Therapeutic landscapes in holistic medicine

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Soc. Sci. Med. Vol. 46, No. 9, pp. 1193±1203, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain S0277-9536(97)10048-X 0277-9536/98 $19.00 + 0.00

THERAPEUTIC LANDSCAPES IN HOLISTIC MEDICINE ALLISON WILLIAMS Health Studies Program, Brock University, St. Catharines, Ont., Canada L2S 3A1 AbstractÐTherapeutic landscapes are places, settings, situations, locales, and milieus that encompass both the physical and psychological environments associated with treatment or healing, and the maintenance of health and well-being. Practices from holistic medicine Ð also known as nonconventional, alternative, complementary or traditional medicine Ð are used to illustrate speci®c humanistic concepts in further examining therapeutic landscapes. In addition to contributing to a theoretically-informed health geography, this paper further develops the concept of therapeutic landscapes and the understanding of holistic medicine. # 1998 Elsevier Science Ltd. All rights reserved Key wordsÐtherapeutic landscapes, holistic medicine, humanistic geography

INTRODUCTION

While medical/health geography continues it's interest in the socio-ecological model* of health (White, 1981; Kearns et al., 1987; Hayes et al., 1990), the discipline continues to be occupied with exposing itself to theoretical positions outside of the traditional realm of positivism (Litva and Eyles, 1995; Philo, 1996; Kearns, 1993, 1994; Dorn and Laws, 1994; Mayer and Meade, 1994; Eyles and Litva, 1996). The active engagement of contemporary social theory and the new frontiers of cultural geography have brought about an enhanced understanding of both the meaning and nature of place, with respect to health and health care (Gesler, 1993; Jones and Moon, 1993; Kearns, 1995, 1996; Kearns and Joseph, 1993). This ``reformed post-medical geography of health'' (Kearns, 1993) has provided geographers with the opportunity to creatively explore a ``complex terrain of theoretical re¯ection'' (Philo, 1996). Therapeutic landscapes are those changing places, settings, situations, locales, and milieus that encompass both the physical and psychological environments associated with treatment or healing; they are reputed to have an ``enduring reputation for achieving physical, mental, and spiritual healing'' (Gesler, 1993, p. 171). Using the new cultural geography as a conceptual framework, therapeutic landscapes are examined in Gesler's overview of the connection between landscape and the treatment or healing of illness (Gesler, 1992). While broadly reviewing the developments in humanism, structuralism, time-ge*The socio-ecological model of health views an individual as one particularly versatile interacting element in a complicated social and physical ecosystem. Health and ill-health are understood from the interaction that one has with their social and physical surroundings (White, 1981).

ography, and the interaction of structure and agency, Gesler ful®lls his purpose of informing health researchers about recent developments in cultural geography, with the hopes of encouraging further research along these lines (Gesler, 1992). Gesler (1992, 1993) makes clear the value of incorporating theoretical perspectives from cultural geography into medical geographic inquiry concerned with the links between landscape, health and healing. The purpose of this paper is to go beyond Gesler's broad overview by further employing the conceptual framework of humanism in extending the concept of therapeutic landscapes, as illustrated through examples gleaned from holistic medicine. The paper is intended to be a broad overview of humanistic concepts, and thereby only touches brie¯y on many points which may be pursued in more depth. In ful®lling the aforementioned purpose, this paper contributes to a theoreticallyinformed health geography. In addition, a contribution is made to the growing literature on therapeutic landscapes (Gesler, 1992), while furthering knowledge about the minimally-researched area of holistic medicine (Anyinam, 1990; Shro€, 1996). Various holistic medical practices will be used to illustrate the connection between landscape, broadly de®ned by humanism, and treatment, healing and health. The humanistic concepts that will be examined include: symbolic landscapes; importance of meaning, value and experience; sense of place; authentic and unauthentic landscapes; landscapes of the mind; and landscapes as text. Before developing these concepts in light of the notion of therapeutic landscapes as applied to speci®c holistic medical practices, both holistic medicine and the humanistic approach are reviewed.

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The humanistic approach gives a central and active role to human awareness and human agency, human consciousness and human creativity, by placing emphasis on the mind's interpretation of phenomena (Gregory, 1991). Human agency, where creative individuals construct, evolve, and operate in their lived environments, is crucial to understanding the connection between landscape and treatment, healing and health. The many concepts found in humanistic geography de®ne the landscape as not only a physical and built environment as modi®ed by human action, but as ``a product of the human mind, and of material circumstances'', and as that which re¯ects ``both intentions and actions and the constraints and structures imposed by society'' (Gesler, 1992, p. 743). The individual is therefore critically instrumental, on both a conscious and sub-conscious level, in creating, living in and being in¯uenced by the environments or landscapes of their lifeworld. Rather than review the multitude of perspectives that make up the humanistic approach*, suce it to say that they are founded on the philosophies of phenomenology, existentialism, pragmatism and idealism (Pocock, 1988). The humanistic approach, although revived in geography during the 1970's as a result of the deep dissatisfaction with the positivistically-oriented spatial-scienti®c geography and concerns about the limits of behavioral geography (Gregory, 1991), it has yet to make an indelible mark on medical/ health geography (Sixsmith, 1988). The main criticism that has been levied against humanism is the lack of acknowledgement given to the numerous structural constraints which impact individual experience. Policies, institutions, economics, social structures, social identities and politics are among the many structural constraints that impact the latitude and conditions under which individuals create meanings. It is these same constraints that play a major role in di€erentially creating illness, maintaining health, and in making available and accessible therapeutic landscapes. For many, the reconciliation of humanist and structuralist approaches has come with the acceptance of struc*These approaches are well documented elsewhere (Cloke et al., 1991). {In light of the growing acceptance of the socio-ecological model and the increased focus on wellness, health promotion and disease prevention, a similar broad de®nition of health which includes an individual's physical, mental, social, cultural, economic and spiritual well-being has been adapted. This is con®rmed in the WHO de®nition of health: ``a state of complete physical, social and mental wellbeing and not merely the absence of disease or in®rmity'' (WHO, 1983, p. 24). {Exceptions exist. The ®ndings of the well-cited place and health study by Abel and Kearns (1991) is based on quantifying qualitative information.

ture and agency interacting in a recursive manner, where both continually in¯uence the other (Giddens, 1984). As shown herein, this interaction between agency and structure is an essential premise to examining the humanistic approach, where the focus is on human agency, or the individual as being in the world (Pocock, 1988). Recognizing the many structural constraints under which individuals create meaning, and the basic individuality of health and ill-health, re¯ected in the individualized experience of health and/or illhealth and the individualized delivery of service (Patton, 1980), explains why the humanistic approach can provide insights that are essential to the development of a ``reformed post-medical geography of health'': The problems that confront the health services concern individuals. Individuals catch diseases, individuals break their legs. There are often circumstances which make individual cases unique. Individuals understand, react to and cope with their conditions in di€erent ways. Moreover the ways in which people are cared for are often related to individual needs and circumstances (Sixsmith, 1988, p. 12).

As individual citizens, particularly in the developed world, are taking greater responsibility for their health and their health care decisions Ð partly as a result of the declining welfare state Ð the need for a humanistic approach in health research becomes essential. Although other social scienti®c perspectives focus on the individual, it is ®tting that the characteristically subjective humanistic research tradition is used in conjunction with holistic medicine Ð which also works from a subjective perspective, in further examining therapeutic landscapes. Unlike the biomedical model, which has traditionally taken charge of the therapeutic process, the holistic model is decentralized and supportive of individual empowerment and choice. In holistic medicine, a client is viewed as an individual, where the unity of mind, body and spirit is emphasized{ (Goldstein et al., 1988), and where practitioners encourage patients to relate their personal experiences, beliefs and feelings in order for the patient's situation to be holistically interpreted (Gesler, 1992). Patient empowerment and choice are central to the model, similar to the central tenet of humanism, human agency. The subjective approach that humanism purports is, in itself, holistic, in that the mind, body and spirit are potentially employed when meanings are conferred to objects or relationships (Ley, 1981a). This is in contrast to both the positivistic framework and, to a certain degree the biomedical model which, in most cases{, characteristically use quanti®cation and reductionism. Similar to humanism and the philosophy of holistic health, the concept of therapeutic landscapes resists the positivist hegemony and ``criticizes positivism for many of the

Therapeutic landscapes in holistic medicine

same reasons that it criticizes the biomedical model itself'' (Gesler, 1992, p. 744). HOLISTIC MEDICINE

Similar to the broad de®nition of landscape employed herein, holistic medicine is broadly de®ned as those healing practices and beliefs lying outside the formalized canon of scienti®c western biomedicine. The breadth of the de®nition in this paper is used in order to best facilitate the examination of therapeutic landscapes in depth. Holistic medicine is understood herein as including alternative, complementary, and traditional medical practices, including homeopathy, naturopathy, spiritual healing, traditional healing, mid-wifery, touch therapy, imagery and visualization therapy, and art therapy. Due to the holistic model perceiving both health and ill-health on the same continuum, landscapes are understood herein as not only healing places, but those landscapes associated with the maintenance of health and well-being. This is a result of holistic medicine being, in addition to its role in eradication of disease (Patel, 1987), dedicated to the achievement of good health through preventative measures. Holistic practitioners purport to view the individual as made up of many dimensions functioning interdependently (Deliman and Smolowe, 1982). As mentioned, the holistic paradigm views the inclusion of diverse causal agents in disease and health Ð mainly a complex interaction of physical, mental, emotional, spiritual, environmental and societal factors. Practitioners use a comprehensive multidimensional approach to practice, so that ``the nature of these dimensions, and their relationships with one another can be understood and used e€ectively in treatment'' (Deliman and Smolowe, 1982, p. 5). Illness is then understood as a disturbance of the uni®ed functioning of the whole and not just an isolated cause or e€ect (Deliman and Smolowe, 1982), while health is the sound functioning of the whole. Holistic medicine has experienced a dynamic history of cyclical stages of reclusiveness and resur-

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gence. The present popularity of holistic medicine in the Western world has resulted in a number of developments, including: a growth in the number of holistic practitioners; the formation of various representative associations promoting holistic medicine; a growth in the number of training programs being o€ered, and the removal of legal restrictions which previously posed as barriers to practice (Anyinam, 1990). The reasons for this resurgence are many, and include: the limitations of conventional, scienti®c medicine in treating chronic illnesses (Kronenfeld and Wasner, 1982); the increasing overall dissatisfaction with conventional medical care (Patel, 1987; Anyinam, 1990); the increased responsibility and control individuals are taking in disease prevention, health and well-being (Salmon and Berliner, 1980); an emphasis on selfcare, self-healing and health education (Goldstein et al., 1988); the changing health needs of the late twentieth century, shown in the prevalence of chronic illness (Coyne and Fiske, 1992; Lyons et al., 1995); greater interest and belief in the connection between mind and body (Goleman and Gurin, 1993); and personal preference. Many of the aforementioned reasons for the resurgence of holistic medicine are both directly and indirectly due to the restructuring of health care provision, which has thrust self-care onto dependant populations. The increased knowledge of holistic medicine has seen a growing number of individuals using holistic practices, also shown in the growth of modern physicians incorporating speci®c complementary practices Ð such as chiropractic and acupuncture Ð into their care (Eisenberg et al., 1993; Hedley, 1992; Yates et al., 1993). Much criticism has been directed at holistic medicine and its practitioners. Berliner and Salmon suggest that holistic practices such as meditation, hypnosis, and biofeedback contain heavy doses of mysticism and charismatic elitism (Berliner and Salmon, 1985). This is undoubtedly true, as the environment is presently unregulated; the growth of ``new age'' practices con®rms this (Shro€, 1996). This misrepresentation of holistic medicine is dangerous, as are claims made by practitioners mas-

Table 1. Humanistic geography as applied to holistic medicine Concept

Health applications

Symbolic landscapes Importance of meaning, value and experience

medical semiotics medical beliefs

Sense of place

psychological rootedness

Authentic and unauthentic landscapes

caring environments

Landscapes of the mind

®elds of care

Hermeneutics/landscapes as text

tapping into the sensory experience

Association with holistic medicine *basic element in therapy e.g. the aboriginal medicine wheel *incorporation of individual and/or cultural belief systems e.g. new age practices *belief that environment holds meaning, signi®cance, and felt value e.g. planned home-birthing *formation of environments through human networks of care e.g. aboriginal hospitals and birthing centers *imagery used in accessing healing environments e.g. visualization *interpretation of health conditions e.g. art therapy

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querading as holistic healers, stating that they can miraculously cure diseases in order to lure vulnerable and ill people into paying large sums of money for unproven therapies. The evaluation of many holistic practices has yet to be carried out, questioning their safety, availability and wide application (Barrett and Jarvis, 1993; Barrett and Herbert, 1994). The speci®c holistic practices that will extend the concept of therapeutic landscapes, as seen through the particular lens of humanistic geography, are outlined on Table 1. The concept of symbolic landscapes will be presented ®rst, as symbols de®ned in and on the landscape are the essence of the association between humanistic geography and holistic medicine, and are the key element in understanding therapeutic landscapes. SYMBOLIC LANDSCAPES

Rowntree and Conkey (1980, p. 460) write that the de®nition of a symbol focuses on an ``information-storing component''. Because the information component of both concrete and abstract symbols is culturally de®ned, they signify meaning to those who know them. Symbolism is evident in most social reality, illustrated well in medical systems: ... [a] medical system is an ordered, coherent body of ideas, values, and practices embedded in a given cultural context from which it derives its signi®cation. It is an important part of the cultural world and as such it is constructed, like any other segment of social reality, by the remnant body of symbolic meanings. (Kleinman, 1973, p. 208)

Examples of symbolic meanings found in medical systems include: the naming, interpreting, and classifying of illness; the structuring of the experience of illness, and; the therapy applied to healing the illness (Kleinman, 1973). The healing and/or maintenance of health thereby ``occurs along a symbolic pathway of words, feelings, values, expectations, beliefs and the like, which connect cultural events and forms with a€ective and physiological processes'' (Kleinman, 1973, p. 210). This symbolic reality is experienced by patients, providers and the society in which they are a part. Many of the symbols found in therapeutic landscapes are, not surprisingly, related, associated or congruent to the symbolism found in the medical system, as discussed above. Landscapes are also symbolic systems, as they are partly the construction of cultural images and signs (Ley, 1985; Smith, 1993). The culturally-de®ned health and healing symbols found in the landscape are central to the concept of therapeutic landscapes, as they signi®cantly determine the ``way of seeing'' the landscape (Gesler, 1991, p. 170). Once such a symbolic system is understood, through medical semiotics, therapeutic landscapes can be interpreted,

de®ned, created, and applied in healing and health practices. Medical semiotics The study and interpretation of signs, objects, ideas, behaviors, feelings and events is called semiotics. Medical semiotics is used in the interpretation of the symbols between medical and cultural codes and, in doing so, de®ne culturally-based symbolic landscapes. Because symbols are culturally de®ned, medical semiotics are most easily applied within the context of cultural groups, such the aboriginal peoples of North America. A well-known cultural symbol for aboriginals is the medicine wheel, which works to mediate between cultural understanding and healing. The aboriginal medicine wheel is literally found on the physical landscape, one of which is described as: ``an elaborate con®guration of stones [which]... lie in a pattern resembling a large 28-spoke wheel, 80 feet across... symbolized by the four directions'' (Brink, 1989, p. 45). It, like any other cultural symbol can also be imagined in the landscape of the mind. The medicine wheel intercedes between the biophysical aspects of health, and the socio-cultural aspects of aboriginal people in treating ill-health, as illustrated in its use in therapy: The wheel re¯ects therapy from beginning to end, a single session, or a moment in a session. The pursuit of the medicine wheel begins in the East and moves clockwise. East is dawn, birth, the beginning of a search, or an individual's decision to begin therapy. Moving South, the physical, trusting, innocent side of life is the stage of life of childhood, of learning to walk and take charge of one's life. South is gaining trust in oneself, trust in the healing powers that come from within, and trust in one's therapist. West, the dark emotional side of the individual, is the struggle of life, of being responsible to marriage, children, and one's profession. West is getting down to work in therapy, exploring the emotional pains of life, and facing the unknown. Facing these unknowns lead to greater understanding and spiritual growth, the North. North is the spiritual experience that comes from deep emotional understanding, the peak experience in therapy, or the ¯ash of insight. It is wisdom gained from life's experience. North provides the understanding and wisdom to make the appropriate decision in life, the East, of using the wisdom and understanding to continue in life and begin the circle anew. Each moment in life is re¯ected on the medicine wheel. (Brink, 1989, p. 48)

Meanings of cultural symbols such as the medicine wheel are ¯uid, as they vary by degree from individual to individual (Pocock, 1988), as well as temporally. The individual meanings of such symbols must be ®rst de®ned by the patient in order for the therapist to e€ectively use them. Although slowly, individual and cultural symbols change, as humans are continually forming and reforming their world and their place in it (Jackson, 1985; Rowntree and Conkey, 1980), as noted by Meinig: ... symbolic landscapes... arise out of deep cultural processes as a society adapts to new environments, technol-

Therapeutic landscapes in holistic medicine ogies, and opportunities and as it reformulates its basic concepts... Such changes do not come quickly... (Meinig, 1979, p. 184)

Because the de®nition of therapeutic environments is dependent upon symbolic landscapes which are ever-changing both individually and within society, they too are subject to similar change, albeit over a very long period of time. Knowledge of and access to the current meaning of these changing symbols are, therefore, necessary if practically used within a therapeutic landscape. The use of symbolism in therapeutic landscapes is evident in the ®ve other humanistic concepts discussed, beginning with meaning, value and experience. IMPORTANCE OF MEANING, VALUE AND EXPERIENCE

Humanistic geographers stress the importance of meaning, value and experience in comprehending the life world (Guelke, 1974). This is similar to the emphasis that holistic practitioners give to individual beliefs about health and health care, as these beliefs often de®ne the meaning, value and experience of disease, healing and health. Medical beliefs embrace cultural and spiritual beliefs, values and experiences. The holistic paradigm, in an e€ort to address the many dimensions of a person, accepts and in some cases incorporates these beliefs, values and experiences in healing and health. The characteristic plurality of many holistic practices incorporates an individual's medical beliefs with ease, as they use adaptive healing strategies which easily combine various in¯uences (Fulder, 1992). The holistic healing environment is therefore a positive milieu for the acceptance and integration of cultural and individual medical beliefs, whether associated with the physiological, environmental, psychological, spiritual and/or supernatural (Fuller, 1989). This ¯exibility will now be examined. Medical beliefs A client's meanings, values and experience of their health and their larger lifeworld are often a topic of inquiry during the ®rst visit to an holistic practitioner. For example, the ®rst visit to a naturopathic or homeopathic practitioner entails the writing out of a detailed life history, which is then the basis of a lengthy discussion. This is done partly because medical beliefs are understood to be of importance in the healing process, as they provide a framework within which to function and explore the client's inner and everyday world (Whitney, 1982). By considering clients' medical beliefs when tailoring the design of the therapy given, the practitioner is better able to work comprehensively with the client (Taylor, 1984). In an attempt to integrate a client's belief system into the healing and/or health process in the creation of a therapeutic landscape, holistic practitioners choose from a great diversity of practices,

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often converging client beliefs with those associated with the particular healing practices chosen. Because holistic practitioners use a comprehensive, multidimensional approach, in order to address the physical, spiritual and emotional aspects of being, it is not uncommon that a number of di€erent therapies that are suited to a patient's medical beliefs are used simultaneously. In addition to the acceptance and integration of various belief systems, practitioners have the freedom to mix and match many di€erent therapies to best meet the speci®c beliefs of their clients. The ``new age'' movement can be seen as the epitome of medical pluralism, as it is a myriad of innumerable di€erent kinds of medical belief systems, which are simultaneously characterized as holistic, secular, western, supernatural, religious, eastern, ritualistic, and postmodern (Levin and Coreil, 1986). Traditional practices can also be employed for those who follow a culturally-speci®c spiritual belief system. Belief in supernatural practitioners and their practices are commonly intrinsic to the social and cultural traditions that evolved in order to enhance health (WHO, 1983). Many traditional practitioners are allegedly endowed with supernatural or magical powers, such as medicine men, priests or witch-®nders. Their role is to diagnose, by identifying the deity, ghost, or other agent causing illness, and administer therapy (WHO, 1983). Just as meaning and value are found in an individual's medical beliefs Ð which often dictate the type of therapy/assistance they seek, meaning, value and experience are found in those environments which have a strong sense of place. SENSE OF PLACE

Sense of place de®nes the identity, signi®cance, meaning, intention, and felt value that are given to places by individuals (Pred, 1983), as a result of experiencing it over time (Relph, 1976; Tuan, 1976). As Gesler summarizes, ``Places provide meaning for people in many di€erent ways: through identity and feelings of security, as settings for family life and employment, as locales for aesthetic experience'' (Gesler, 1992). It is through lived experience that moral, value, and aesthetic judgements are transferred to particular sites which, as a result, acquire a spirit or personality. It is this subjective knowledge that give such places signi®cance, meaning and felt value for those experiencing them. Just as some environments have negative connotations, experienced environments that have a strong positive sense of place have a therapeutic e€ect ``on human attitudes and behavior'' (Jackson, 1989). This is illustrated using a culturally-de®ned example of the Navajo of the southwestern United States. The Navajo Indians have delineated certain physical formations as sacred, and understand such places to be exemplary in the unity of earth, sky

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and all things (Miller, 1991). These sites, such as Monument Valley in northern Arizona, have a strong sense of place for the Navajo who use them for ritual, ceremony, and meditative acts. Other less culturally-speci®c examples of landscapes endowed with sense of place include places of meditation and prayer or weekend and summer retreats, where the positive meaning associated with them is central to their therapeutic value. Gesler (1992) describes landscapes endowed with a strong sense of place as being known only from within over long periods of acquaintance. This knowingness is exempli®ed in the home, where ``networks of interpersonal concern'' (Gesler, 1992, p. 738) have existed for an extended period of time. Networks of interpersonal concern which may enhance healing are also found in long-time meeting places, such as practitioner's oces or rooms for therapy. Gesler (1992) de®nes the health application of a strong sense of place as psychological rootedness. Psychological rootedness Psychological rootedness is usually achieved through a long-standing and possibly ongoing relationship with a certain place. Feelings of self-identity and security are characteristic of psychological rootedness. The holistic model views a psychologically rooted environment as a component in the healing and/or health process. Such an environment is understood to be an individual's ``personal home'' (Dossey et al., 1989, p. vii), providing an integrative network of physical, spiritual and psychological factors merging together to promote the creation of a healing and/or healthy place. Any type of care in the home, such as long-term care for the invalid or planned home-birthing allows the healing qualities of the home environment to continuously take e€ect. If home-birthing has been chosen from an array of appropriate birthing options as the favored method of giving birth, the planned home-birthing experience illustrates an environment with a strong sense of psychological rootedness. The importance of planned home-birthing as a conscience choice by individuals or couples is critical in this illustration, not only because of it's limited accessibility, but because of the critique surrounding the idealism and androcentric assumptions of humanistic constructions of home (Rose, 1993). As well as satisfying the wish to follow a noninterventive philosophy that promotes a natural process (Barrington, 1985), the personal choice of home-birthing is also motivated by the need to maintain a strong sense of place, both in the physical environment, and interpersonally (Abel and Kearns, 1991). Tuan (1974, p. 4) describes ``topophilia'' as this a€ective bond between people and place or setting''. Similarly, Relph describes this bond as existential insidedness: ``the most funda-

mental form of insidedness... in which a place is experienced without deliberate and self-conscious re¯ection, yet is full of signi®cance'' (Relph, 1976, p. 55). Cosgrove (1978, p. 69) surmises that ``home is perhaps that place where most of us experience true existential insidedness''. A conventionally trained medical student's perception of home-birthing expresses these environmental characteristics well: I had a feeling of peace in that apartment that I had not had in the hospital. To choose your own foods and furnishings, to know where everything is, to be able to move around the house and take a walk outside, to pack in your whole family, to have friends and neighbors drop in Ð you'd have to move your whole apartment to the hospital to get that kind of freedom and familiarity there. (Dickson et al., 1984, p. 13)

Because planned home-birthing allows for personal control and individual decision-making, it also contributes to strengthening the sense of place inherent in the home. The role of a mid-wife is critical in planned home-birthing. The continuity of care provided by the mid-wife in the pre and post-natal stages allows the birthing woman to be assisted in an interpersonal caring environment throughout her whole reproductive cycle (Barrington, 1985). Environments such as these are characterized with having strong networks of interpersonal concern, bringing about a strong positive sense of place. Such environments are described as authentic landscapes, just as those associated with placelessness are described as unauthentic (Relph, 1976). AUTHENTIC AND UNAUTHENTIC ENVIRONMENTS

Closely related to sense of place and its opposite, placelessness, is the typology of Relph (1976) of ``authentic'' and ``unauthentic'' landscapes. This typology distinguishes between ``networks of interpersonal concern'' found in caring (authentic) environments, and ``spatial separateness and isolation'' found in uncaring (unauthentic) environments (Gesler, 1992, p. 738). Contrary to unauthentic landscapes which incarcerate, quarantine, and exclude the mentally ill and AIDS patients, among others, authentic landscapes work as therapeutic environments through the merging together of environmental, and most importantly interpersonal factors. Although agency plays a critical role in de®ning the authenticity of a landscape, structure also plays a role, as environmental, political and associated socio-economic forces may in¯uence the ``authenticity'' of a landscape. Caring environments From a users' perspective, hospitals are often understood to be unauthentic because they are perceived to be hostile environments which reduce an individual's locus of control (Middlemiss et al.,

Therapeutic landscapes in holistic medicine

1989). This is not always the case, as certain hospitals encourage authenticity through supporting networks of interpersonal concern. The Sioux Lookout Zone Hospital, which serves the aboriginal population living in the northern reaches of the Canadian province of Ontario, allows family and friends to reside in the hospital so they are able to spend prolonged periods of time with the patient (Hagan et al., 1989). Such an authentic landscape encourages positive interpersonal relationships with family, friends and practitioners, providing continuous social support. A new aboriginal-speci®c hospital is being planned for Sioux Lookout which, in addition to operating as a family-friendly environment, will serve traditional aboriginal food, as well as provide translation services in aboriginal languages (Elliot, 1997). The majority of the hospital board is aboriginal (including one traditional healer), ensuring that aboriginals will have full participation in hospital governance and service delivery (Elliot, 1997). Alternative birthing environments, spurred by planned home-birthing practices, also illustrate positive networks of interpersonal concern. They include birthing centers and in-hospital birthing rooms, both of which humanize the out-of-home birthing experience through modelling characteristics of the home. A survey of users' views of maternity services (Melia et al., 1991) reveal that women regard a home-like environment in the delivery suite as important. Similar to home-birthing, the presence of family and friends contributes greatly to the authenticity of such environments, which is also achieved through incorporating general home furnishings, such as comfortable chairs, windows, and soft lighting (Melia et al., 1991). Many holistic practices focus on the human element, and thereby contribute to the formation of authentic landscapes. The use of these practices, such as therapeutic touch, contribute to the creation of therapeutic landscapes in that they alter the authenticity of the environment with which the client is interacting in a way which enhances the healing process (Quinn, 1992). Quinn (1992, p. 34) reports that therapeutic touch can bring about a caring environment that can ``over¯ow'' into the physical environment to create a safe place, a literal energetic cocoon of caring and support. Authentic landscapes can also be achieved in environments of the mind, through imagery and visualization. *``Place, in the sense of experienced space... which we claim by thoughts and feelings'' (Jackson, 1985, p. 9). {``An environment is an association of factors drawn from both natural and cultural components of life'' (Jackson, 1985, p. 8).

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LANDSCAPES OF THE MIND

The relationship between the mind, space, and place*, landscape or environment{ is well summarized by Cosgrove (1978, p. 66): ``Human ideas mould the landscape, human intentions create and maintain places, but our experience of space and place itself molds human ideas''. The latter part of this relationship, where the experience of space and place molds human ideas, is of special importance in discussing therapeutic landscapes in the practice of holistic medicine. This is because the landscapes that individuals may have the choice to experience, either physically or mentally, in¯uence their overall health and well-being. As discussed, a positive sense of place is strongly associated with a healing environment, as it is ``deeply relevant to the basic need for internal cohesion, mental health, a sense of security and direction, and a feeling of relationship with the world around one'' (Jackson, 1989, p. 13). This same sense of place can be achieved in the interpenetration of the mind and environment, through imagery and visualization: Human life may exist anywhere on earth, but living Ð in the sense of participating and experiencing Ð presupposes the use of imagination, of the senses, and of memory... the fullest possible use of faculties, allows humans to ®nd a place that is really a personal cosmos. (Jackson, 1989, p. 12)

Imagery and other related psycho-therapeutic practices, such as autogenic training, relaxation techniques, and meditation can only work when there exists a belief in the connection between mind and body. Similar to how ``emotions, thoughts and psychological conditioning of a conscious and unconscious nature have been shown to produce neuro-hormonal changes in many organ systems'', causing health problems such as ulcers and asthma (Locke and Colligan, 1986, p. 170), psychological treatments have been shown to prevent, cope with, and even assist in the healing of such ailments. Fields of care Similar to real physical environments, landscape images which are authentic and/or have a strong sense of place have a strong ``®eld of care'' (Quinn, 1992). Landscapes of the mind include images which are either practitioner-de®ned or individually-de®ned (Simonton, 1978). Examples include: a familiar beach, where an individual can relax and listen to the rhythm of the water against the shore and feel totally calm and peaceful (Miller, 1982); a previous home or neighborhood where comfort and acceptance were guaranteed; or a favorite place or natural scene that evokes meaningful feelings of being one with the world. Such landscape images are used in ``stress-related illnesses'' (Hall, 1984, p. 159) and in care which involves introspection aimed at fostering a greater self-awareness in relation to

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some aspect of health'' (Rossman, 1984, p. 231). These techniques bring about a greater feeling of control, possibly due to the increased participation clients have in the therapeutic process which allows the client to be in touch with positive possibilities (Miller, 1982). The practice of imagery characterized with a ®eld of care exempli®es the ``links between environment, landscape, and the human mind'' (Cosgrove, 1978, p. 66), and allows considerable insight into the meanings that places and landscapes have for us, particularly as individuals (Cosgrove, 1978). The use of these imagined therapeutic landscapes is often introduced by holistic practitioners. Therapeutic landscapes of the mind use culturally-de®ned physiologic symbols in the process of visualizing the body healing from within (Miller, 1982). The work of Carl Simonton is well-known for his application of this technique in his work with cancer patients. He teaches clients to visualize their cancer tumor as a distasteful image, such as a black rat which eats their healthy body cells. The client simultaneously imagines their own white blood cells attacking the cancer cells (Simonton, 1978). Results have shown remissions, which seem to be connected with an improved immune response. Therapeutic landscape imagery has also been applied to depression, phobias and pain control, and has been proven to improve concentration (Sheikh, 1984). Another way to access these images is through the creation of art, carried out in art therapy. HERMENEUTICS/LANDSCAPES AS TEXT

Landscape images can also be expressed through visual art forms, literature and/or poetry. The impetus behind the intersection of geography and these various art forms is to broaden our understanding of the landscape to encompass subjective narratives, and thereby provide a more nuanced cognition of space and place (Gilbert, 1994). Literary geographers continue to adhere to a humanist emphasis on the subjective perceptions of the landscape (Ley, 1985; Meinig, 1979; Duncan, 1990; Cosgrove and Jackson, 1987; Barnes and Duncan, 1992). As an important component of the new cultural geography, the study of landscape perceptions in textual material has been theoretical*, interpretative, and subjective (Ley, 1981b). Tuan (1974, 1976, 1978) has established the foundation for the interface between geography and literature, noting that literature should be examined for its ``articulation of experience'' (Tuan, 1976, p. 262). This theme is clearly shown in Pocock's *Cultural geographers have been engaging in social and cultural theories, incorporating politics, class, social identity, and power relations into their analysis (Duncan and Ley, 1993).

exploration of themes in British writing, including the antinomy of home and away, and the personality of places (Pocock, 1979, 1980, 1981). Pocock's e€orts point to the importance of literature and the arts in de®ning regional (spatial) identity. Love of place and regionalism continues to be popular themes in literary geography (Simpson-Housley and Norcli€e, 1992). Porteous' range of works on di€erent ``scapes'' such as bodycapes, smellscapes, inscapes, sensuous landscapes intersect the antinomies of the inside/outside and home/away, expressing feelings of rooted/rootlessness and place/ placelessness (Porteous, 1986a,b, 1987). The work of Rodaway (1994) on sensuous geographies provides another example of the association between humans and space. Landscape, like a text, can be read and interpreted. If one recognizes that place is not just a physical entity, but rather invested with meanings, one understands a place or landscape through the conceived and perceived world. Thereby, places are open to multiple meanings and representations. Similar to reading the landscape in text, practitioners are able to ``read'' a patient's therapeutic landscape through art or writing; although having limited accessibility due to structural factors, both art therapy and writing therapy can be read as text. Artistic expressions must be interpreted if they are to contribute to the understanding of an individual's state of health, as they can then be translated into therapeutic ``landscapes of meaning'', and used in therapy. Works of art created in art therapy re¯ect the underlying medical beliefs, behavior and ideas of the individual creators and the world to which they are aliated. Similar to the humanist approach to cultural geography, which uses hermeneutics, or the interpretative method in understanding the recovery of meanings (Ley, 1981b), art therapists interpret a client's art work to ®nd health-related meanings. The therapist, like the geographer, is ``arguing from a world of exterior surfaces and appearances to an inner world of meaning and experience'' (Jackson, 1989, p. 177), and both fully understand the potency of communication through symbols and images. Symbols and images revealed through art therapy can inform the condition of ill-health, the therapeutic process called for, and/or the client's medical beliefs, behavior and ideas. Tapping into the sensory experience Art therapy is a particularly important psychotherapeutic method, as it is used in situations where more common methods, such as verbal communication, do not work in expressing psychic con¯ict. This is often the case with victims of trauma (Sheikh, 1984). The central medium of communication is therefore pictorial rather than verbal (Murphy, 1984). The methods used in art therapy, such as free association and spontaneous ex-

Therapeutic landscapes in holistic medicine

pression, are psycho-analytic therapy procedures that aim to make contact with the true core of the individual concerned. Art therapy works to tap into the sensory experience (Sheikh, 1984), as it is in creating art that a client's psychological symbolic images can be expressed, and only then interpreted. The interpretation of symbolic images found in therapy takes place in a two-way dialogue between patient and therapist, which in itself is therapeutic, as the client ``can gain insight both intellectually and emotionally by connecting the meaning of the picture to his or her own life situation'' (Dalley, 1984, p. xiv). The mutual exploration and co-participation in the interpretation of art done in therapy must be accomplished within an authentic environment of trust, openness, and safety'' (Dalley, 1984, p. xxiv), as the subjective perspective of the client, rather than the objective assessment of the art therapist, is central to interpretation. Health assessments are made by taking an overall account of the development and change of an art work during the course of therapy (Dalley, 1984), as ``paintings both accurately record and monitor change since they can be compared over time'' (Dalley, 1984, p. xxv). A consistent pattern of recurrent imagery in the progressive themes of patients with anorexia nervosa has been found, and is documented by Murphy: ... the intricate patterns and vortex (1) that appear, most noticeably at the beginning of therapy, could be an indication of the anorexic's barriers of personal expression and human involvement... The dogs and horses (2) seem to throw light on the anorexic's urge for exercise... this corresponds with their lack of fatigue and overactivity, which are notable features in the anorexic's behavior. The variety of plant forms (3)... are drawn with general competence and great attention to detail... indicators of how the anorexic perceives herself. The landscapes and trees (4)... usually appeared in the later stages of therapy. A general pattern emerged as the composition ``progressed'' from one tree to a set of two trees in a landscape, and were usually painted in symmetrical balance... one is blossoming and healthy, the other contrastingly dead and stick-like... the trees represent an expression of the two opposing aspects of the ``self''. (Murphy, 1984, p. 105±106)

Similar to artists who use illustrations to depict meaningful landscapes, art done in therapy can illustrate ``landscapes of meaning'', and with the help of a therapist, work towards healing and health. Just as imagery techniques using ``sense of place'' are helpful in health and healing, so too are the expression of landscape images in art, as ``art o€ers a medium which can give both communication with others and confrontation with the self'' (Laing, 1974, p. 17).

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holistic medical practices. As the individual experience of health and health care becomes more recognized, evident in the increased use of the personal narrative in the social scienti®c health literature (Kleinman, 1988; Kearns, 1997), the humanistic framework will undoubtedly be more commonly used in health geography. It is through employing humanism that an enhanced understanding of both the meaning and nature of place with respect to health and health care has been possible. In addition to further developing the concept of therapeutic landscapes, holistic medicine has been better understood. This work also provides a contribution to the analysis of the role of health care in contributing to the experience of place, and vice-versa. Due to the many di€erent kinds of holistic medicine, the concept of therapeutic landscapes can be further examined within this paradigm. Field research in any of the applications examined herein will bring about a better understanding of place as having meaning in both healing and health. While doing so, an increased understanding of both holistic medicine and therapeutic landscapes may be achieved. By applying medical semiotics to the medicine wheel, symbolic landscapes were shown to be a basic element of therapeutic landscapes. ``New age'' healing and health practices illustrated the importance of meaning, value and experience in healing and health. The concept of sense of place allowed a better understanding of the psychological rootedness inherent in certain therapeutic environments, as was discussed in the planned home-birthing experience. Caring environments were de®ned within the framework of landscape authenticity, as was shown in aboriginal hospitals and alternative birthing environments. Fields of care were discussed in the context of therapeutic landscapes of the mind, illustrated through imagery and visualization techniques. Through hermeneutics, where landscapes are viewed as text, art therapy illustrated how the sensory experience can be tapped into. Further examining the connection between landscape and treatment, healing and health has been facilitated by the fact that humanism and the philosophy of holistic medicine share subjectivity and human agency as fundamental. While contributing to much-needed socially constructed understandings of wellness and illness (Kearns, 1994), this examination contributes to further understanding the importance of human agency in achieving and maintaining health, as well as managing and healing disease and ill-health.

CONCLUSION

This paper has contributed to a theoreticallyinformed health geography by further examining the concept of therapeutic landscapes through the lens of humanistic geography, illustrated through

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