, the passivity is worth it” (53) and brutally underscores the innate desire of the person to be back where they existed before illness crept into their life. It shows our acquiescence to the perceived role of medicine in our culture and our fear of incoherence as a state.

This power of categorization and naming, then, creates a virtual identity that overshadows the individual’s self-defined identity. The virtual identity can acquire some social credibility if it responds in an accepted manner. Here the virtual identity takes on the form of the institution as container of the deviant and creates its own social relationships (Parr 1999).

“Behavioral health care professionals call disorders, illnesses or diseases that have prominent emotional, behavioral, and psychological symptoms mental disorders” (“Mental Disorder”, www.behavenet.com). With these symptoms and the resulting diagnosis of mental disorder, the person is thus “reduced in our minds from a whole and usual person to a tainted, discounted one” (Goffman 1963, 3). And through this reduction, stigma is created which “constitutes a special discrepancy between virtual and actual social identity” (Goffman 1963, 3). The whole person is recreated as the sum of her symptomatology and this external imposition reinforces the power of the medical model. The creation of this virtual identity, that of the deviant, assists the medical model to gain compliance from the individual in the treatment of the illness through social pressure and the assertion of specialization. This specialization lends a preciseness to deviance – not simply mental illness, but schizoaffective disorder; not cancer but lymphoma. It further reduces the colonizing forces of the medical establishment to a select few who specialize in that exact disorder and forces the person with the illness further away from an understanding of the whole. The body has been fragmented into healthy/not-healthy,  and now the illness, too, is fragmented. The map of the body is torn into shreds making it harder and harder for the person to gain his or her bearings in relation to the whole. 

The terminology of “disorder” is in direct relation to our view of deviance. If a person is deviant they are out of order in our society, this person is “other” to our view of what is “normal’ and must be looked after or managed in order to control.  “We construct a stigma-theory, an ideology to explain his inferiority and account for the danger he represents” (Goffman 1963, 5). To effectively manage this perceived threat, we feel the need to classify by some form of recognizable and repeatable criteria by which we can identify persons that are deviant. The circularity of reasoning is evident here. Classification leads to diagnosis which leads to stigmatization which then leads back to control through medicine, the creator of classification of mental illness.

In the DSM-IV there are 404 various diagnoses, many of which are considered “disorders”, that classify “strictly in terms of patterns of symptoms that tend to cluster together” (FAQ, www.psych.org , 2) and the primary purpose of these classifications is “to facilitate communication among mental health professionals [and}…provide a convenient shorthand when communicating about patients” (FAQ, www.psych.org, 1). It is important to note that these diagnostic criteria are for speaking about the deviant not to the deviant and are used “by mental health professionals from a variety of disciplines and backgrounds for a wide variety of purposes, including clinical, research, administrative, and educational” uses (FAQ, 1). Proof of deviancy through classification is achieved by the use of these diagnostic criteria that have met the test of empiricism.

In revising the DSM, the American Psychiatric Association states “ new categories were only considered for inclusion if there was significant data available to allow critical consideration of the relevant merits and risks of inclusion” (FAQ, 2).  The attainment of this data is achieved from within the psychiatric community as they have the authority required to present the data as valid and thus the evaluation never escapes the controlling desires of the medical model. And although the psychiatric community recognizes that there are risks to inclusion and that “sociological and other considerations must also be taken into account” (FAQ, 2), the reality of stigmatization as a result of diagnosis is underscored in favour of treatment and compliance consigning the individual to inhabiting the virtual identity and social level created for the deviant. By considering this process carefully, it becomes clear that a truly fascinating sleight of hand occurs. While removing control of the naming experience from the individual, the medical paradigm then turns back the locality of the deviance to the individual. All control over the situation is removed from the individual but the consequences remain for the individual to integrate into a significantly altered life.

However, even the medical/scientific community display rifts in their agreement, in their interpretation of the data. In the case of schizophrenia, it is clear that not only is definition is problematic but so is causation. “Some theorists maintain that schizophrenia has a specific cause, although they disagree on what that cause is. Others use the diagnosis in a very broad way, almost interchangeably with psychosis.” (About Schizophrenia, www.bio.metu.edu.tr,  Pp. 2).  What is clear about mental illness is that in order for a person who is having difficulties to access service they must fall within certain diagnostic criteria, controlled by a body of evidence outside of their experience. In effect, they must conform even before diagnosis to a view of deviant/not-deviant to even explore what is happening. In this regard, the creation of deviance through to treatment is predetermined by a model that does not consider the whole individual in their landscape nor the ramifications on the individual but instead sections off pieces of the individual for specialists to map and define. This leaves the individual outside of the entire process without the knowledge of how to get back in and without a terminology to describe the incoherence of their experience.

A major feature of the medical model is the determination of cause. Whether the cause of mental illness is a product of upbringing or social class, a chemical or electrical imbalance in the brain or genetic, (About Schizophrenia pp. 12-17) the resultant diagnosis facilitates the removal of responsibility for and active participation in health decisions from the individual, much like a child under the care of a parent.  It also enables the creation of a categorization of victim (if the cause is seen to be outside of the person’s control) or villain (if the cause is seen to be the result of the individual’s own actions). The naming of villain is especially true if the cause of the mental illness could be in any way linked to drug usage, sexually transmitted disease, or any other defined- as-deviant behaviour.

Foucault (1973) documents a range of care throughout history of those considered mentally ill. The main themes behind the varieties of era-determined models of institutional care are the ideas of isolation and the power of segregation. One model saw towns driving those considered deviant “outside their limits; they were allowed to wander in the open countryside…” (8). Other models were institutions that locked the deviant away from the non-deviant population. Whatever the model, the idea was the same. Institutions, begun to house the economically inactive, the lazy and the ill, became “the geography of haunted places as in the landscape of the moral universe” (57).  The trend of institutional closure and the idea of community care is a contemporary continuation of the landscape that Foucault highlighted only the walls in our era consist of medical interventions; the segregation and isolation of the individual remains. The use of assertive community treatment plans, whereby the person who is diagnosed with a serious mental illness is cared for in his or her own home through intensive interventions by mental health professionals, has gained increased acceptance by funders and ultimately by mental health organizations. Medication compliance and the reduction of hospitalizations are touted as the greatest benefits of this form of care. The walls of the institution are replaced by the walls of an apartment or house. Best practices papers (The Clarke Institute of Psychiatry) highlight the cost savings in having clients conform to their medication regime in that it reduces the use of costly hospital services. Interestingly, but not unexpectedly, the voices of people with the illness are not heard in this discourse. Best practices research come from reviewing the literature of the specialty, similar to the method used to update the DSM. The person is described as “the schizophrenic”, the “manic-depressive”, the “obsessive-compulsive”. The illness becomes the main defining characteristic of the person, the virtual identity, and other identity is lost. The person is discussed as if they are not present, as a “case” not a person. Research is based on outcome measures, data collection, and process measures highlighting the medical model’s roots in scientific methodology. Key diagnostic criteria in the DSM are designed for mental health professionals to converse with each other, not with the person with the mental illness. The deviant is only the portrayal of symptomatology and is not an active participant in diagnosis. Their role is of passive acceptor, the item of discussion, the unit of data.

And while there is serious effort by the survivor movement to fight such things as assertive community treatment and forced electro-shock therapy, the control over diagnosis and care is firmly in the control of the medical establishment. The simple naming of their cause as “survivor” reflects the sheer effort it takes to maintain their actual identity in light of the mental health community’s impressive control over the creation of the virtual identity of mental illness.   “The assumption [in the medical model]…is that the individual body, which is at fault, can be treated by largely medical interventions and technologies” (Butler and Parr 1999, 3). The villainization of the body or mind, depending on opinions of cause, deflects criticism from the model that creates it to the individual that presents it

The medical model of disability is rooted in an undue emphasis 

on clinical diagnosis, the very nature of which is destined to lead 

to a partial and inhibiting view of the disabled individual” (Brissenden, 

cited in Butler and Parr 1999, 3).

With this “othering” of the person using diagnosis complete, we can then see how this experience is then overlaid upon geographical prejudices created in urban environments which typically view the “rural” as other.

In terms of serious mental illness and persons living in rural locations, US research indicates, “ the prevalence of clinically defined mental health problems among rural and urban adult populations is similar” (Kessler et al, 1994 cited in National Rural Health Association May 1999). And while occurrence numbers may be similar in rural and urban populations, what is not similar is the access to and availability of care, which is seen by health organizations as detrimental to the person experiencing illness. There are few other benchmarks by which rural service, whatever that may be for the individual, are measured against. Services and then the evaluation framework of those services are established in urban environments and overlaid on a rural location without consideration of some fundamental differences. Wrinkles to this methodology are seen as products of rurality, not in the flaw of design that assumes transferability. This is the overarching bias of urban views. If it works or doesn’t work in our environment, then the same should be true of rural environments.  Urbanites even get to determine what is rural and this issue and how rurality affects those with mental illness is considered in the tour presented by the geographers.     

Day Two – Itinerary

Another action-packed day! Today, we take a special trip with the aid of the spatial arrangements of the areas we are about to visit. This visit is unique to Social Construction tours as the scenery is dense, loaded with difficulty, and led by Social Geographers. Specializing in looking at landscape and how it affects those who live there, the leaders today will show you a side of the world that you probably never considered. Your view of the world will change, the landscape will shift before your eyes and you will begin to understand the political creation of rurality. Today’s tour is sponsored by the American Society of Geographers.

**Note: Today’s tour is organized and led by academics, the social geographers and may not be of interest to those seeking first hand experience of the rural mentally ill. Not considering the majority of the populace, the directions can seem obscure and the language used to describe the landscape is difficult. Travel without a terminology book is discouraged, as there are no other signposts on the journey in case you should get separated from the group. Unfortunately, most of the tour guides are from urban areas so please be on the lookout for urban bias in the writings. Our goal today is to integrate what we learned on the medical tour within the context of geographic location to see if there are any nuances of place that affect how we view mental illness and people who live outside of the boundaries of urban realities. 

Today we venture out into the rural areas surrounding our compound. But first we encounter what seems to be the greatest debate in this region: what is “rural”. Although different measurements of “rurality” are used, the majority of tour guides agree, “rural areas…are often described as being peripheral to urban cores in terms of a variety of factors, such as level of economic activity and access to resources” (Gesler et al. 1992, 1).  The lack of access to service, remoteness of living accommodation, lack of “qualified personnel”, and transportation difficulties are isolated as identifiers of rurality (Gesler et al, 1992; Alun, 1992; Ilbery, 1998; Furuseth, 1998; Smith, 1977). Still there is, however, a perception that rural means idyll “an open and clean environment, free of the stress and pathologies associated with fast-paced urban living” (Furuseth 1998, 233).

So here in our tour, we have another dichotomy. First we encountered the normal/deviant mind in the medical tour. Now we face the rural/urban and idyllic/flawed debates even before we leave on our tour. Our personal perceptions of the rural impact the tour. Halfacre (1983,  cited in Ilbery 1998) identified four approaches to defining rural which have been very useful in the design of this tour. Here rural can be seen as: “descriptive which assumes the existence of rurality and empirically describes, through the use of different parameters and measures, its socio-spatial characteristics;  sociocultural, which assumes that (low) population density in some ways affects behaviour and attitude; locality assumes a distinctive type of locality defined according to those characteristics that make them rural, either the specific geography or the main economic activity; and a social representation that relates to lay discourses of rurality and the words and concepts understood and used by people in everyday talk.” In this final approach, attention turns to how the rural is perceived by the inhabitants; it is a still a social construct because the emphasis is placed on how the occupants of rural spaces view themselves. This consideration of self-perception and definition was lacking in the tour on the first day, while the consideration of social environments and their impact on the individual, while considered, are biased by an urban view of how those social environments are structured.

The first attitude towards rurality, that of empirical distinctions, closely resembles the model of the medical community in their reliance on measurements and parameters predefined by those not affected by the definition. The second and third definitions highlight some urban assumptions that colour the representation of rurality. The first is the quaintness of community and that its small size necessarily changes the way people relate to each other. And while it may be true that rural communities do view themselves as distinct and different from urban areas, the difference lies in the balance of power to impose a particular definition. When the definition comes from outside of the community being considered, the colonization viewed in the medical model of the individual’s body grows to the meta-level and replays that conquest substituting urban for medical and rural for individual. The separation of rural areas into economic activity zones or specific geographic features reduces community to factors of its whole self, much like the diagnosis of deviance reduces the individual to inferiority. 

Although the definitions of “rural” are the subject of debate, each of these presented definitions has inherent in its argument aspects of the idea that “rural areas are designated by exclusion” (Hewitt 1992, 52), by their comparison to urban areas for the unveiling of what is missing, by what is not urban. Statistical surveys such as the Census in both the US and Canada define populations in terms of numbers and while many researchers acknowledge the problems of definition and strive to “[extend the] definition of rurality to more adequately identify differences” (Dottl and Greenley 1997, 312), they also acknowledge that in order to “allow for comparison of [their] results with other findings” (312) they retain the definitions provided by census derived statistical definitions of rurality.

Statistics Canada “for census purposes utilizes factors related to population density to determine rurality” and “population density [is] frequently being employed as it is readily available and practical” (Parikh, Wasylenki, Goering, & Wong, 1995, 63).  And “many federal policies…rely on dichotomies of rural/urban designations” (Gesler et al. 1992, 22) so that these definitions, while determined outside of the community being examined, exert enormous power over the community and its study.  This is very similar to the dichotomy of normal/deviant that is used in the medical establishment, with the urban being the normal way of living and rurality being viewed in the deviant position. It also facilitates the removal of power and determination from individual or community control to an outside entity.

In much of the academic work surrounding mental illness and rural geography, we encounter a social science method of explanation. The data we encounter shows “both historical and recent evidence …that rural residents have more serious and severe health problems than their urban counterparts. These problems are often compounded by poverty, poor nutrition, substandard housing, occupational hazards, and limited medical resources” (Gesler et al. 1992, 11) and yet as Hewitt (1992) points out the definition of “rural” impacts how health problems are approached. Even the definitions of health problems that rural areas experience are created in urban centers and imposed upon rural situations through a process that begins with research on urban problem. This is then translated onto rural areas that, as acknowledged, have far fewer of the urban defined services required for health. This methodology threatens to miss entirely community designed responses to illness and removes the possibility that a community will learn through the incoherence of illness how to regain coherence and meaning for themselves. This vital aspect of growth increases community resilience and leaves a legacy of confidence.  How then do urban-designed programs function within this different environment? Assertive community treatment, introduced by the medical tour guide, is one such program that shows serious disadvantages when implemented in a rural location, especially when it is implemented from a larger regional center (Fekete, Bond, McDonal & Salyers 1998). The distances that need to be traveled to meet clients may be great, the need for personnel might be higher per capita than in an urbanized environment for safety considerations and lack of staff collegiality concerns many researchers (Roberts, Battaglia, & Epstein 1999; Badger, Robinson & Farley, 1999; Merwin, Goldsmith & Manderscheid 1995). And while stigmatization, not effectively dealt with in the medical information, is considered in the social research of geography and mental illness, the assumptions and questions highlight some potential urban prejudices of rural behaviour such as the perceived “high regard for autonomy and self-help” (Esters, Cooker & Ittenbach 1998, 470).  What is perceived by rural dwellers as a strength, their self-sufficiency, is viewed by the urban researcher as a barrier to treatment. It is unclear whether or not researchers consider these traits as unique to rural inhabitants but evidence suggests that the differences in the rural experience is related to stigmatization and results in the delay of rural inhabitants to seek care thereby being more ill upon diagnosis (Kane & Ennis 1996).  It is interesting to note, that research indicates that the health of rural residents depends more upon political and economic realities than on social relationships and cultural expectations and yet the emphasis on explaining the regard for autonomy if firmly located within the social context. Rural residents have historically experienced political and economic isolation that is possibly the reason for the desire for self-sufficiency. The choice of focus upon social and cultural contexts instead of political and economic arenas mirrors the naming procedure we viewed on the medical tour when smoke and mirrors assumes the power of authority to name and yet leaves the stigma with the individual.

When we consider that despite the “growing political influence of nationally recognized consumer groups, rural mental health service delivery has yet to be impacted” (Bjorklund & Pippard 1999, 347) we see how deep the urban focus for service extends. Consumer groups designed in urban areas and underutilized in rural communities require trained personnel and a significant number of consumers with adequate access to transportation. Ironically the identification of being a mental health consumer is usually required by the program and yet sets up a probability of social isolation for the individual from the community at large. The stigma is directed at the association with the medical diagnosis and the individual, as we have seen, is reduced to being the container of this diagnosis. The “stigma surrounding a psychiatric diagnosis is often magnified in a small community as opposed to a larger urban area” (Bjorkland & Pippard 1999, 350) not because the bias of small communities is greater but because the medicalization process attacks a main cultural survival mechanism, a person’s autonomy. It is the colonization of the person by an outside force in a time of incoherence that creates a backlash response. Self-sufficiency may be a cultural expectation of urban researchers looking at rural locations while it also, with decidedly differing definitions, may be viewed as desirable by rural residents. The threat exists in the perceived conquest of one definition, the lived experience of the rural, by the presumption of “otherness” by the urban. This necessarily creates fear and apprehension.  Intriguingly, studies into the effect of this cultural expectation in urban residents are absent from the debate. Where there is room for growth is in the discussion around definitions and how those definitions came into being.

As Philo (cited in Ilbery 1998, 4) points out “not all people living in rural areas conform to the rural idyll of a white, heterosexual, middle class male who is able and of sound mind”. If this is true then, how much more marginalized is the rural woman of colour, or the low-income male with illness? How are our decisions on service provision limited by our inability to leave the fairy-tale countryside? Our impressions of the rural, whether it is of the idyll or of the disenfranchised other, inform how we respond to problems encountered there. In much of the academic writing, we are hearing from the professionals, university trained, most often urban, who study the rural as the ethnographer studies foreign cultures. The inclusion of the voice of the rural individual is evident in very little of the writings.

And if we view the rural as idyllic, our decisions on how to spend diminishing health care dollars will be very different than if we look with an openness to difference. The stakes are extremely high for rural regions that face cuts to their already scant service. In urban areas, those needing service might be inconvenienced by the closure of a service agency while in rural areas, the service agency may be the centre of the community, providing very crucial health care needs. “A full array of community services is universally recognized as a fundamental ingredient in rural development programmes” (Furuseth 1998, 236). The universe that recognizes this fact again shows the overlapping an urban bias on the inadequacy or rural service delivery and justifying potential cuts. “The view of urban America by urbanites and suburbanites seems to be one of incredulity. One seems to know that good mental health care could not possibly be delivered under such primitive conditions as isolation, provincialism, social immaturity and the absence of ‘specialty care’ professionals” (Kane & Ennis 1996, 450). This view of rural service provision as primitive and immature is ironic and has the potential to become a self-fulfilling prophecy as it becomes the urban justification for rejecting requests for service. This judgment is the voice of the urban and the rural are portrayed as the hapless victims of the whims of governmental reorganization.

Rurality exists on a continuum of dichotomies, from the impoverished to the rich, and the isolated to the connected. These dichotomies exist in urban areas but rural dwellers experience this on a smaller population scale with more geographical land mass. It is not the severity or treatment of physical or mental impediments that defines rurality, but the geographical, cultural and economic landscape in which these populations exist. Unfortunately, “rural services are pulled back as decision-making processes are focused upon…the higher costs of providing rural services” (Furuseth 1998, 242). Coupled with the uneven political power realized because of low population density, these services are primary targets in eras of fiscal restraint.       

What is evidenced here is not the lack of service use nor of the demographics of the population that changes rural service provision. It is how the problem is defined and by whom it is defined that interprets the economics and cost of providing services to geographically dispersed populations. And rural communities, because of their lower population density have less political clout than larger and denser urban populations. The voice of rural people, barely audible in the academic writings, is a mere whisper in the political landscape. And while the “urban poor are a highly visible fixture of life in the industrialized world…the rural poor…are becoming more invisible” (Furuseth 1998, 242). This invisibility makes it possible for the political agenda of cost containment to reallocate rural service dollars to the more visible urban populations.

The stigma of mental illness and the tendency of rural people to put off seeking help from identified mental health professions combine to make it easier for the political climate to remove mental health services from rural locations while still appearing to offer them through the centralization of service in regional cores. This distancing of service provision completes the distancing of the individual from the community that is started with diagnosis and association with the medical tour. The colonization of the body and the landscape is complete. What is left is for the people to discover a voice within the lexicon of the colonizer to express their experience and to gain back the lost coherence.

Butler and Parr (1999) state that “by acknowledging the problems and possibilities of naming and aligning such experiences of mental health problems, chronic illness, and physical impairments, [social geographers] seek to destabilize what [they] see both as a limiting mind-body dualism in human geography and a reluctance fully to reveal or to critique the myth of the perfect mind/body” (2). That they are reuniting the mind and the body within the consideration of rural geography is indicative of their attempt to reform the “two basic models (social and medical) which inform disability studies” (Butler and Parr 1999, 1) but also looks at decreasing the separation of individual and community, of trying to find that lexicon to describe experience to a culture that views them as “other”. Looking at the continuum of rurality overlapping the continuum of disability, these ranges they reveal that the term “geography of disability [is] a broad term capturing a wide range of interests, theoretical orientations, and empirical studies” (6). This is the third overlapping continuum in their study. The concern is that in the of making distinctions between different types of disabilities, between different types of geography, between different types of methods of study, we allow the categories to acquire different value levels and consequences that are then played out within the wider societal structure. It is the specialization that we viewed in the medical tour that effectively shuts out the individual. This is the pinnacle of victim naming/villain naming; of being able to accept a disability because the person was not at fault for causing it, or of being able to accept a physical disability more easily over a mental disability, or thinking that mental illness is not as common, or is more common, in the countryside. It tears up the map of experience and throws the pieces to those who can only decipher bits of information. The individual and the community as whole entities are lost. What Butler and Parr describe is a way to glue those pieces back together and to do that, the person or the community has to be involved as only they have the history required to recognize the whole when it is complete.

To view the continuum of disability without social value placed on the various segments “is to deny that such difference has to equal a series of fixed and othering boundaries by which people are clearly defined and geographies are narrowly understood” (Butler and Parr 1999, 9). This springing of the definitional boundaries flies in the face of the raw categorizations of the medical establishment. It removes the superficial boundaries laid upon the landscapes and allows a clearer and more personal look at the lives of the people living with differences. It removes the need for a victim or villain and looks at the situation as a variety of life, of which there are many. The inclusion of multiple voices in the discussion allows for the reintegration of the individual and the community and shifts the power of naming away from the colonizing forces back where it originally existed.

Day Three – On Your Own

Today you are left on your own to ramble through the rolling countryside. You may wish to visit on your way, the William Wordsworth cottage and view the romantic vistas from his window. Another stop of interest is the home where John Clare was born. This is a more run-down home and a bit out of the way but the view there is 180° from the Wordsworth cottage. You might also wish to try to engage the locals but a word of warning; they can be difficult with tourists and may try to challenge you. That said it is even hard some days to find a local to talk to. For this day, you may even wish to remain with the tour group and play cards in the lounge. If you do venture into the landscape, please be aware that the tour group is not liable. A map of places that you may wish to avoid is located at the front desk.

Note: This tour is a recent addition to our package. It was included on the request of previous tourists who wished to see more of the local experience. This is the first time we have been offering it in conjunction with the other tours and there are still some bugs to be worked out. While we have endeavored to present a wide choice for travel, the locals remain hesitant to participate. Our hope is that the vistas that you experienced previously will find some context in the day to day lives of the people who remain here and we can judge from this how accurate the promotional materials from other tours actually is and how our personal experiences affect what we gain from our travels. 

As the previous two tours have highlighted through omission, the voices of people who experience the incoherence of illness are not often heard in literature directed at researchers. They are, however, heard in Literature. The main difference is that in capital “L” literature, the entire process is seen as subjective, of one person’s experience or imagination. But if we are to cease the colonization by specialists, we must begin to consider the whole person. Expressions of experience and imagination, then, are integral pieces for our understanding. Bloom (1994) asserts that “in strong writing there is always conflict, ambivalence, contradiction between subject and structure” (27) and this allowance of things not expected or even dreaded is what is lacking in the tours of the first two days. Literature allows for difference, even exalts in it, uses it to shock, to stimulate and ultimately to understand. It is a process of gaining coherence that examines its ugliness and beauty both with equal interest. So this is where the tour will lead, into the cottages of some people who write. Some are famous, some are not. This does not matter. What does matter is the expression of experience which allows us see outside of our colonized borders into another country.

At the Wordsworth Cottage, I see where my expectations for the idyllic countryside have their origin. I remember from earliest days:

                                    “I wandered lonely as a cloud

                                     That floats on high o’er vales and hills

                                     When all at once I saw a crowd

                                     A host, of golden daffodils;

                                     Beside the lake, beneath the trees

                                     Fluttering and dancing in the breeze.”

But looking at this again, in this cottage, I am struck by the singularity of the experience; by the aloneness, one person viewing nature, a nature that is beautified and adored. There seems little link between humanity and nature here. Nature is a deity standing apart from the human. It is too perfect, clean, still, and I know that this poetry has shaped my expectations of the natural, of the rural; the idealized and beautiful, the aspiration of every city dweller, the place where all things are in harmony. This is my postcard to send home: “Having a wonderful time. Wish you were here”. This is the poetry of the tourist, enchanted by the countryside but not a part of it.

I search through the cottage for something that is not so much a postcard. I find the “Ruined Cottage”.  Finally, a view not so idyllic nor familiar.

                                    “I rose and turned towards a group of trees

                                    Which midway in that level stood alone.

                                    And thither come at length, beneath a shade

                                    Of clustering elms that sprang from the same root

                                    I found a ruined house, four naked walls

                                    That stared upon each other. I looked round

                                    And near the door I saw an aged Man,

                                    Alone, stretched upon the cottage bench;

                                    An iron-pointed staff lay at his side.

                                    With instantaneous joy I recognized

                                    That pride of nature and of lowly life”

Still there is the tourist looking at the “lowly life” glorified, personified in the “aged Man” but at least here there is the recognition that the rural world is not just a postcard of beauty. This is the opposing urban view of the rural, of the less than, of the “other”. The separation of tourist and toured is still evident and there is little personal engagement required other than the recognition of a scene. The cleanliness of the rural finds its first chink, a glimpse into the reality of life evident in the ruined house and the naked walls. All is not idyll. What is obvious is that this is not defined by the aged Man, the rural dweller, but by the urbanite, the educated, the poet.

Looking for a different view, I walk over to John Clare’s cottage. Clare spent the majority of his life writing from inside of an asylum. I read in his biography that “the place was for him a refuge as well as a confinement for he was treated kindly allowed to wander about the countryside, and encouraged to go on writing his verses; some of his best achievements are the poems composed in his madness” (Norton 1999, 907). The notion of the asylum as refuge challenges my “learned” beliefs about institutionalization and this new experience is intriguing. Maybe here we can find the attachment and inclusion. He writes:

                                    “I am – yet what I am, none cares or knows;

                                        My friends forsake me like a memory lost:

                                     I am the self-consumer of my woes –

                                        They rise and vanish in oblivious host,

                                     Like shadows in love’s frenzied stifled throes

                                       And yet I am, and live – like vapours tossed

                                     Into the nothingness of scorn and noise,

                                       Into the living sea of waking dreams,

                                     Where there is neither sense of life or joys,

                                        But the vast shipwreck of my life’s esteems;

                                     Even the dearest that I love the best

                                        Are strange --  nay,  rather, stranger than the rest.

                                    I long for scenes where man hath never trod

                                       A place where woman never smiled or wept

                                    There to abide with my Creator God,

                                       And to sleep as I in childhood sweetly slept,

                                    Untroubling and untroubled where I lie

                                       The grass below, above the vaulted sky.

The longing in this poem is palpable.  The desire for a childhood sleep untroubled by adult cares, built on the “shipwreck of his life’s esteems” is total experience, which incorporates many dualities.  I am still a traveler here but at least in the Clare cottage, I get a sense of the struggle with illness and seeing in nature, not salvation but meaning, the description of his experience in a way that is understandable to others.

Looking out the window of this old cottage, I notice construction underway. I walk across to a new cottage and notice that it has many rooms and many voices. These voices, too, are describing their experience. These experiences are far removed from the canon that recognizes experience but portray the dualities that we are seeking to combine in a form that is less tourist and more traveler.

While Clare is the epitome of the rural dweller negotiating his existence within the medical paradigm and rural reality, his voice is merely a whisper in the Canon compared to Wordsworth. Turning then to survivor poetry, we seek new voices to see if rural living informs their experience.

I can hear the music cats play
melodies and harmony
sacred notes in disarray
a chorus plucked from a broken piano choir
a choir of haunted souls

The enchantress of unholy salvation
purifier of thought
pontifical to a God of love

Mirrored minds the son of thee
disappearing twisting images

My mind outcasts friends
and mends broken ends

Copyright © 2001 Colin Van Der Woude ( www.poetrysz.net))

In this cottage, the writers speak for themselves. Without acceptance into the canon of accepted experience, their publication depends upon their initiative as survivors. Here we view up close the cultural values portrayed as rural revealed by the geographers. While their existence in rural localities in never clear, the cultural value they exhibit should at least offer them honorary resident status. These writers write against the existing tour and it is only right to let them speak here for themselves.

Bio:

I'm a 24 year old writer from Tassie Australia...was diagnosed with a mental illness at the tender age of 14...I write about thoughts and experiences, mainly at night when I'm too tired to reach for a pen. I have written poetry since the age of 15, a year after being diagnosed with Schizophrenia... used to also be an artist but my creativity in that area was "haloperidolised" and I gave up painting a year ago. Writing is now my main creative outlet.

This tour guide is different from the other cottages. The “twisting images” are reminiscent of the Wordsworth cottage’s “clustered elms” springing from the same root. It is interesting to see past the twistedness to the ruined cottage that it disguises. But the new cottage and the new writers use that twistedness to “mend broken ends”. Their expression comes not from being accepted but from wanting to be accepted without abandoning the reality they experience.

Turning around, I notice another voice:

Keep on digging up brand new ideas
  facing the day of hell on earth which is New Year's Eve
Locked up with no chance of parole or receiving visitors
  then comes the day when all emotions disappear for good.
I never realised i was in hell until it was too late
  but we all live in one kind of hell
You can't go outside to play when it's pouring with rain
  because there are more puddles than jackets.

I watched the explorer once as he was exploring
  i could run fast but he could always run much faster
And i screamed aloud but he could always scream louder
  now i am walking down this lonely road alone.

Desperation has once again entered into my life
  if i listen hard enough i can hear God laughing at me
Sometimes it's as if even the poetry seems incomplete
  maybe i finally have become my own worst enemy.

Why work when you can play?
if you think you know the real me sorry you don't,
When it isn't good but as good as it's ever going to get
with 456 poems written ten times over.
I'm never what you expect to see
what monsters in my head giving false answers weekly,
Acts of pure weakness hang around like smells from a lavatory
eyes see but not always the truth.

it is possible to live without knowing it
kiss the wind and those liars play their cruel games,
One day every answer will show itself loud and clear
for now i believe this game is real.
Every one of us born with a killing instinct
as mighty as the devil can make a sound,
The truth hurts me like a knife deep in my soul
life is a cruel game and i must find the missing link.

Copyright © 2001 Rae Burton (www.poetrysz.net)

Bio:
I am 30 years old and i suffered a nervous breakdown a few years ago which lead to a few problems but it also brought a new strength to my writing as i find it easier writing down my thoughts and feelings than actually speaking. Although i am no longer considered at risk to myself and no longer have to hear the b.s my shrink threw at me the thought of suicide goes through my mind everyday but i have learned to fight it .

The traveler is engaged by the visceral quality of these images although at the same time acknowledging their difference to their own experience. The language is clear and the need to fight prominent. That they have been altered by the system which defines and controls their reality is foremost a survival mechanism proven out through their biography notes. Although geography is not an apparent aspect of these two experiences, the linkage of mind/body and experience reveals a metaphorical geography that is more singular and more personal. Here we realize that geography is not only locational and related to landscape but considers the individuals place and perceptions of control over their space. Interestingly, Milligan (1999) highlights the fact the “local geographies of mental ill health are also shaped by the interaction of individuals with their social and spatial environments” (229).  This reversal of the shaping forces of the interaction between the mentally ill and their environment suggests research that remains to be completed.  They describe the effort back from a colonized existence using a language that those still colonized or yet to be colonized can understand. They also impact the colonizer as the rawness of emotion and quality of their voice force competing definitions into the vernacular.

Day Four – The Way Home

We hope that you have had an interesting trip with us. This is by no means an inclusive tour and we encourage you to return another time to view more vistas.

This trip has focused on the production of “otherness” in terms of mental illness and rural geography. While the medical tour maintains its supremacy over the control of the production of mental illness through its categorizations and diagnosis, the geographer’s tour is striving to include the considerations of how we view and place boundaries on social situations. The inclusion on this tour of the poet’s voice shows how those most affected by these considerations respond to these boundaries. Each of the tours that we did take is affected by the political will of the larger nation, although the evidence in some is more visible. Choices for type and extent of care are resigned to cost-effectiveness and cost-benefit decision-making tools following the cyclical patterns of economic will. Any control that was afforded to the presented tours comes directly from the political/economic tour. What we saw as the experience of an individual with mental illness when the medical tour usurped personal power and control in favour of diagnosis and classification becomes our experience in the political and economic paradigm.  The recognition that we share experiences with people with mental illness, experiences of the loss of power and lack of control in areas of basic need is an area requiring significantly more research and has the potential to reduce stigmatization through the acknowledgement of the otherness found in all of us.

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