Why are certain places perceived to be therapeutic, to make people feel better about life, about themselves, and about their bodies? What is belonging? And how can we, as clinicians, harness the power of place and belonging to evoke therapeutic outcomes? Ezra Griffith, Professor Emeritus at Yale University, former president of AAPL, and for two decades the Editor of the Journal of the American Academy of Psychiatry and the Law, provides a roadmap in his most recent book, Belonging, Therapeutic Landscapes, and Networks: Implications for Mental Health Practice. This book is a deeply personal exploration that conveys wisdom gleaned from decades of clinical leadership, scholarship, and bearing witness to people's stories. At turns compassionate, pleading, and tough (spoiler alert: Yale University does not get off easily), Dr. Griffith pulls no punches in exhorting clinicians to up their game: to listen closely, to be generous with explanations, to place themselves in the shoes of the other, to avoid facile assumptions, to be kind.
Chapter by chapter, Dr. Griffith leads the reader through a kaleidoscope of complex landscapes in which we live our lives. The term “landscape” initially brings to mind an expansive view of physical space, yet it readily accommodates additional abstract elements, such as culture, productivity, social networks, and philosophical practices used in extreme environments such as forensic psychiatric hospitals. Early in the text, Griffith identifies topophilia, the bond that develops between person and place, as a common ingredient for our sense of belonging, which he characterizes as an “indescribable feeling” of total relaxation, confidence, and grace experienced when we feel genuinely accepted. The book shines when Dr. Griffith describes personal experiences from his youth that evoke belonging: eating warm, doughy “bakes” during tropical rainstorms, running in his beloved soccer fields, or listening to open-air church services carried on the warm evening breeze:
In front of my home in Barbados there was an open space large enough to accommodate about thirty people. They would stand around in a circle and participate in a church service in the early evening hours. At the center of the circle, there were usually a small table with a Bible and a kerosene lamp for illuminating the meeting. Those who attended the service engaged in singing hymns, praying, and testifying about God's goodness and mercy. The people who lived in the houses closest to the outdoor service would sit at their windows and join in the singing and praying. Others from the village might join the group and participate at different levels of commitment. There were also passers-by who stopped and quietly observed what was unfolding. This was the classic open-air service of the 1950s in the Caribbean [p 99].
Dr. Griffith is also quick to illustrate how activities, thoughts, feelings, and relationships that transpire within a space sculpt the quality of our lives. With this in mind, he describes the following life landscapes: home, work, sacred spaces, travel/migration, prisons/forensic psychiatric hospitals, and lei- sure/citizenship groups. He weaves together data gleaned from anthropologic and sociologic literature with illustrative personal anecdotes. He then punctuates each of these landscape narratives with a call to action for mental health clinicians to acknowledge and consider the impact of these spaces in patients' lives. Such “life stories” can, in turn, inform treatment:
I have documented the ways these elements fit together, forming a model useful for the conceptualizing of a life story. First comes the clarifying of the structures in which people spend their lives. This is achieved through a visual representation of the spaces in which they pass their time, the architecture of the spaces, the advantages and inconveniences of the structured space, and placement of those who share the space. The second step is the codifying of the interactions taking place in the spaces, their qualitative frequency, and the marker events flowing from them. The author of the story should be encouraged to state what problematic encounters exist. This facilitates the development of a narrative the story's author can own and enrich. In the third phase, the clinician can step up and collaboratively contribute to framing the problems so clinician and patient jointly consider the treatment program [p 228].
Many readers will find the chapter on “Prisons and Forensic Psychiatric Hospitals” highly relevant to their work. As clinicians working in a forensic psychiatric hospital, we approached Griffith's text with curiosity about fostering a sense of belonging when many individuals occupying the space are there against their will. Griffith first cautions us to resist the tendency toward the erosion of dignity and au tonomy. We also must acknowledge the suffering that comes with uncertain length of stay, noting it can feel impossible to work toward future goals while relentlessly coping with “being tried and tested every day” (p 157). Furthermore, embracing the Recovery Model philosophy in the long-term care environment requires a semblance of support similar to what is typically obtained in the landscapes of home, work, spiritual space, and leisure activity. The therapeutic space, and the activities and relationships it enables, cannot be so artificial as to create an impassable chasm when the patient is released from the institution. Griffith reminds the reader of the inherently disruptive nature of psychiatric hospitalization, which by design removes people from their usual networks of support in the community and places them in geographically and socially iso- lative “extreme” conditions. Thus, he implores clinicians to view transition planning as a moral imperative:
Further consideration of the inmates and patients occupying these mundane but extreme environments imposes an obligation. It is to question the interventions needed to prepare these individuals for an eventual return to community living. We may not ignore that imperative. If we do so, we run the risk of banishing these individuals to a zone of exception or invisibility, producing social control and clinical inattention [p 229].
With historical perspective, Griffith maps out the intentional design of secured facilities (traditionally prisons) to induce “mental destabilization, promoting the power of the jailer and influencing prisoners to contemplate their transgressions and ultimately change their behavior” (p 168). Yet current evidence indicates the promotion of humane respect and the de-emphasis of punishment leads to less misconduct. This begs the question of how the design of modern- day, secure health care environments influences behaviors. Griffith mandates that, in extreme environments, particularly in the context of mental illness that causes damage by disrupting our connection with others, support must be “consistent, reliable, and not demeaning” (p 24). And although safety must be ensured, so must dignity and some degree of autonomy and privacy. Therefore, we begin by asking how the physical landscape can help achieve these ideals. Are we making use of therapeutic design elements, including strategic lighting, colors, sound, access to outdoors, and material textures that influence mood and interaction style of both patients and staff? Are there diverse spaces available to provide a sense of home, vocational self-worth, and spiritual nourishment?
Griffith does not propose easy solutions to the complex problems raised by displacement and isolation within the various landscapes he reviews. Rather, throughout the book he provides a set of guiding principles by which sympathetic clinicians may help others navigate their difficulties. First is the willingness to bear witness to people's stories with sensitivity and compassion.
The journey away and the return home are always difficult to untangle. But the clinical imperative of being willing to travel with the client on this uncharted journey is a first and important step to grasping the significance of landscapes and what can be done to evoke hope and channel it with sensitivity and compassion [p 157].
Second is to appreciate complexity and to avoid making assumptions when listening to others; homes and parents can be good and bad, spiritual support from church members can be limited by human foibles, work places can be in some ways supportive and in other ways destructive:
This is a warning to the clinician that facile diagnosis of these difficulties is not so easy as sometimes thought at first …. Whatever the result, clinicians must be careful of rushing to judgments about how and why the stories unfold as they do [p 155].
Griffith calls upon clinicians, who typically occupy positions of power and privilege in our communities, to play an active role in including and welcoming others, whether in small ways (e.g., making room for a new colleague at a meeting table) or large (e.g., mentoring in professional organizations):
We must be aware how exclusively or inclusively we draw the circle of belonging Themoral imperative is there in the idea of belonging Belonging should not belimited to those possessing the dignity of worth This approach to the struggle defines belonging in a unique way but also places a moral obligation on those who wield power to redraw the circle of inclusion and to bring others inside the perimeter. The excluding of outsiders is an act of moral decay [p 12].
Ultimately, Griffith points out that clinicians have moral obligations that transcend clinical work and involve a humanistic commitment to create strong, deep communities that welcome the most disadvantaged and vulnerable. These inclusive communities are fundamentally what sustain us, a concept with timely salience in the context of the current political debate on immigration policy. As Griffith quotes from Michael Rowe, “Our humanity is not a given. It can wear away. We maintain it by drawing on structures that nourish it” (p 150).
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2019 American Academy of Psychiatry and the Law
