Rural mental health and social geographies of caring

Social & Cultural Geography, Vol. 4, No. 4, December 2003

Rural mental health and social geographies ofcaring1

Hester Parr1 & Chris Philo2

1Department of Geography, University of Dundee, Dundee DD1 4HN, UK;2Department of Geography, University of Glasgow, Glasgow G12 8QQ, UK

This paper contributes to an emerging geographical literature on the social geographies ofcaring. Drawing on recently undertaken empirical work in the Scottish Highlands, personalaccounts about the provision of both formal and informal care for people with mentalhealth problems are evaluated. The notion of ‘community care’ is critiqued, as too areclaims about how rural and remote rural locations engender particular configurations ofcaring roles, practices and relations. It is shown that geographical distance, social proxim-ity, stoic cultures and rural gossip networks all have a part to play in how caring occursin such places. The paper concludes by suggesting areas of future research.

Key words: mental health, caring practice, roles, relations, formal and informal care.

Introduction

To ‘care’ for someone is a complicated socialact. Geographers have recently become increas-ingly interested in the politics and practices ofcaring, and in thinking through how care is aspatially differentiated activity which spansboth formal and informal realms of public andprivate life (Cloutier-Fisher and Joseph 2000;Gesler and Kearns 2002; Gleeson and Kearns2001; Gould and Moon 2000; Halseth andWilliams 1999; Kearns 1991, 1997, 1998;Kearns and Joseph 1997; Milligan 1998, 1999,2000; Mohan 1995; Robson 2000; Robson andAnsell 2000; Williams 1999a, 1999b). Geogra-phers of health, in particular, are active in

re-examining spaces of caring in ways thatbuild upon, but certainly differ from, the tra-ditional ‘health care’ foci of an older medicalgeography. There is a move away from re-search and analysis that constructs mappedspatial distributions of formal health care re-sources and access patterns, towards theorizingcare and caring relations in ways that highlightdiverse political and economic processes in-volved in care restructuring. At the same time,community empowerment and social organiza-tion around declining care services start toattract attention, as well as the experience ofreceiving care in its many different forms.These recent developments also dovetail withother work which has interrogated the notion

ISSN 1464-9365 print/ISSN 1470-1197 online/03/040471–18 2003 Taylor & Francis Ltd

DOI: 10.1080/1464936032000137911

472 Hester Parr & Chris Philo

of ‘therapeutic landscapes’ (Gesler 1991, 1998;Williams 1999b), environments fostering sensesof well-being and ones that, in the most widestof senses, can be considered to be places andspaces which involve caring relations of varioussorts. These developments are facilitating anuanced (if not all that sustained) appreciationof ‘care’ as a concept, although there is perhapsa lack of attention to important empirical de-tails about caring roles, practices, knowledgesand relationships, as they are negotiated andplayed out within and through space (but seeDyck and Kearns 1995; Robson and Ansell2000). This paper explicitly focuses on theseelements in telling the story of particular ‘ge-ographies of caring’ and as such seeks to buildon the above in order to expand our under-standing of this important fact of social life. Inparticular, we want to explore further the ideathat care and caring are thoroughly social ac-tivities and always constituted by aspects of theplaces in which they occur. By using case studymaterial from a project on rural geographies ofmental health, we hope to elaborate this no-tion.

Kearns (1998: 227) is one geographer whohas highlighted social and cultural dimensionsof care by using the ‘example of health care ina remote region of New Zealand [which] pro-vides a “lens” through which more generalrelationships between place, health and socialprocesses can be examined’. That Kearns’swork has focused on the diverse relations, re-lated to matters of ethnicity, history and cul-ture, that surround ‘care’ (albeit formal careservices in this case) in a remote rural region isof significance to us. We intentionally want todevelop research that highlights how care inspecifically rural places can be argued to bemore than just ‘a medical interaction’ (Kearns1998: 236; see also Robson and Ansell 2000;Williams 1999b). Other research has high-lighted how ‘medically under-serviced rural

places are usually without the resources neededto address their services needs … and [this]forms an important motivational force behindself-help community organisation’ (Halseth andWilliams 1999: 41). The suggestion here is thatfor rural places in particular, care (health careservices, community care and care in the formof self-help) is configured in specific ways as aresult of the particular economic, political andsocial geographies of such locations. By high-lighting rural dimensions to social geographiesof care, we are deliberately developing ‘situatedunderstandings’ (Cloutier-Fisher and Joseph2000) of the relationships between health, careand place. Through the materials below, how-ever, we seek primarily to interrogate howaspects of the sociality of rural places contrib-ute to particular configurations of ‘care andcaring’ activities, asking about what this mightinvolve in terms of roles, relations, practicesand negotiations at individual and communityscales. Here, both formal and informal provi-sions of care are critically highlighted in waysthat elaborate the above research agendas.2

This paper interrogates the notion of ‘com-munity care’3 as an umbrella term that includeswide-ranging practices of formal and informalcaring related to people with mental healthproblems in rural areas. The materials dis-cussed have emerged from a project based inthe Scottish Highlands called ‘rural geographiesof mental health: experiences of inclusion andexclusion’.4 This project seeks primarily to un-derstand the ‘place’ of people with mentalhealth problems in different types of Highlandcommunity. We have sought to understand this‘placing’ through an appreciation of the socialand cultural milieux that frame experiences ofeveryday social life, primarily through the ver-bal accounts of the people themselves: namelypeople diagnosed with mental health problems.However, it is the carers of such individualsupon whom we are concentrating here. Follow-

Rural mental health 473

Figure 1 Selected service provision map. Source: authors.

ing a brief explanation of methods and dataselection, the paper draws on this project’sfindings to outline contextual aspects of thesocial and spatial relationships characterizingrural and remote areas of the Scottish High-lands. We critically consider accounts of formalcare providers that highlight how formal caringwork in particular rural geographies involvesculturally sensitive caring practices, negotia-tions of community membership and roles, andattempts to balance individual and collectiveexperiences of care. Interview materials frominformal carers of people with mental healthproblems are then privileged in order to elabor-ate further how caring in these localities is acontested social practice with difficult relation-

ships and negotiations occurring on an individ-ual, family and community scale. The paperwill conclude by offering thoughts on how thesocial relations that characterize formal andinformal caring are often uniquely intertwinedin rural communities, as well as briefly outlin-ing possibilities for future research on socialgeographies of care and caring.

Methodology and data selection

We have interviewed over 100 users of psychi-atric care in four Highland locations—Inver-ness and surrounds, Easter Ross, North-WestSutherland (NWS) and the Isle of Skye—cover-


ing a number of issues, including the perceptionand experience of care in its various forms (seeFigure 1).

Despite the key purpose of this researchbeing focused on the views of users, we havealso interviewed sixty-two providers of mentalhealth care in the same locations, and theseproviders include General Practitioners (GPs),Community Psychiatric Nurses (CPNs), socialworkers, psychiatrists and informal carers(family, friends, neighbours).5 Recruitment ofusers and formal care providers occurredthrough mental health teams, GP practices andrural mental health drop-in centres. Recruit-ment of informal carers was more difficult, andoccurred through the latter strategies andspaces, but also through snowballing and for-mal carer support organizations. That therewere difficulties in the recruitment of self-identified informal carers speaks to the issue of‘invisibility’ that surrounds this group, as weoutline further below. Interviews with formalcare providers, informal carers and users werecarried out by both authors and a researchassistant,6 and roughly the same numbers ofpeople in these categories were interviewed ineach location. In a deliberate attempt toachieve a more situated understanding of theinterviewees’ lives in rural and remote places,up to two months were spent in each locationcarrying out interview work, but also engagingin ethnographic research, primarily, but notsoley, focused around rural drop-ins for peoplewith mental health problems.7 All interviewswere analysed through the software packageNVIVO and anonymized for the purposes ofreport and academic writing. It is the views offormal and informal carers that we are mainlydiscussing in this piece, although some moregeneral claims about Highland social geogra-phies are supported with references to inter-views with users. For the purposes of thispaper, we are not fully drawing out the differ-

ences in caring relations and practices betweeneach of our four study areas, but rather wepresent key themes that traverse narrativesfrom the remoter rural parts of each. However,in doing this we draw most heavily on datafrom NWS and Skye, these being the mostremote rural locations. That such areas are notwell resourced in terms of a diversity of formalcare providers also explains why only specificproviders are represented in these areas, mean-ing that their narratives are drawn out dispro-portionately to those of other types ofproviders in other areas. In some ways, then,the narratives selected and represented herepoint to localized concerns, localized to theremoter rural parts of the Western Coast ofHighland Scotland, but we also feel that manyof the issues raised here are applicable to othertypes of rural areas, to greater or lesser degrees.

‘Community care’ and social geographiesof the rural and remote Highlands

When discussing mental health in rural areasthere is an interesting conceptual need to startthinking rather differently about that phrasecommonly associated with contemporary men-tal health issues: namely ‘community care’. Of-ten, it could be argued, when policy makers,journalists and even academics envisage com-munity care, they are thinking very much aboutan ‘imagined geography’ of community care: animagined ‘moral landscape’, as has recentlybeen discussed by Gleeson and Kearns (2001),of communities who are supposed to be able tocare. These could be interpreted as rather unre-alistic imaginings, given the realities of dis-charging psychiatric patients into rather‘uncaring’ inner-city locations and suburbanneighbourhoods. Inner-city locations are oftenmade up of fragmented individuals and groups,all leading disparate lives, and as such they are


places which might be characterized as physi-cally proximate but socially distant. In thiscontext, the term ‘community care’ often has aparticular meaning, really referring to the dein-stitutionalization and fragmentation of large-scale psychiatric care facilities into small-scalecentres, located in different neighbourhoods,rather than to any real approximation of a‘caring community’ wherein neighbours trulylook after each other and support local peoplewith mental health problems who come toreside in their street.

By contrast, community care is rarely envis-aged in the context of rural locations, even lessin the context of remote rural locations (but seeMilligan 1999). Yet, questions of ‘community’,let alone of community care, are here highlypertinent. In some rural places, exactly theopposite social–geographical relationships tothose in urban locations can arguably be foundin that people are physically distant fromneighbours (particularly in crofting communi-ties) but more socially proximate. This socialproximity means that neighbours five milesapart might know intimately each other’s per-sonal histories and biographies, family relation-ships and so on. The genealogy of an individualand their family is something collectivelyknown, placed, remembered and narrated byother community members, especially thosewho have long links with the area and residentsin question. This may have particular implica-tions for people who have experiencedemotional and psychological disruption. Cru-cially, though, we cannot assume that this so-cial proximity will always lead to more caringcommunities, especially with respect to mentalhealth issues. It is in such a social geographicalcontext of remoter rural places and communi-ties, therefore, that we begin to consider what‘community care’ might mean for people withmental health problems.

As discussed above, we are interested in the

considered reflections of those people who insome way, shape or form—as practitioners orinformal carers—have an input into construct-ing the meaning of mental health, illness andcare in different rural places. It is also possibleto appreciate how carers understand their carework as being mediated by or adapted to localconditions: the local geographies, the social andspatial proximities of crofting communities, thelocal understandings and attitudes towardsmental health and illness, and so on. In thissense we are concerned with how formal careand its delivery is infused by the social andcultural conditions within which it exists, as weshall see below. But it is also important tounderstand how care operates beyond the for-mal service, and here we are not just talkingabout informal caring as it is conventionallyacknowledged—although this is a concern—but rather are also seeking to understand howand if communities, especially small and re-mote rural communities, can care for theirvulnerable members through different forms ofindividual and collective actions. Conversely,we are also concerned about occasions whenthese caring practices do not exist, and whenlow-level expressions of support and inclusion-ary relationships break down or are never es-tablished because of more negative communityattitudes and cultural beliefs about mentalhealth and illness. The reality, of course, formany rural areas is unlikely to be one of aneither/or: either caring or uncaring. The storyis always more likely to be a messy fusion ofthe two, as the case studies below highlight.

The interview accounts below elucidate suchthemes, and are primarily drawn from researchin the remote and rural Highland locations(North-West Sutherland, Skye and EasterRoss), although cross-referenced with somesupporting comments from the rural surroundsof Inverness. In terms of formal mental healthcare, there is sparse provision in these areas:


for example, in NWS there is just the one CPNwhose client list covers patients from five GPpractices, and who is supported by a visitingconsultant psychiatrist from Inverness (a va-cant post in 2001). The clients are spread overan area of circa 100 square miles on single-track roads across hills, glens and around ir-regular coastlines, making service-access andclient support difficult. From interviews withboth the CPN and the five GPs, there is apalpable sense of a marginalized health service,poorly resourced and poorly understood by therelevant centre(s) of health care decision-mak-ing and resource allocation (Inverness and Ed-inburgh).8 The material reality which makesthis particular geography of mental health careis paralleled by social–cultural geographieswhich help to shape a distinctive provision ofcare by both the CPN and informal carers inthe area. The broad issues that colour thisillustrative example are replicated in the otherresearch areas in ways that convey complexrural spatial contexts to social geographies ofcare work.

As briefly outlined, these localities are onesin which social proximity is the norm: people’severyday lives and activities are highly visible,and, despite the physical distances involvedbetween neighbours, it is hard to keep secrets.If something happens, the local gossip net-works springs into action, and, as has oftenbeen said to us, ‘if they [community members]don’t know anything, they’ll make it up’. Thisis also a place in which people are accustomedto sparse services (of all kinds) and ‘getting by’is normal: there is a strong underlying dis-course about a regional Highland culture ofself-reliance, something flagged by care practi-tioners and users alike. When it comes toemotional and psychological problems, there isa sense in which people ‘soldier on’, often notdiscussing such things with neighbours andeven family, partly to avoid the gossip and

partly to avoid the perceived stigma that con-tact with formal services can bring, especiallyin a region which had as its only form ofmental health service provision for many yearsa widely feared asylum based over 100 milesaway.9 Undoubtedly, in sketching such a boldpicture we have not conveyed the nuances andcontradictions which are already apparent inour wider research results, but there is a sensein which these characteristics do contain a‘truth’ for many of the people to whom wespoke. These social and cultural characteristics,coupled with the material realities of limitedformal mental health care provision, are im-portant contexts with which to frame the ac-counts of care-givers below.

Formal caring

In rural and remote localities the burden offormal care delivery for people with mentalhealth problems falls mainly on GPs and CPNs.Whereas in urban locations people withemotional and psychological problems mightbe routinely referred on to a mental healthteam or a specialist consultant, in some remoteareas this option is seen as the one least pre-ferred, most obviously because of the distancesinvolved for the users of specialist services (thiscould be a 200 mile round trip to Inverness forclients in NWS, for example), but also becauseof the risk of stigma associated with such areferral:

From my point of view, I would try and cope, yes.

Yes I would, I would refer as a last resort. (GP(a),

NWS, 25 July 2001)

We’re taking more responsibility for … their care.

Obviously that’s relying on our experience and any

mental health training … And if we have any prob-

lems we try and find some psychiatrist in Inverness


who will give us some advice. (GP(b), NWS, 13 July

2001)

The consultant psychiatrist, who has just left the

post … wasn’t really interested in coming to the

remote areas … so what we have to do is see people,

diagnose people, medicate people, dispense drugs

and when in terms of the psychological treatment it

tends to be over to [the CPN]. (GP(c), NWS, 15 July

2001)

The lack of access to specialist services in ruraland remote areas means that ‘primary’ carestaff are disproportionally responsible for thecare of ‘secondary’ health care needs. Thisraises concerns about adequate levels of exper-tise, training and treatment decisions, and someGPs acknowledge that a side-effect of GP-basedformal care for mental health problems is oc-casionally a reliance on medication for dealingwith emotional matters which in other geo-graphical contexts might be dealt with by ‘talk-ing treatments’:

We don’t have the time, we do spend lots of

time … but we don’t have the time and the coun-

selling skills to deal with ‘I’m feeling a wee bit low

Dr’ … you know and there’s a temptation to say

‘right, try this and come back in a week’. There’s a

huge underlying pool of people who could do with

counselling if you like. Your traditional Highland

culture … you went to the minister, they don’t any

more, they come to the Dr. (GP(d), NWS, 18 July

2001)

Whilst the rural GP is undoubtedly an import-ant figure in the provision of formal mentalhealth services in the Highlands (at least interms of diagnosis and prescription), the ruralCPN is the key provider of daily and weeklysupport for people with mental health prob-lems. The CPN accounts indicate still more

clearly how social dimensions of geographicallocation impact upon their provision of care.All providers of care have to tailor their ser-vices to the local communities that they serve.In a very real sense both GPs and the CPNsinterviewed as part of this research projectwere conscious of the ‘local moral orders’ per-taining to social behaviour, recognizing howsuch orders infuse what is regarded as accept-able locally in terms of thinking about andresponding to all manner of health and illnessissues. This recognition linked in turn into thepractices of care adopted by these formalproviders themselves, practices which were, byand large, clearly attempting to be sensitive tolocally constituted cultural meanings and socialrelations surrounding ill-health. One CPNtalked of the importance of her being able tobuild the trust of her clients by guaranteeinganonymity in small communities where anon-ymity is such a fraught consideration, as al-ready explained in our outline comments onsocial proximity and gossip. She would go tothe lengths of leaving her car a mile away froma croft house in order that the recipient of carewas not at risk of being associated with her(for in small places where it is not unknown forpeople to follow and to identify cars withbinoculars, the CPN’s car would be instantlyrecognizable). By walking to her client’s home,and effectively trying to mask or at least toadjust her identity in her caring practice, she istaking seriously the weight of local feelingsabout psychiatric services and the associatedfear of stigma. Whilst accessing a GP for medi-cation may be fairly anonymous, the receipt ofcare from CPNs is clearly much more of avisible activity. In a region where culturalnorms include stoicism and non-disclosureabout health and emotional problems (es-pecially for self-identified ‘indigenous’ peo-ple10), this can be seen as a form of ‘risky’ carerelation. This local knowledge informs the


CPN–client relationship, then, and the ways inwhich care is delivered and received.

The perceived risks associated with caringrelationships in socially proximate rural areaslink not only to the CPN as a known mentalhealth practitioner, but also to the CPN as acommunity member. The community status ofa formal care-giver can impact on whether ornot a potential client will access a psychiatricservice. For example, for those CPNs who are‘indigenous’ to the places in which they prac-tise their care, this can act as both an advan-tage or a disadvantage:

I think there are advantages and disadvantages,

some people don’t want to see me because I am

local, some people do want to see me because I am,

because they don’t want to see someone who is

English or they don’t want to see someone who is

male. (CPN, Skye, 11 September 2001)

The notion that for some clients the ethnicityof the care practitioner is important relates tothe significance of the rural Highland context:for some ‘indigenous’ people, this will be re-lated to the presence of Gaelic language skills(being able to explain complicated emotionsthrough familiar vocabularies); for others, itwill simply be related to the implicit assump-tion that a Highland care practitioner will bemore sensitive to the social and cultural rela-tions surrounding illness, emotional problemsand the common (non)disclosure of these.Whilst we will say more about the communitymembership of the CPNs later, we wish toelaborate the notion that such practitioners(whoever they are) have place-based knowl-edges enabling different and culturally sensitivepractices of care.

Through interview and ethnographic materi-als, one CPN in NWS conveyed her consciousattempts to adjust her practice of care to localmoral orders, particularly in relation to gender

roles. She maintained that there are a lot ofhidden problems, especially relating to de-pression in the district, among men in particu-lar. A common and culturally acceptable wayto cope with these feelings (one continuallycited across the region by all respondents) wasthrough the (ab)use of alcohol, instead ofreaching out to the health services. For thisCPN, one way around this has been to seek toinvolve (when appropriate) male partners inher community visits to female clients, notexplicitly as part of a therapeutic discussion,but more through general conversation andother activities such as massage and aromother-apy. Through such practices, she can oftenmake connections with other household mem-bers, who, in some cases, begin to gain anawareness of, and hear about solutions for,their own emotional and psychological distress.This very informal practice is related in thefollowing interview extracts with service users:

Hamish: In little places like this … people don’t

speak about it … I was depressed myself for years

… but I never went to the doctor about it.

Ishbel: Oh yeah and what was your medication?

[sarcastic]

Hamish: I just tipped bottles down my throat for

years and I was doing it to a serious extent … but

people up here don’t want to accept that they have a

problem like that … It took me a long long time to

realize I was suffering from depression and in fact it

was [the CPN] who eventually pointed it out, wasn’t

it … You know, when I told her about how I was

leading my life [laughs] she couldn’t understand how

I could have gotten through it as what I did.

Ishbel: He still doesn’t take medication.

Hester: When [the CPN] comes to see you, do you

talk mostly about medication?

Ishbel: No not really, not now.

Hamish: But when she was coming first of all …

the first few times … she was dealing purely with

you [Ishbel], the depression and the medication, but


then as she saw Ishbel coming out and getting better

and her mood getting improved … it’s now like a

social visit …

Ishbel: And it involves the two of us.

Hamish: As Ishbel improves, it has become more of

an informal visit than the formal visit it was in the

first place.

[discussion of being able to pick up the telephone]

Ishbel: And now she’s helping Hamish with his

shoulders and back and everything, and you know

she’s special.

Hamish: You know she was the first person to

discover that I felt depressed from time to time.

Ishbel: And she’s very aware of his depression,

which it is …

Hamish: And the funny thing is, even though I know

her now, … I wouldn’t sit there and say ‘God I’ve

been feeling really depressed for the last week’. If she

started to ask me about it I might tell her, … but

I wouldn’t volunteer any information myself.

Ishbel: [laughs] It’s like drawing blood from a stone.

Hamish: But I don’t think I’m unique in that, I think

that’s the way you’ll find most of the indigenous

people to be I would think. (User and husband,

NWS, 15 July 2001)

Although these are lengthy extracts, they show,through the italicized words of the clients, howthe CPN has gradually engaged with the malemember of the household with regards to hismental health issues. Through this extract, theCPN is shown to be trying to work within thecultural possibilities and constraints that sheunderstands to exist around her practice ofcare. She has to be sensitive to these in order tobe able to assist a man like Hamish, realizingthat here perhaps more than in other placesmen and mental health problems are not sup-posed to have any relationship to one another,and also that a common male response to‘emotional stuff’ in this part of the world isindeed to seek solace in the bottle.

This gender dimension to care practices in

rural Scotland was highlighted by other (mostlyfemale) workers, who also discussed thedifficulties of caring for ‘indigenous’ maleclients and the different ways in which theysought to address their needs. Interestingly, it isoften the case that a female family member (inthis case Ishbel) acts as an important bridgebetween the formal care worker and the maleclient (emphasizing how formal and informalcare can mesh).11 However, some clients havealso raised the possibility of the need for more‘local’ male workers to deliver mental healthcare to men:

It almost needs like ‘a Hamish’ to go into these

homes … he understands the lifestyle … he is indige-

nous to this part of the world … he has lived and

worked this part of the world and he would be more

received … women would be more open … but there

are a lot of men … who suffer. (User, NWS, 15 July

2001)

Whilst the ethnicity, ‘localness’ and gender ofcare practitioners are clearly issues in ruralmental health care delivery, there are otherimportant dimensions to the caring role forrural CPNs. As mentioned above, issues ofcommunity membership and status impactupon care providers. In places where theirworking role may be very visible, formal carersare careful about their everyday interactionswith other community members:

I know from my own professional point of view I

keep a low profile. Most people they don’t know

what I do. They know I’m a nurse and I am in the

hospital. My close friends know. I don’t say I’m a

psychiatric nurse, because tomorrow their mother

could be referred to me … Maybe that’s wrong but

I feel I should be keeping a low profile. (CPN, Skye,

11 September 2001)

It’s about knowing your boundaries. I’m quite clear


where my work starts and where it stops. I think you

have to be absolutely clear, especially living in a

rural area. It’s very easy to allow these roles to be

blurred. That has happened. I’ve seen colleagues that

has happened to—it’ll destroy you. It means you

need to be able to say no to people, you need to be

able to say to people if they stop you in the co-

op … I have seen colleagues who are quite happy to

hold a consultation in the co-op and I don’t think

it’s at all appropriate. (CPN, Skye, 11 September

2001)

The difficulties of maintaining other com-munity roles apart from formal carer are hencepronounced in rural areas where mental healthcare practitioners may have to negotiate beingcustomers, parents, committee members andneighbours to the people with whom they areinvolved in therapeutic relationships (see Philo,Parr and Burns 2003; Roberts, Battaglia andEpstein 1999; Williams 1999b). Not only dorural care workers have to practise culturallysensitive care, they also have to manage dualworking and personal roles in ways that allowthem to interact successfully with other com-munity members on several different levels. Atthe same time, CPNs are realistic about the factthat ‘I think when you live in a rural area likethis, I think you have to give a bit more’ (CPNinterview, NWS, 29 July 2001), even discussinghow they become attached to particular indi-viduals, partly as their clients do not move onto other practitioners or parts of the service assuch facilities do not exist. For some CPNs, theinvolvement of their selves in care relationshipsbecomes more than just formal work, but alsoabout friendship, pleasure and companionship:

I think you get nurses that think ‘oh they’re nice’

and so they … it’s easy to have someone like that—

it’s comfortable and it’s maybe because they’ve been

such a part of the nurses’ life for a long time. (CPN,

Easter Ross, 28 November 2001)

In general, however, considerations such asmaintaining confidentiality, being discrete anderecting boundaries around working rolesmeans that ‘community care’ in rural areas ismostly about individuals receiving face-to-faceservices in isolation. This is the best way,favoured by clients it seems, for preventing anyleakage of information about their conditionfrom one domain to another.

There is little evidence from our researchthat particularly remote rural places are con-ducive to more collective experiences of care,such as are experienced through drop-in facili-ties, group therapy and self-help groups (al-though some do exist). Several CPNs spoke ofthe difficulties in establishing this kind of orga-nization of care:

They wouldn’t go—there would be a stigma there.

(CPN, NWS, 29 July 2001)

Y’know, I said ‘why don’t you meet in someone’s

house, you know every couple of weeks’. I said I

could come and do an evening—even theme it

around aromatherapy—but no—it never hap-

pened … it’s perhaps different in [the village] but in

the remote valleys, you know. (CPN, NWS, 15 July

1998)

Interestingly, because they find it difficult togroup clients together, this means that careproviders have less time to spend with individ-uals, especially when they are spread over alarge geographical area. Here we can see thatthe sensitivity to the components of socialproximity in the rural Highlands—namely gos-sip, fear of difference and cultural stoicism—perhaps mean that a more efficientorganization of collective care experiences isnot possible.

Despite these examples, this material shouldnot be interpreted as arguing that careproviders like CPNs are always battling against


local cultures and social relations in sociallyproximate places, as on occasions these pro-cesses do assist with the provision of care in thecommunity. CPNs from all areas have told usof telephone calls that they would occasionallyreceive from concerned community members,who have seen someone behaving strangely orout of their normal routine:

[P]eople in the community would contact me if they

were worried … I mean nothing would be really

discussed … but someone might phone me and say ‘I

saw so and so in the shop today and he didn’t look

too well and he said some things’, you know … and

it’s like a safety valve. (CPN, NWS, 29 July 2001)

In this way the gossiping of small communitiescan act as an informal safety net for stretchedformal services in remote geographical areas,especially if someone is going into crisis. Thenotion of a genuine ‘community care’ is notentirely dispensed with in this case, and it canbe argued that community members assist andsupplement formal care provision with infor-mal caring practices:

I would have been lost on numerous occasions had

it not been for the goodwill of neighbours going in

to check if someone is alright or keeping an eye on

them. (CPN, Skye, 11 September 2001)

For both rural Highland GPs and CPNs, it wasfound to be important for people to receiveformal care within their own locality if at allpossible. For the GPs especially, they are some-times wary of sending people away to hospitalin urban locations like Inverness partly becauseof the difficulties of individuals retaining andre-establishing community social relations onreturn. Although attitudes and referral patternsare changing in this part of the world, forsome, the social sensitivity of local GPs to localgossip and stigma can sometimes cause prob-

lems when there is hesitation over diagnoses orover the need for hospitalization (and we willcome back to this below). Overall, then, theprovision of formal mental health care in re-mote and rural geographies is difficult, as thereare quite distinctive social and cultural prac-tices and discourses regarding mental healthand illness, which means that services have tobe delivered discreetly, sometimes very differ-ently to what might be the case for a similarservice in an urban locality.

Informal caring

Informal carers who support individuals withmental health problems are also greatlyinfluenced by the localities in which they live.They too are aware of local moral orders inplaces where people rarely discuss mentalhealth issues. Informal carers tend to sufferwhat might be termed a kind of ‘double invisi-bility’. If general mental health problems re-main terra incognitae locally, any difficultiesfacing informal carers are thereby renderedeven more obscure, unknown and unheeded.Sometimes ‘carers’ do not actually think ofthemselves in this role or use such language todescribe themselves (and thus they contributeto ‘making’ their own invisibility). As Mark, acarer from a rural area outside of Invernessargues:

Carers don’t know they’re carers anyway. I didn’t

know I was a carer. (Informal carer, Inverness, 10

May 2001)

I’m somebody’s mother—it’s very difficult to call

yourself a carer—I’m just somebody’s mother … I’m

sure Kate has difficulty thinking of me as her carer.

(Informal carer, NWS, 24 July 2001)


One index of this reluctance to identify withthe caring role is that we have found it incred-ibly hard to recruit informal carers to interviewin our project. For a variety of reasons, theyremain unwilling to come forward to talkabout their lives in the remoter rural areas ofHighland Scotland. Nonetheless, we havetalked to a few people, and their remarks shedlight on both their own caring practices andhow these practices are contextualized in thewider cultures of caring within the places andcommunities where they reside. In this contextwe shall highlight a few brief points about howinformal carers are supported by both localformal services and local communities.

One of the major problems facing informalcarers in rural areas is the negotiation of sup-port for themselves in light of issues such associal gossip and fear of stigma. Often forinformal carers their caring role is hidden,partly because of pressure from those that theycare for:

I mean the user goes into the surgery. Doesn’t pick

up a leaflet … you can go in to accompany them and

you can’t … You just sit there and you can’t pick up

a carer leaflet [whispers, imitating the user] ‘Can’t

pick up a carer leaflet, these people will know I’m

being cared for’ … you just sit there in the surgery

looking at all these leaflets and nobody says ‘Look

have you got a carer? Take this to them’. (Informal

carer, Inverness, 10 May 2001)

Whether a carer self-identifies as such or not,they nonetheless have important roles in nego-tiating relationships between those they carefor, formal carers and the rest of the com-munity. In the former case the relationship canbe difficult in the sense that there are fewalternatives should the carer feel that adequatelevels of input are not being achieved. Forexample, given what we have already saidabout Highland medical practitioners often

wishing to provide care in local communities,we have found from some carers a feeling thatthey have to battle to gain access to specialistmedical expertise and alternative forms of care:

We had seven years of Betty’s illness—and we had

most of these years knowing that Betty had some

sort of a mental illness, but to have it diagnosed was

horrendous, I could write a book on how difficult it

was, looking back I hardly know how we survived

it … the GPs were very good to her and they were

very good to us, but they weren’t of the opinion that

Betty should see a psychiatrist … I had to fight for

that … They said it was teenage thing and that they

would give her medication and that things would

sort themselves out … I had to actually beg to get

her to see a psychiatrist. (Informal carer, NWS, 24

July 2001)

This experience is replicated in other narra-tives, especially where a diagnosis is disputed.For another carer, Elsa, this has meant hours ofresearch, trawling Internet sites, contacting re-searchers elsewhere in Britain, debating withthe CPN and sceptical local doctors her ideasabout her partner’s diagnosis. The phenomenaencountered here by both carers may not beentirely specific to the Highlands, but the frus-tration for these people is perhaps intensifiedby isolation from sources of alternative exper-tise and information because relevant special-ists are located miles away in Inverness.

It is not only the difficulties of accessingappropriate specialist services that confront in-formal carers, it is also the attitudes of othercommunity members once such care is received.For some interviewees, this means meeting withsignificant levels of community disapproval:

I think initially when she went into Craig Dunain

[the asylum] some of my husband’s family and other

friends really turned against me for the fact that she

had gone into Craig Dunain. They felt they had only


seen this very nice little old lady who presented

when they visited, one day a week, one day a month,

whatever and it upset them greatly that she went

into Craig Dunain. But that was about them. They

couldn’t handle her being in there. They obviously

felt there was a stigma attached to it or whatever.

(Informal carer from Coll, Inverness, 14 May 2001)

Given such experiences, and the strong percep-tion of this sort of outcome, some carers at-tempt to mediate the relationships between theperson they care for and the wider communityin ways that ‘limit’ their difference, and per-haps keep them out of specialist services. Con-sider the following exchange between Elsa(carer) and Steve:

Elsa: He’s well known for doing weird things in

public places. [laughs]

Steve: Not so much now, though.

Elsa: I’ve tamed him a bit, I mean there are some

things that aren’t acceptable—you know what I

mean … You have got to learn to sort of fit in, blend

in a bit. (User and carer, NWS, 11 July 2001)

The burden of care for the informal carer liesnot just with meeting the needs of the personwho they care for on a daily basis, but alsoinvolves complicated negotiations of (some-times hiding) their own role, access to specialistservices and the perceptions of the wider com-munity.

There is clearly a need for carer supportservices in rural and remote parts of the Scot-tish Highlands (especially for incomers whocannot always be assured of family or com-munity support), or at the very least an infor-mal collectivity between carers who live in thesame areas. Here there are perceived benefits aswell as barriers to these sorts of activities, aswitnessed by three different carers below:

I went to the support meetings and I would phone

them up and I got a lot of help, practical help, basics

of dealing with the system, knowing the ins and outs

of it. I didn’t get personally involved with other

carers but I needed a group to support me because I

felt very isolated. You start to question yourself, am

I making the right decisions, where am I in all this?

(Informal carer, Inverness, 10 May 2001)

Well, it is very difficult here as they have them in

Wick and mostly they have them in winter time so

you’ve got the travelling … I went to three probably

and I did find that very good … hearing the same

problems. (Informal carer, NWS, 24 July 2001)

Steve: I’ve even contacted the Scottish Association

for Mental Health, and there’s no help or support

for partners or carers, their mental health, there’s

absolutely no support for them at all.

Chris: There is actually a Carer’s Association …

Elsa: Yeah, they’re not much good,

though … They’re not much good.

Chris: … based in Inverness?

Elsa: They are, yeah, everything’s based in Inverness.

Chris: … which is one of the problems, there’s not

much here is there?

Elsa: Yeah, well … the thing is, you couldn’t actually

start anything here, because what is needed here is,

like, a very revolutionary type of women’s

group … where women start to talk about these

issues and demand what they need, yeah, and de-

mand what I need when I’m in a position where I’ve

got someone with a mental health problem who is

attacking me.12 (User and carer, NWS, 11 July 2001)

Elsa’s suggestion of the need for ‘a very revol-utionary type of women’s group’ is intriguing,and may point to the need for further reflectionon gender and mental health in remote loca-tions as indicated earlier. What this latter ex-change also reveals, though, is the simpleconcern that there is basically nothing availablelocally formally to assist informal mentalhealth carers such as Elsa, and there is a sense


from all carers that both regional and nationalcarer organizations are failing those in remoteareas. These difficulties with providing formalassistance to informal carers is inevitably tiedup with the distinctive social and culturalnorms that we have already highlighted. Theabsence in particular of carer collectives islinked to the relative absence of both client/user and carer ‘identities’ and ‘politics’, andthis is a distinctive feature of the wider socialand cultural geographies of caring in the re-moter rural localities. The brute facts of ‘physi-cal geography’ are obviously relevant here:namely the difficulties of getting together peo-ple who may live many miles apart along poorroads, treacherous ones in the winter, andwhose mental states or caring commitmentswill often make it near impossible for them toleave their homes for any length of time. A fullexplanation, however, will also need to en-compass certain cultural aspects of the localcommunities which render them actually quiteweak as resources for caring, despite—or poss-ibly precisely because—it is the case that theseare close-knit communities where social famil-iarity exists alongside spatial fragmentation (toreturn to bigger themes introduced earlier).

Conclusion

In trying to explain the complex issues involvedin caring relationships in rural areas, manyusers and formal and informal carers returnagain and again to gossip networks and to thesocial proximity and visibility that character-izes social life in this part of the world. Thesefactors are often evoked as part of an expla-nation for why both carers and users of mentalhealth services would not seek care or supportfrom the wider community in general (althoughthis is not the case for all of our interviewees).In these interviews we were also told lots of

local gossip about suicides, sexual abuse, rapeand the mental health problems that ac-company these tragic tales. And yet whenasked, in several different ways, if any of thesewell-known events had produced any examplesof community intervention or collective caringpractices, the answer was usually a regretfuland reflective ‘no’. The barriers to more collec-tive practices of caring (through supportivegroups, organized community networks) andmore open care relations (for both formal andinformal carers) hence seem to be structured inpart by a geography of fear—a fear about whatwould be said or done by other communitymembers if caring relationships or acts weremore widely acknowledged and known. Thismaterial may also suggest that, while there isindeed a lot of social familiarity based upongossip that spreads local knowledge of virtuallyeverybody’s personal, social and emotionalbusiness in rural places, this gossip seems rela-tively empty of emotional resonance and care.For some of our interviewees, then, there was aperception that rural ‘community’ seemed notto coincide with an emotional openness to thesubstance of mental ill-health and care, andseemed devoid of collective forms of caring forthose affected by mental health problems. As ishighlighted above, this means further isolationfor informal carers, as they are reticent aboutinvolving or utilizing wider community mem-bers by way of support. In various respects,Steve and Elsa illustrated the veracity of such aclaim, both in general and with specific refer-ence to mental health issues:

Elsa: [T]hey only look after people when they’re

nearly dead or after they are dead up here … The

nearer death you are, the more special you be-

come …

Steve: They care more for you after you’ve died than

they do before that … If you’re dead, everybody’s


‘oh, what a nice person they were, and all the rest of

it’ …

Chris: … you wouldn’t say that the community

around here was supportive of you, in any way, to

help you to come to terms with having some sort of

mental health difficulty?

Elsa: No, far from it.

Steve: Quite the opposite, quite the opposite. (User

and carer, NWS, 11 July 2001)

We have clearly only begun to scratch thesurface of the spatialities of caring in relationto mental health problems in regions like theHighlands, but the core of what we are arguingis that the rural geographies involved—verymuch interleaved physical, cultural and socialgeographies—engender particular caring prac-tices seen in both formal and informal caringrelationships. This squares with other researchfindings on rural health cultures where it hasbeen noted that ‘peoples in rural areas con-struct unique cultural knowledge about healthand health care which affects their linkages tothe available mental health services’ (Hill 1995:556). It is still debatable how ‘unique’ caringrelationships are in the rural Highlands of Scot-land, since they certainly share characteristicswith ones found in, for example, rural Aus-tralia where ‘self-reliant and stoic … rural andremote cultures’ (Fuller, Edwards, Proctor andMoss 2000: 149) help define access to andacceptance of mental health care practitioners.All of this means that, despite countless smallacts of caring which can be identified in theHighland region, fostering ‘care in the com-munity’ for people with mental health prob-lems is proving really quite difficult. Wealready know that achieving good communitycare in urban and suburban areas is hard work,and that physically proximate people cannoteasily be rendered socially proximate in theireveryday treatment of neighbours with mentalhealth problems. It might be assumed that the

task would be easier in ‘idyllic’ rural places andcommunities, given supposedly Gemeinschaft-like characteristics which mean that there is apre-existing nexus of social proximity andcloseness. In practice, however, such socialproximity appears not to be automatically pro-ductive of caring for people with mental healthproblems: indeed, it is perhaps that the verynature of this social proximity is itself militat-ing against producing a more inclusive environ-ment for people with poor mental health andthe people who care for them.

In future geographical research on social ge-ographies of caring in rural and remote placesthere are many questions which remain to beanswered. It is clear from this short paper thatthere are gendered dimensions to caring in suchlocations (indeed most community nurses andinformal carers were women) and as such thisneeds further interrogation, not only in respectto the gender of carers but also in respect to thegendering of caring acts which occur outside ofestablished caring relationships. Much of thispaper hints at the ‘care’ which operates withinand between community members on an every-day basis—what Laurier, Whyte and Bucker(2002: 352) would call evidence of ‘good neigh-bouring’ in which ‘rights and obligations arereflexively tied to … settings’—and, althoughwe have been largely negative about such widercaring relationships above, they undoubtedlydo occur and need more consideration to un-derstand fully what ‘community care’ can en-tail and can also be made to entail in smallremote places.

Despite wanting to contribute to the buildingof a research agenda for ‘geographies of caring’by drawing on the work of other researchers, itis clear that this paper is largely empirical, andas such there still a need to theorize care inrural geographies. We would like to suggest,via our contention that social proximity mayitself be militating against more inclusive caring


relationships, that there is a place here forpsychoanalytic thinking, where certain ideasconcerning self–other relations (like, for ex-ample, Freudian notions of unheimlich asexplicated recently by Wilton 1998) may helpto explain why close neighbours seek to dis-tance themselves from the full disturbing re-ality of mental health problems and the carewhich has to surround these. Wilton (1998)and Sibley (1995) suggest that a key dimen-sion to geographies of difference is the frac-turing of assured self-identities that in turnfuel spatial separations from threats that areperceived to destablize those identities.Wilton’s adoption of the notion of unheim-lich specifically points to the problem of so-cial and spatial proximity (to illness, deathand strange behaviour) which can cause ‘un-canny’ (familiar) human memories of timeswhen self-identity was not assured and stable(if it could ever be). This proximity (in thiscase to people with mental health problems),and the instability it can provoke, could beargued to be a key explanatory feature ofsocial geographies of inclusionary or exclu-sionary practices in rural places, and there-fore this concept could be examined andextended in future research.

To return to some of the introductory com-ments to this paper, there is clearly a need inhuman-geographical research to spatialize no-tions and practices of caring in ways that gobeyond mapping exercises. Geographers havebegun this task, although they have perhaps sofar neglected some aspects of the complex so-cial relations of care-giving. In this paper wehave attempted to redress this imbalance, butin doing so we have raised even more questionsfor future research agendas in rural and socialgeographies of caring: there are many moretoo, but we hope that this paper goes some wayto setting the scene for why such questionsshould matter.

Notes

1 The majority of the empirical materials for this researchwere collected with the help of our research assistantNicola Burns.

2 By ‘formal care’ we mean state and voluntary sector-funded care relationships and care that occurs in insti-tutions like day care centres and drop-in facilities andso on. ‘Informal care’ refers to family, friends or neigh-bours who provide essential daily care support forother community members.

3 ‘Community care’ can be a term used to signify thedispersed organization of formal care services. Thedifferent but associated phrase ‘care in the community’can be argued to encompass the informal ways throughwhich families, friends and neighbours assist each otherin daily life. With reference to informal mental healthcare, this can mean supporting people to take medi-cation on time, helping to attend appointments, a com-mitment to ‘watch’ or ‘mind’ individuals on an hourlyor daily basis, and a willingness to ‘look after’ themwhen they are feeling ill. These differing processes areimplied in some of the quotes in the paper, and cer-tainly should be differentiated in a theoretical explo-ration of ‘caring’, although we do not have space tofully elaborate them here.

4 ESRC-funded project: R000238453.5 There are other individuals and agencies involved in the

care provision for people with mental health problemsin the rural Highlands including psychologists and vol-untary-sector out-reach workers. However, these wererare in the study areas that constituted this project andhence do not feature in this discussion. Voluntary-sec-tor provision was mostly centred in and around threedrop-in centres in Skye, Inverness and NWS (the Na-tional Schizophrenia Fellowship Scotland being a keyprovider in this area). Religious and church-based net-works for support in rural and remote parts of theHighlands are notably lacking, and this may be becauseof particularly strict versions of presbyterianism whichdiscourage strong displays of emotion in some High-land places (hence contributing to the non-developmentof church-based support networks for psychologicaland emotional difficulties). For background details tosupport this claim, see our findings paper ‘Highlandeconomy, culture and mental health problems’ on theproject website: http://www.geog.gla.ac.uk/Projects/WebSite/main.htm.

6 Nicola Burns collected data for Skye, Easter Ross andInverness with support from the authors.


7 Each area studied had one voluntary-sector mental-health drop-in, except for NWS which had no collectiveprovision of this sort.

8 Edinburgh is the centre for national-level decision-mak-ing and policy frameworks, whereas Inverness is thecentre for regional resource allocation decisions andhealth and community care planning.

9 The general claims that contribute to a ‘picturing’ ofHighland social geographies are supported from in-depth analysis of interviews with users of services. Fora series of findings papers that elaborate and substan-tiate these themes, please see http://www.geog.gla.ac.uk/Projects/WebSite/main.htm.

10 We use this term as it was one adopted in interviewsby those people who had long connections with anarea and were self-consciously part of family group-ings which claimed links to past generations of High-land dwellers. The term ‘local’ was also usedalongside ‘indigenous’, and this semantic device isone used to separate off an ‘authentic’ place-basedidentity that was seen as different from those peoplewho have migrated to the area (and who are termed‘incomers’, or ‘white settlers’). It should be notedthat, even if migration to the Highlands occurredtwenty to thirty years ago, some families might stillbe identified as ‘incomers’ and hence different fromother ‘local’ parts of the community. See also Jedrejand Nuttall (1996).

11 Whilst these gendered dimensions of caring may bereplicated in urban areas, there are specific issues whichinfluence some aspects of gender relations and caring inHighlands places. These are partly related to the com-mon use and abuse of alcohol amongst men as part ofdealing with and covering up mental health issues. Thestrong masculinist norms that characterize social life inthis region and contribute to excessive drinking culturesmean that women are routinely positioned as caring formen who drink. This ‘care’ may be constructed inmultiple ways, ranging from ‘looking after’ men ininebriated states, to cleaning up the physical conse-quences of excessive drinking, to ‘mending’ damagedsocial relationships as a result of drinking and ‘watch-ing’ men through phases of ‘drying out’. As a result,women in Highland places are often already routinelyengaged in specific caring roles, ones unacknowledgedby individuals and communities.

12 Steve has occasionally attacked Elsa when experiencingacute phases of his illness. Local police have attemptedto charge Steve for such attacks, despite Elsa’s protesta-tions that all she requires is protection at such times.

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Abstract translations

La sante mentale en region rurale et les geographiessociales du bien-etre humanitaire

Cet article se veut une contribution a la litteratureemergeante sur les geographies sociales du bien-etrehumanitaire. En s’inspirant d’un travail empiriqueentrepris recemment dans les Highlands en Ecossesur la procuration des soins de type formel ouinformel, une evaluation de recits de gens souffrantsde maladies mentales est effectuee. La notion du« bien-etre communautaire » est critiquee de memeque l’affirmation voulant que les regions rurales oucelles qui sont encore plus reculees engendrent desformes particulieres de roles d’entraide, de pratiqueset de rapports sociaux. Il est demontre que la dis-tance geographique, la proximite sociale, les culturesstoıques et les propos de commeres retrouves enregion rurale contribuent tous au bien-etre humani-taire dans ces milieux. Cet article se termine ensuggerant des pistes de recherche a suivre.

Mots-clefs: sante mentale, pratiques de bien-etre hu-manitaire, roles, rapports sociaux, soins de typeformel et informel.

Salud mental en sitios rurales y las geografıas so-ciales del cuidado

Este papel forma parte de una emergente literaturageografica sobre las geografıas sociales del cuidado.Hacemos uso de trabajos empıricos elaborados enlas tierras altas de Escocia para evaluar relatosparticulares sobre la provision de cuidado, tantoformal como informal, para individuos con prob-lemas de salud mental. Hacemos la crıtica de lanocion de ‘cuidado en la comunidad’ y tambien deafirmaciones sobre como sitios rurales y sitios remo-tos y rurales engendran configuraciones particularesde modelos de cuidado. Demostramos que tanto ladistancia geografica, como la proximidad social, cul-turas estoicas y redes de cotilleo rurales afectan elmodo de cuidado en este tipo de lugar. Concluimospor sugerir temas para futuras investigaciones.

Palabras claves: salud mental, cuidado, papeles, rela-ciones, cuidado formal e informal.

Documents

Rural mental health and social geographies of caring