Therapeutic landscapes

Anthropological perspectives on health and place

Margaret Winchester, Janet McGrath

17 Apr 2017
doi.org/10.17157/mat.4.1.472

The motivation for this special issue was to fill a void in the conversation between geography and anthropology. Margaret Winchester, the editor of this issue, is a medical anthropologist who completed her postdoctoral training in health geography. In her work on health care access in South Africa and her reading of geographic literature, she struggled to find language on the symbolic nature of space, beyond that of a static notion of emplacement. The concept of therapeutic landscapes emerged as a possible bridge between the disciplines, though one that had not been theorized in anthropology in a systematic way. In 2014, Winchester organized a session at the American Anthropological Association meeting in Washington, DC, which garnered strong interest and a collection of thoughtful papers. As discussant for the section, Janet McGrath provided invaluable comments linking the papers together and contextualizing therapeutic landscapes within broader trends in medical anthropology. This special issue is an extension of the original session, with additional articles, photo essays, and invited commentaries. Together these pieces represent new ways of engaging with a traditionally geographic concept through an ethnographic lens, and they illuminate some of the challenges in building theory.

To introduce this special issue, we first describe several components of the concept of therapeutic landscapes as employed in the literature on health geography and then explore anthropological work in the area. Next we present an overview and synthesis of the contributions to this special issue. Finally, we end with a discussion of the thematic links between the contributions and some future directions for anthropological research on therapeutic landscapes.

Therapeutic landscapes and the boundaries of geography

Although geography has a long history of engagement with landscapes, the concept of a ‘therapeutic landscape’ was developed by Gesler in 1992 to examine the healing dimensions of specific sites. The concept draws our attention to the connection between place and well-being, or as Gesler (1992, 743) writes, how the ‘healing process works itself out in places (or situations, locales, settings and milieus)’. Therapeutic landscapes are thus defined as specific spaces of healing, particularly where the natural environment intersects with the social environment (Gesler 2003). In practice, the concept usually refers to spatially delineated areas with ‘health-enhancing’ properties (Williams 2007). However, as Gesler and Curtis (2007) have noted, landscapes can be either therapeutic or not (or both), depending on the constellation of components and people’s subjective experience of the space (Gesler and Curtis 2007; Smyth 2005). 

In broadening the scope of the concept of therapeutic landscapes beyond spaces specifically designed for healing, Gesler and Kearns (2002, 133) note that ‘a wide variety of influences on the healing power of place exist’. The idea of therapeutic landscapes, therefore, is inherently interdisciplinary; it is ‘geographic in that it deals with specific places, but it brings together layered landscapes of meaning from several sources’ (ibid.). As such, several domains from the health social sciences are taken up in the discussion of therapeutic landscapes in efforts to clarify and expand the concept.

In light of these expansions of the therapeutic landscape idea, the identification of boundaries between health geography and other health social sciences, including medical anthropology, is challenged. Geographic and anthropological perspectives on the role of place and health converge to some extent, as is evident from the reliance on the concept of culture (see for example Smyth 2005). Thorsen (2015), for example, borrows from medical anthropology in his focus on local health beliefs. And Gesler (1999, this issue), for his part, cites anthropologists who study experience and meaning in local contexts and/or through a political economic lens.

To better understand the linkages between health geography and medical anthropology in this realm, it is informative to discuss several key domains found in the expanded therapeutic landscape literature that have considerable theoretical heft in the conceptual frameworks of contemporary medical anthropology. These include: conceptualizationsof healing, the meaning and significance of culture, and the political economy of health.

In his initial work defining therapeutic landscapes, Gesler (1992) focused on symbolic conceptualizations of healing, particularly as reflected in nature, such as plants, parks, and water, thus evoking a conventional view of ‘landscape’. Clearly, however, this view of healing cannot be equated with biomedical definitions of healing that are linked to cures and treatments of physical symptoms. Although some of the locations he examines purport to address physical manifestations of ill health, many focus on spiritual meanings of healing. Even in examining biomedical settings such as hospitals, Gesler (2003) focuses on ways that physical features create a symbolic sense of ‘nature’ and healing. Indeed, Gesler and others are explicit in their embrace of an expansive definition of health, one that encompasses all aspects of well-being, far beyond the absence of physical disease as represented in Western biomedicine. Here the boundaries with anthropology are especially blurred. In anthropology, the definition of healing is tightly linked to local settings, and symbolic and spiritual healing are well studied.

Culture and the importance of understanding local practices and meanings are, of course, a long-standing focus in anthropology. Local beliefs, understandings, and practices related to health and well-being are a core domain of medical anthropology. But the importance of culture is appreciated across many disciplines, including health geography. In 2002, Gesler and Kearns reviewed the development of the fields of cultural and health geography, noting the importance of culture as a component of the relationship between place and health. More broadly, geographers have embraced efforts to explore the meaning of health and place as experienced by individuals in different cultural settings (Smyth 2005; Wilson 2003).

Smyth (2005) argues that consideration of links between space and behavior/values can lead to understanding contested ‘landscapes of resistance’ and ‘landscapes of exclusion’. Frazier and Scarpaci (1998) use the idea of landscapes to examine mental health issues and what they refer to as ‘landscapes of state violence’. Political economic approaches in medical anthropology highlight the ways in which space is not neutral in its impact on individuals, demonstrating how the political-economic history of a place determines the distribution of both health risks and of resources to achieve better health. In this way, political economic approaches are also place-based.

Some geographers have divorced the concept of therapeutic landscapes from physical space and instead use it to refer to health beliefs and practices in a specific place, seen as resulting from cultural practices and economic/political inequalities in that setting (see for example Madge 1998). Thorsen (2015) argues that the reference to ‘local’ in medicine refers both to a cultural meaning and to a local place. He also notes that therapeutic landscapes should be understood as fluid, consisting of a suite of health care practices changing over time rather than a static set of specific practices. Here again, the linkages to anthropology are clear.

Anthropological uses of therapeutic landscapes

Apart from one notable exception (Williams 2007), therapeutic landscapes have not been systematically and fully examined through an anthropological lens. In the edited volume by Williams (2007), four anthropologists contributed chapters exploring the relationship between place and environmental psychology. These chapters are also the result of a special conference session and engage directly with place in an explicit sense though the study of purposive communities, dementia care, art memorials, and aesthetic-therapeutic places. This special issue builds on those efforts by expanding them into international and domestic arenas of health, broadly understood. Anthropologists are well positioned to illuminate, as Pfeiffer and Nichter (2008, 413) write, ‘social processes, power relations, development culture, and discourses that drive the global health enterprise’, beyond the earlier boundaries of therapeutic landscape analysis.

Despite a lack of anthropological work specifically employing the concept of therapeutic landscapes, anthropological fieldwork is, for the most part, place and space specific and frequently comparative in nature. Additionally, the comparative approach – whether implicit or explicit – seeks to place cultural variables in the context of the broader array of human cultures.  But an important point of historical distinction between anthropology and geography is anthropology’s focus on subjective experience. Recognizing that experiences of illness, health, and health care provision involve a significant subjective component, anthropological perspectives highlight the heterogeneity of ways that space is experienced as therapeutic or not. In addition, anthropological studies frequently focus on non-Western locations, expanding the scope of landscapes (Thorsen 2015).

More broadly, another focus of anthropological considerations of health and illness is the social relations within which people live, construct, and negotiate therapeutic landscapes. The recognition that individuals do not navigate these locations of healing independent of other social relations requires consideration of those social networks within which people identify illness, seek care, and make sense of healing. Such therapeutic networks, on their face, seem contrary to a spatially focused concept of therapy because they often span multiple physical locations. The consideration of social relations highlights the value of expanded notions of therapeutic landscapes that incorporate social and symbolic landscapes. That said, however, anthropologists have long engaged with space as a key component of the context of health and disease as well as care seeking. Susan Reynolds Whyte and colleagues (2014, 68), for example, describe the spatial movements of HIV-infected people in Uganda as they negotiate a complex setting of intersecting landscapes of care providers, family resources, employment, and more, in what they refer to as the ‘projectified landscape of care’. In this context, the therapeutic nature of the landscape derives from this interwoven set of social relations, placed on top of the economic reality of available care, which itself is shaped by the global political economy of HIV.

Overview of special issue

The articles and essays in this issue cover a wide range of geographic and ethnographic research that together consider space and place in health and healing. The issue includes six articles on ways to apply therapeutic landscapes across settings. Amy Cooper writes of the state expansion of healthcare in Venezuela, where the movement of clinics into marginalized neighborhoods has had a transformative effect. Through physical construction and public health initiatives, space has been transformed discursively through language, physically through clinics, and symbolically through social activities. Former zones of exclusion can be resignified through state endeavors, and, indeed, Cooper argues that they should, in an effort to enact ‘sociospatial change’ and reduce inequalities. Karasaki, Warren, and Manderson write of another shifting notion of place: the transformation of a sense of ‘home’ for stroke survivors and their spousal carers in Australia. They use the framework of orchestration to analyze the relational and shifting dimensions of how the meaning and experience of home can change when it is the primary site for rehabilitation and caring. The significance and therapeutic value of this particular landscape is one of negotiation and reconfiguration through space, time, and relationships. Martha King details the construction of a genetics clinic in an Amish community in Lancaster, Pennsylvania. Through its careful consideration of space, the clinic has engaged with a community that has historically resisted such connections, and gained widespread acceptance. The physical construction of the clinic was done after the process of building a relationship in the community and visually manifests Amish architecture and craft, making the clinic a ‘literal and ideological extension of everyday Amish landscapes in the realm of the biomedical’.

Jesse Hession Grayman uses the geographic language of field, topography, and scale to examine a maternal and child health program in Indonesia. He argues that the intervention’s scope and challenges map metaphorically onto a changing and constructed therapeutic landscape. In another contested terrain, Jennifer Mokos analyzes an encampment for homeless people in a river bottom in Southern California. She shows the tension between homeless settlers and environmental protection groups in defining the therapeutic value of a space, and argues that despite the existence of so-called invasive plants, the camp has significant protective and therapeutic value for its residents. Margaret Winchester and Brian King write of the intersection of utilitarian and symbolic resources related to health for residents in one rural village of South Africa. They highlight historical and social notions of space that limit its current therapeutic value and the ways in which residents turn to natural and ecological resources to improve their health.

As physical surroundings are key elements of landscapes, the visual nature of these is explored in three probing photo essays. Nina Nissen’s photo essay traces the contours of everyday men’s health in Denmark. Participants in her research took the photos themselves to highlight significant elements of their health care practices. Nissen analyzes these as relational elements of landscape that emerge in social and symbolic ways, giving depth to traditional ethnographic research. Sarah Phillips and Jill Owczarzak likewise take their gaze outside of clinical care in their essay on HIV care in Ukraine. Using a framework of precarity, they show the shadows within traditionally therapeutic landscapes, where vulnerability and uncertainty can exist. This challenges the notion of therapeutic landscapes as universally healing areas, particularly in zones of significant geopolitical upheaval. Heather McMillen, Lindsay Campbell, and Erika Svendsen documented living memorials for the 9/11 attacks developed through the US Forest Service. They have found the therapeutic aspect of memorials to be not only in their construction but in the ongoing stewardship of the natural environment at the various sites. In a more traditional notion of therapeutic landscapes, groups have created natural sites for healing in ongoing interactions with the environment.

Framing the articles and photo essays are several commentaries. Marlee McGuire uses ongoing dissertation data to draw connections between the physical landscape of oil extraction, the local economy, and the symbolic landscape of perceived ‘deservingness’ for those with especially precarious access to medicines. She highlights the explicitly political nature of affect in an uncertain political climate. In an invited essay, Wil Gesler shares his reflections on the concept of therapeutic landscapes, more than twenty years after he first offered it. He notes that while he is a geographer, he developed the concept of therapeutic landscapes to bridge disciplines, even though it has not been widely applied outside of its original field. As Gesler rightly credits, Allison Williams has done much to promote the use of ‘therapeutic landscapes’ within anthropology. Her invited commentary also reflects on the shift toward the symbolic in the way therapeutic landscapes have been applied in anthropology. She challenges anthropologists to take therapeutic landscapes even further. By applying the lens to vulnerable populations, Williams argues that we can promote sustainability and become agents for change.

Future directions for anthropology and geography

These contributions share important elements: fieldwork, recognition of the multiple meanings of space, and attention to the significance of power. Each is based, at least in part, on ethnographic fieldwork, true to their roots in anthropology. Although these contributions hew to the dichotomy between utilitarian and symbolic meanings of space and place, each also recognizes the ways in which the domains are intersecting. Indeed, utilitarian and symbolic representations of space are dialogic; symbolic uses of space and place relate to and emerge out of the utilitarian uses of space, and spaces gain utilitarian purpose through their symbolic meaning. This issue thus calls us to examine the physical resources that constitute our living spaces, and, therefore, the spaces in which we get sick and seek healing. A timely expansion of the idea of therapeutic landscapes considers the actual space and its resources as a foundation for understanding how this space is shaped into a socially meaningful space by authorities, experiences, and the physical resources themselves. 

Several themes crosscut the contributions to this volume. First is this dialogue between uses and meanings of space. Each of the papers demonstrates in one form or another how symbolic and utilitarian uses of space are mutually emergent. For example, King describes how local Amish cultural values related to ‘crafting’ served to shape both the physical space of the clinic and the meaning of the space for the families seeking care there. In Venezuela, Cooper describes how spaces designed for a range of ‘health’ activities gain symbolic meaning as loci of safety, socializing, and inclusion. In both cases, the healing nature of the space extends well beyond the physical benefits of care provision through a form of recognizing and, indeed, nurturing local culture. In this sense, the use of space achieves two purposes that are mutually reinforcing. 

Expanding on this idea of inclusion and safety, a second theme across these contributions is the fragility of healing in some spaces. Mokos argues that the riverbed settlement offers a space of safety and community, however unpredictable, for the homeless who camp there. This resembles the precarity depicted by Phillips and Owczarzak in their visual representation of HIV care in Ukraine. Like the women in Venezuela who are able to move out into the community again, these healing spaces offer a form of spiritual or emotional healing. For the homeless in California and those with HIV in Ukraine, however, their social and political marginality creates both the need for a space of emotional healing and renders that space subject to political and social retraction.

The intimate relationship between space and time is also apparent. Perceptions of the therapeutic nature of a place shift with actual or perceived reduction in resources, as discussed by McGuire in regard to accessing drugs for rare diseases. Perceptions of the symbolic meaning of specific spaces may also shift based either on specific events (such as police sweeps of the homeless settlement described by Mokos) or expectations, as exemplified in concerns when stroke patients’ recovery is less than was imagined (Karaski et al.). Nissen’s photo essay reminds us of the quotidian nature of care seeking that drives perceptions of healing in varying spaces, while King describes how the organization of time in the Amish clinic (waiting for care, staff rushing about) represents a fissure in the ‘crafted healing’ of the space.

The physical environment has long been recognized to have a direct role in health. The contributions in this volume, however, remind us that the physical environment can matter both physically and symbolically. Grayman and Winchester and King, for example, note that topographic features of the natural environment directly impact care seeking. The symbolic weight of specific environment configurations is seen in Winchester and King’s depiction of locally available pharmacopeia that shape the local therapeutic environment, even while invisible to a biomedical lens. The symbolic healing of ‘nature’, often represented in Western imagination, is seen in the expressions of being at peace with nature among the riverbed homeless (Mokos) and in the use of memorials in National Parks as sites of grief and recovery, as depicted by McMillen et al.

Each author also employs to some extent a political economic lens to understand the links between space, place, and health. In so doing, they uncover spaces of inequality and the challenges in building a consensus on the value of any given space. The fluidity of so-called therapeutic landscapes has both physical and symbolic dimensions. Spaces are defined and understood through nonlinear processes of negotiation, relationships, and practices of power. These can alternately empower people through therapeutic access and resources, and marginalize others in ‘shadows’ (Phillips and Owczarzak) or through ‘spatialized inequality’ (Cooper). ‘Hierarchies of power’ and exclusion can also shape the perception of deservingness within the metaphorical landscape of public health interventions (Grayman).

One might well argue that the therapeutic landscapes concept is ‘old wine in new bottles’ as geographers ‘discover’ the role of culture, health care seeking, and the political economy of health. Indeed, in his commentary for this volume, Wil Gesler describes his slow embrace of political economy as a lens through which to view therapeutic landscapes. Besides a desire to avoid unnecessary disciplinary squabbling, we argue that geography and anthropology each have much to gain by working collaboratively to refine the therapeutic landscape concept. For anthropologists, the spatial organization of social relations has both tangible and symbolic implications. When considering health, space is important not just in terms of exposure to risk of disease but also in terms of ability to achieve a therapeutic outcome. Both sickness and health result from who we are in a particular context, and therefore they shift in each setting, at the household, community, and national levels. Space is not neutral, because the spaces in which we live are arranged along socially meaningful categories. For this reason, the ability to achieve healing (however defined) cannot be viewed as simply a geographic issue but rather is one in which space is the tangible manifestation of the social (Baer and Gesler 2004).

The power of the therapeutic landscape concept lies, perhaps, less in attempting to imbue space with new meanings but rather in illuminating the intersection of space and social relations in terms of how they impact health. If so, then the concept of therapeutic landscapes requires a combination of place-based attention to meaning and experience and to the political economic contexts in which experience unfolds, a combination that is illustrated in this special issue.

About the authors

Margaret Winchester, PhD, is Research Associate in the Department of Health Policy and Administration at Pennsylvania State University and coordinator for the Pan Institution Network for Global Health. Her work has centered on HIV, health care access, and vulnerability, primarily in Uganda and South Africa. Currently she is working on several other projects, including with informal workers in New York and India.

Janet McGrath, PhD, is Professor of Anthropology at Case Western Reserve University. She is a medical anthropologist with research interests in HIV risk, women’s health, HIV prevention, and access to HIV treatment. She has been an active member of the CWRU-Uganda Research Collaboration since its inception in 1987. She cofounded the Center for Social Science Research on AIDS (CeSSRA) in collaboration with the School of Social Sciences at Makerere University in Kampala, Uganda.

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