The Handbook of Mental Health and Space

Community and Clinical Applications

Laura McGrath, Paula Reavey, Laura McGrath, Paula Reavey

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317216599
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Handbook of Mental Health and Space brings together the psychosocial work on experiences of space and mental distress, making explicit the links between theoretical work and clinical and community practice. The change from an institutional to community care model of mental health services can be seen as a fundamental spatial change in the lives of service users, and the book aims to to stimulate discussion about mental healthcare spaces and their design.With contributions from those involved in theorizing space, those drawing on their own experiences of distress and space, as well as practitioners working on the ground, the book will beof interest to mental health practitioners and academics.

Part I
Institutional spaces

Containing distress in the walls of the hospital

1
Regulation and Resistance in the Smoking Room at a Mental Health Ward

Struggles for a space ‘in-between’

Agnes Ringer and Mari Holen

Introduction

This chapter explores the significance of the smoking room in a mental health ward in Denmark – as a place of struggle, regulation and resistance. Our data, produced by participant observation and interviews at an acute locked ward, indicate that the smoking room was an important place for service users. Many users stayed for hours at a time in the smoking room and reported that the relative privacy of the room and the company and open conversations with other users provided crucial support during their stay at the ward. This was in contrast to the other spaces of the ward, which were construed as belonging more to staff (Ringer, 2013b). This is in line with other ethnographic studies on psychiatric wards, which have noticed a symbolic meaning of the smoking room as an often ‘staff-free’ and special place for users. Ethnographies have alternately characterised the smoking room at mental health wards as a ‘free area’ for users (Terkelsen, 2009, p. 207), as a ‘patients’ arena’ (Skorpen, Anderssen, Oeye, & Bjelland, 2008, p. 731) and as an ‘inner sanctuary, a world within a world’ (Thomas, Shattell, & Martin, 2002, p. 102). The smoking room has been described as a place where users can engage in an activity not related to ‘being treated’ and hence a space that may temporarily destabilise a position as ‘psychiatric patient’ (McGrath, 2012; Ringer, 2013b). In their study of the smoking room at a psychiatric ward in Norway, Skorpen et al. (2008) note that the smoking room became an arena for strategic resistance for users in that it provided ‘a space and opportunity to retain parts of their civil life and dignity’ (p. 733).

Our fieldwork reproduces many of the findings of other studies on the importance of the smoking room for service users. The present chapter, however, goes beyond an analysis of the significance of the smoking room for service users. Instead, we explore the smoking room as a space, whose status remained unresolved – and hence as an area of negotiations and struggles between users and professionals. The smoking room in our study constitutes space at once produced as ‘other’ (Foucault, 1986) and subject to discipline and regulation. From this perspective, rather than it being a sanctuary or ‘free space’, we will argue that the smoking room at a mental health ward may be understood as having a complicated status as a space ‘in-between’: simultaneously part of the institution and yet different from it.

In 2007, it became illegal to smoke in public places in Denmark, including hospitals and psychiatric institutions. The introduction of the smoking law brought with it changes to the daily practices of psychiatric wards and new smoking rooms were arranged. Meanwhile, hospital employees were banned from smoking in the area of the hospital and were to be shielded from entering areas with cigarette smoke. This was in contrast to earlier practices, where users and staff could drink coffee and have a cigarette together in the same space (Skorpen et al., 2008). The smoking room now constitutes the one room at mental health wards in Denmark that does not have any clinical function, and where the professionals’ presence is largely unwarranted. Since the professionals are responsible for the order of the ward and for treatment, finding an appropriate way of relating to such a space may become Difficult. The chapter specifically analyses the course of events during a conflict on regulations of the ward’s smoking room. Data are derived from an ethnographic study conducted by the first author (AR) involving participant observation, informal conversations and formal interviews at a locked acute psychiatric ward – here called ward D.¹ The fieldwork lasted six weeks and was conducted in 2011. The data selected for presentation primarily come from the first author’s presence in the smoking room and the staff room, as well as interviews with users and professionals.

Based on Foucauldian perspectives on space and discipline, the analysis examines how negotiations about the smoking room connect to larger issues concerning the production of space, time and bodies at a mental health ward. The time at the ward and the time spent in the smoking room are separate, but interconnected. The disciplining of bodies, present in other spaces of the ward, becomes differently magnified and tangible in the smoking room. Thus, we argue, the ‘in-between’ status of the smoking room provides a ‘mirror’ for specific tensions and problems that epitomise fundamental issues concerning space and discipline in psychiatric hospitals in general.

Space and discipline in mental health practice

There is a growing interest in the importance of space and matter in mental health care, as evidenced by this book. Social constructionist accounts have traditionally placed a great emphasis on language in mental health practice and user experience, often neglecting to incorporate an analysis of the material and spatial aspects of the world. Yet, as Latour (2005) has argued, material objects are inherent to the social world of humans; objects mediate and transform interactions and experience and hence cannot be seen as either ontologically separate or only made meaningful through discourse (McGrath, 2012). From this perspective, space and the material participate in the production of social life and human experience and – conversely – the meaning of a particular space is emergent from the social interactions that take place in the space (McGrath, 2012)

Mental health wards are not just ‘clinical spaces’ or places for treatment. They are also juridical spaces, whose function is to separate and to attempt to ‘same’ individuals who have been rendered ‘different’ (Parr, 2008). Mental health wards have been argued to be spaces whose material makeup is permeated by a concern with risk, monitoring and observation (McGrath & Reavey, 2013; Rose, 1998) contributing to positioning users as ‘risky’ individuals in need of surveillance. The material and spatial make up of a mental health ward thus may be said to shape the experience of service use and the types of interactions that may take place in a ward.

In this chapter we draw on Michel Foucault’s (1986, 1991) work on discipline and space to analyse the production of time, bodies and space in the smoking room. Fundamental to Foucault’s argument is that discursive and non-discursive elements are intimately linked – and that the material and spatial context as well as a person’s embodiment participate in the production of disciplinary power (McGrath & Reavey, 2013). Space plays a fundamental role in regulating and disciplining bodies (Foucault, 1991) and Foucault’s analysis of the history of madness may essentially be read as a history of unreason being disciplined by reason through regulation of space, bodies and time (Parr, 2008).

Foucault’s genealogical analyses have sometimes been interpreted as presenting a full picture of mental health care (Parr, 2008). Meanwhile, a ‘totalising’ application of Foucault’s theories runs the risk of reducing the complexities of mental health practice to great unspecified patterns of domination (Barrett, 1996; Parr, 2008; Ringer, 2013a). Instead, as Parr (2008, p. 14) puts it, a Foucauldian analysis of mental health space must also make efforts to: ‘rescue the mental patient from being an unreachable “other” in the history of the asylum, an “other” merely subjected and silenced into a docile body’. This provides an argument to select as our case the smoking room – a space produced as ‘other’, and not entirely ‘institutional’ by both professionals and users. By analysing a conflict between some users and professionals, we catch sight of how the smoking room exists by virtue of specific ways of disciplining time and bodies. At the same time the smoking room also becomes a platform for resistance, which allows for struggles to emerge for the right of access, ownership and self-determination.

The trouble in ward D

Ward D occupied one floor in a building surrounded by other mental health wards, next to a middle-sized town in Denmark. The ward had recently been refurbished and with its sparsely – but expensively – furnished clear spaces, it gave the impression of a modern clinic. It contained 14 single bedrooms for users, a staff room, a television room, a dining room, two rooms for conferences and conversations and an activity room with a table-tennis table, which usually stood folded by the door. The ward was a locked acute ward and the users were both voluntary users and users who were treated involuntarily. Individual user privileges, such as leave, no leave or assisted leave and the right to hold cigarettes were meticulously registered on a whiteboard in the staff room.

The smoking room was a glass booth adjacent to the outer wall of the ward, with grid flooring so smoke could escape. It did not contain any furniture, but the users would often sit directly on the grid-floor to smoke. Physically at once part of the ward and outside its walls, the entrance to the smoking room was located by the television room, with a glass door leading to it from the inside. As it was intended for users, and almost always remained ‘staff-free’ due to non-smoking workplace health regulations, many users would gather in the smoking room and sit for hours on the grid floor. The rules of the ward were many and included a ban on talking about distress, illness and medication, as the professionals believed this would confuse and worsen the users’ condition. While the users therefore learned to regulate their topics of conversation in the other places of the ward, in the smoking room they could cover a range of ‘forbidden’ topics. They shared experiences of distress, discussed worries and thoughts about being at the ward, comforted each other, had disagreements and laughed together. Many users said they used the smoking room therapeutically to get ‘peer-therapy’ (Skorpen et al., 2008). One user said about the talks in the smoking room: ‘We’re not allowed to talk about each other’s illnesses, but I’ve gotten more out of talking with the patients than with the staff […] so we’ve really helped each other a lot’. Consequentially the smoking room played a symbolic role for many users, and it was produced as a ‘private space’ (McGrath, 2012; Ringer, 2013a) where they could negotiate topics of conversation without the influence of professionals.

The trouble in ward D began when the professionals attempted to introduce a ban on sitting down in the smoking room. The reason for enforcing the ban, they explained to me (AR), was that they wished to reduce the amount of time spent in the smoking room and prevent the formation of cliques among users. This rule was subject to debates both within the user group and during joint meetings between users and professionals. Two of the users who attended the smoking room frequently included a woman in her twenties, Hanna, and a man in his mid-thirties, Emil. We will explore the unfolding of events surrounding the smoking room by focusing on them.

During a staff morning meeting in the staff room, shortly after the introduction of the rule, the nurse, Amy, who had been away for some time, came back. She seemed upset and said that she had just been to the smoking room where she asked David, a service user and a friend of Hanna’s, to stand up and not sit down. David got on his feet, but then Hanna, who had previously been standing in the smoking room, sat down right in front of the nurse. The nurse explained that she had asked Hanna to stand up, but Hanna had just replied calmly ‘What’s that to you?’ Nothing like it had ever happened before and the nurses started discussing what to do. They all agreed that Hanna’s behaviour was unacceptable and they discussed different ways of reacting. Amy’s final remark was ‘I thought 1–0 to Hanna, that triggers me, I want to win!’

Later that day, I (AR) heard Hanna discuss the ban on sitting down with Emil in the smoking room, asking him to support her aim by also sitting down when the nurses came. Emil agreed and they spent a part of the day sitting down in the room. During the joint meeting for users and professionals, Hanna complained that all the rules at the ward made her feel worse and that she was feeling very ill. Emil lent her support, calling the rules ‘inflexible’. After the meeting, a nurse explained to me that she enjoys working with patients who are very ill – unlike Hanna. She said: ‘patients who feel very bad don’t think about these things’ and stated that Hanna does not really belong at the ward. Two days later when I came to the ward, Hanna had been moved to another ward. The professionals called Hanna’s displacement ‘a punishment’ and congratulated the ward psychiatrist on taking such a firm stance. They explained that Emil had attempted to protest Hanna’s removal together with some of the other users, and they jokingly imitated Emil saying ‘you only want to separate us’.

Time and space in the smoking room at ward D

The trouble in ward D raises questions such as: how may we understand the actions of the professionals and users in the case? Why does the conflict emerge and intensify? What type of a space constitutes the smoking room since it may trigger such strong reactions for both users and staff? A close analysis indicates that the conflict may be understood as a struggle about two fundamental aspects at a mental health ward: time and bodies. We will start by analysing negotiations of time, which is both an explicit and implicit presence in the case.

Time is a pivotal, though often invisible, factor at ward D. Time is constituent for institutional space (McGrath & Reavey, 2013). A mental health ward is not a permanent place. The time of discharge and the duration of hospitalisation is subject to negotiations (Ringer & Holen, 2015). While the users often have their own perception of when hospitalisation and discharge is useful, it is up to the professionals to decide the time frame for they stay. The time inside a mental health ward is equally regulated. The days are structured generically, as an ideal picture of how a healthy daily rhythm ought to look, for people who are well. This regulation of time is justified as being conducive to recovery and it is couched in biomedical terms: there is time for treatment, medication tim...