The therapeutic landscapes concept as a mobilizing tool for liberation

In this reflection, I argue for using the therapeutic landscapes concept as a tool for mobilizing positive change in the world. I first lay out three major research areas in therapeutic landscapes inquiry, and provide a review of similarities in this area of inquiry in both health geography and medical anthropology. Next, I argue for the application of the therapeutic landscapes concept in liberating, if even in a small way, the growing population of the most vulnerable in our society, countries, and the world. I note two anthropological contributions that illustrate how the concept of therapeutic landscapes can be employed in liberating vulnerability, before discussing a work in progress, specific to an intentional ashram community with a mandate dedicated to world peace. I conclude by setting out the importance of this new direction for the future application of the therapeutic landscape concept as a tool for liberation.


Introduction
In this reflection I review how the concept of therapeutic landscapes has been broadly employed over the last decades and argue for its use as a tool to mobilize positive change in the world, whether environmental or social.As a health geographer who has been following the work on therapeutic landscapes for more than twenty years, I begin by describing the three major research areas in therapeutic landscapes inquiry, as evident in the published literature across a wide range of contributing disciplines.I follow this with some observations on how the disciplines of anthropology and geography have used the concept of therapeutic landscapes, focusing especially on the many similarities their approaches share.I argue for the application of the concept of therapeutic landscapes to liberate the most vulnerable in our societies, and subsequently note two anthropological examples that illustrate how this might be done.Before concluding, I discuss an example from my current work in progress, which examines the therapeutic landscape of an intentional ashram community with a mandate dedicated to world peace.

A deep-rooted typology
Health geographers and a wide range of associated disciplines, such as nursing, physiotherapy, recreation and leisure studies, and medical anthropology, continue to employ the therapeutic landscapes concept in a wide variety of areas of inquiry (Williams, 2007).As with earlier classifications (Williams 1999(Williams , 2007)), most work can be placed within one of three categories that distinguish the context in which the concept has been applied: traditional, distinct populations, and health care sites.Traditional therapeutic landscapes encompass natural and built environments that reflect healing qualities, such as wilderness environments and retreat houses.Applications of the concept for distinct populations focus on how unique place-based interventions, such as substance abuse centres for addicts and home design for autistic children, contribute to the health and healing of the populations concerned.The application of the concept to health care sites, such as mental health hospitals, long-term care facilities, and community care homes, focus on how these sites can be improved to address the needs of care recipients more holistically.A forthcoming scoping review will provide a synthesis of the work done in the last ten years, confirming this threepronged typology, whilst pondering ongoing applications of the therapeutic landscapes concept (Bell et al., forthcoming).There is still much interest in traditional spaces and places, such as those categorized as 'blue/green' (Foley 2010), as well as shrines dedicated to healing (Williams 2010).Applications of the concept to distinct populations have grown extensively to include experiences of migration for immigrants and refugees (Agyekum and Newbold 2016) and experiences of grief (Maddrell 2016).Uses in health care settings have continued to look at both institutional (Gesler and Curtis 2007) and deinstitutionalised community care settings (Donovan and Williams 2007;Williams 2002).One of the promising threads in this literature employs the therapeutic landscapes concept as a tool for informing and mobilizing positive change in the world -whether environmental or social change -as is evident in both the maturing health geography and growing medical anthropology literature.

Health geographers and medical anthropologists unite
It was with great excitement that I had the pleasure of inviting anthropologists to contribute four chapters to an edited volume in the Ashgate Geographies of Health series, entitled Therapeutic Landscapes (Williams 2007).The introductory chapter to this final section in the edited volume, entitled 'Transcending Geography: Applications in the Anthropology of Health', co-authored by Setha Low, set the stage for understanding therapeutic landscapes from an anthropological perspective.Low (2007, 291) asserts that it was somewhat surprising that, given medical anthropologists' long interest in the cultural context of health and well-being, 'the study of therapeutic landscapes within the discipline of medical anthropology is still in its infancy, and that this collection is the first of its kind to be published'.Further, she argues that, in contrast to environmental psychology, the study of therapeutic landscapes was still being established within the discipline of anthropology, and that the four contributing chapters 'begin the hard work of building anthropological theory in this area' (ibid.).Finally, Low (2007, 295) argues that a multidisciplinary perspective, incorporating anthropology, environmental psychology, and geography, 'allows different aspects of environments to be explored when trying to understand why a specific landscape is therapeutic', while also permitting a multiplicity of methods to accrue knowledge about the healing elements of place.
What occurred to me in editing this section of the volume was the overriding similarity between geography and anthropology in the ethnographic and other qualitative methods used in applying the therapeutic landscape concept to space and place.Not only was the application similar but so too was the curiosity about the actual places of study, such as intentional or purposive communities, health care sites, and public art.Given the interest of both of these disciplines in human health and well-being, this was not a huge revelation; what did surprise me was the common focus on cultural place-based contexts.To illustrate, Hoey's (2007) anthropological chapter on the intentional space of purposive community overlapped with the long history of asylum research conducted by health geographers Moon, Kearns, and Joseph (2015).Similarly, McLean's (2007) anthropological contribution on the culture-change movement in dementia care corresponded with Gesler's (2003) work on long-term care facilities for those with dementia, where he applied the tenets of his therapeutic landscape theory to institutionalized care for Alzheimer's patients.Further, Collins's (2007) anthropological examination of the therapeutic aesthetic, where artwork was studied in two English hospitals, resembled the work of geographers Crooks and Evans (2007), who interpreted the interior space of the hospital waiting room.This illustrates the similar interests both disciplines share in the actual places of study, with respect to places of health, healing, and well-being, and points to the untapped richness of a multidisciplinary perspective in this substantive area of common interest.Although there are minor differences in methodological approaches -given that anthropologists use ethnographic research to understand the cultural contexts of health and well-being in healing spaces and places, while geographers use a plethora of quantitative, qualitative, and mixed-methods approaches in better understanding the spatial and temporal elements of such places -the shared focus on certain types of places brings unified attention to characteristics of place, as outlined in Gesler's (1993) therapeutic landscapes theory.
The anthropological contributions that make up this special issue continue to share many commonalities with health geography.What strikes me most about these contemporary contributions is the consistent recognition of culture within a place-based context, as dynamic, emerging, and progressing.Culture, most simply defined, is 'a way of life'.As this special issue attests, medical anthropologists have continued to provide further critical reflection on the therapeutic landscapes concept, contributing to its continued maturation and application within the discipline.

Therapeutic landscapes of liberation in a globalizing world
Given the massive economic and technological changes we have experienced, and continue to experience, in our globalizing world, our cultures are rapidly changing, and so too are our health and wellness needs and demands.These changes are accompanied by growing inequalities in access to health and wellness.As the therapeutic landscapes concept continues to be applied to a great array of places and spaces, across the seven continents, we need to take up the challenges of being more intentional with respect to the needs of vulnerable populations.There is no shortage of vulnerability in our world today, given the many challenges we face, including growing inequalities, climate change, population growth, environmental injustice, and social exclusion due to race, religion, sexuality, gender, or other forms of diversity.
My plea is for researchers -whether scholars or those working in community developmentto, in some way, act on these injustices and forms of social exclusion through employing the therapeutic landscapes concept in relation to these issues, and thereby informing and mobilizing, even if in a small way, the solutions needed for a healthy, sustainable planet.The challenge is to discern how to best employ the learnings to date and apply them in ways that support the liberation of vulnerable populations.As Low (2011, 390-91) succinctly writes: 'I have found that spatializing culture -that is, studying culture and political economy through the lens of place and space -provides a powerful tool for uncovering material and representational injustice and forms of social exclusion'.The opportunities for applying the concept to efforts to liberate vulnerable populations are many, given that vulnerability is often defined by space and place, such as in the case of impoverished neighbourhoods, prison environments, refugee camps, and religious dictatorships.We have a number of great examples of how this can be done in the field of health geography, such as the work of Sperling and Decker (2007) on the highly vulnerable Kaqchikel peoples of Guatemala, the work of Cutchin (2007) on residential care environments for the elderly in the United States, and Wilton, DeVerteuil, and Klassen's (2007) notable application of the concept for those seeking substance abuse treatment in Winnipeg, Manitoba, Canada.There are a few examples evident in the growing medical anthropology literature, two of which are discussed below.

Anthropological inquiry and liberation
Of the four anthropological chapters in the edited volume discussed above, the therapeutic landscape of dementia care studied by McLean (2007) was, in my editorial estimation, the most compelling.Not only was it exquisitely written but it communicated and convincingly argued for dementia caregiving as a moral enterprise, one in which empathy, vulnerability, and suffering are the basis of an intersubjective ethics of dementia caregiving, characterized as providing spiritual and emotional healing.Employing therapeutic landscape theory to analyse dementia care, McLean suggests that the therapeutic possibilities for dementia care lie not in cure but strictly in caring for this highly vulnerable population who only experience decline.
A similar approach to employing the therapeutic landscapes concept to vulnerable populations, such as Venezuelan neighbourhoods, is evident in this special issue.In Cooper's article, 'Moving Medicine inside the Neighborhood: Health care and sociospatial transformation in Caracas, Venezuela', the therapeutic landscapes concept is applied to revitalization projects in the barrio.Public health projects, like the Grandparents' Club, transform the social spaces of the neighbourhood.Given the extremely high crime rate characterizing these poor neighbourhoods, those residing there are vulnerable with respect to their health and safety.Such interventions illustrate the therapeutic aspects of neighbourhood landscapes, which enable the improved social health, quality of life, and liberation of those residing there.
A work in progress: Yoga as a path to peace A globalizing world creates not only growing medical pluralism but the possibility of a global village, where there is unity in diversity.A microcosm of such a global village was well represented in an open and welcoming ashram (or yoga retreat) named Sivananda, in the Bahamas, which is one of nine Sivananda ashrams worldwide that I recently visited.This intentional community welcomes all religious denominations and belief systems, and recognizes the similar values that the entire world's religions share: service, generosity, love, peace, and prayer.Following the work of Hoyez (2007), in her research on the world of yoga as a therapeutic landscape, this work in progress outlines the possibilities for yoga as a path to peace.

Philosophy
The ashram community represents a global village, made up of people from around the world, many of whom often travel days to get there.Although many languages were spoken at the Bahamas site, where I undertook observational research, the lingua franca was English, with all the daily activities -from morning meditation to yoga classes and educational workshops -being offered in various aptitudes of English language attainment.All members of the community, whether long-term residents or short-stay visitors, shared the common objective of realizing peace, both within themselves and in the wider world.The open and welcoming nature of the ashram was made accessible to all walks of life and incomes, with many price-points on accommodations and tent camping available for those on a tight budget.Yoga teacher training is central to the mission of the International Sivananda Organization, whose mission is to spread peace, health, and joy through the practice and philosophy of yoga.One of the mainstays of the ashram is its Teacher Training Program, which is a three-month long offering regularly taught multiple times per year.For those who wish to do more, a four-week, two-hundred-hour Advanced Teacher Training Program is offered.Central to this program's curriculum is how yoga has the capacity to change lives and change the world through the realization of peace.Many go on to teach yoga to a wide range of vulnerable populations, such as those who are incarcerated, abused, or impoverished in one way or another.

Daily life
The speed of life in the ashram is slow, allowing for meditative contemplation in moving from one activity to the next.Generous breaks are provided between activities, such as the thirty minutes between morning meditation and yoga class.These windows of time allow for social exchange with fellow community members, with brunch and dinner being the most intense opportunities for socializing.
The ethical and sustainable vegetarian cuisine, which is served twice daily, is prepared as a service by those in the karma yoga program, which can last from one to three months.Karma yogis work seven hours daily in exchange for their board and access to the daily program of mediation, yoga classes, and educational workshops.In addition to serving in the kitchen, karma yogis work in the boutique, selling books, music, clothes, and eatable goods.Other service positions for karma yogis include working in the reception office, where visitors are received, grounds keeping, transportation, and assisting guests to and from their accommodations.
Daily workshops led by both community residents and guest speakers are many, with two or three often being offered simultaneously.Here community members can explore and learn an array of practices, from juice fasting to meditation to sustainable farming.All workshops pertain to health, wellness, self-actualization, environmental sustainability, humane lifestyles and practices, and spiritual fulfilment, all leading to a peaceful and just world.

Physical, spiritual, intellectual, and psychological/emotional healing
Each day offers two one-and-one-half-hour satsangs, or prayer sessions, which are comprised of meditation, chanting, and teachings, as well as two one-and-one-half-hour yoga classes, two meals, and numerous afternoon workshops that often run two to three hours.The morning satsang begins at 6 am and the evening satsang, which starts at 8 pm, completes the day.Given that no loud music, caffeine, alcohol, or drugs are permitted on the ashram, most are asleep by 10 pm, preparing for the next day of retreat.This intentional community, like many others, makes space for approaching health holistically, addressing the physical, spiritual, intellectual, and psychological/emotional needs of its members.The daily activities offered are complemented by services offered for a fee by a wellness centre, including yoga therapy, therapeutic massage, and Ayurveda medical consultations.
Although clearly not for all, given the strict code of conduct with respect to addictive substances, the ashram itself is very much a therapeutic landscape, given its built and natural environment; focus on physical, spiritual, and mental health; daily schedule of activities that bring order and calmness to the community; and social inclusivity.The ashram operates as a place of healing, health, and renewal for all who live there or visit it, while also contributing to the ideal that peace, through partaking in the yogic lifestyle, can be shared and achieved across the world.How to best realize the scaling up of such intentional communities as therapeutic landscapes, in order to reach larger populations, is the challenge that is presented to us all.

Conclusions
I have argued for the application of the therapeutic landscapes concept in efforts to help liberate the growing population of the most vulnerable in our societies and countries, and across the globe.Applying the therapeutic landscapes concept to places and populations characterized as vulnerable allows us to contribute to the solutions needed for a healthy, humane, and environmentally sustainable planet.Irrespective of discipline, scholars are tasked to use research as an opportunity to facilitate positive change, particularly for those places and populations most disenfranchised in the world.The therapeutic landscapes concept is well placed to be used as a tool in facilitating this positive change, healing the places of injustice and social exclusion.

About the author
Trained as a health geographer, Allison Williams works in many interdisciplinary groups, examining issues related to health, quality of life, and well-being.In addition to keeping her finger on the pulse of applications in therapeutic landscape research, she holds a Canadian Institutes for Health Research (CIHR) Research Chair in Gender, Work & Health, and is examining how workplaces can best accommodate family caregivers.She currently supervises a team of seven trainees and works collaboratively with a wide range of partner organizations.