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The study of mental health in the rural context has moved beyond simple notions of what defines rurality. Researchers in the field of rural mental health have realized that what constitutes 'rural' - in terms of its impact on the mental health and wellbeing of rural residents - entails more than physical geography and spatial localities. They have expressed the need to progress the agenda for rural mental health research beyond simple rural-urban comparisons in the prevalence of mental health problems1. In so doing, these researchers have pointed to the apparent emphasis on socio-demographic factors in the rural mental health literature as a weakness, and have argued that further research on psychological, attitudinal or contextual factors is warranted2.
Ironically though, rural mental health researchers in pursuit of this broader research agenda have failed to appreciate that geography as an academic discipline is concerned with more than just the physical features of places. This article will assert that the answers to fundamental questions in rural mental health research lie in the branch of geography known as social geography, the subject matter of which many rural mental health researchers are currently unaware. The purpose of this editorial is to introduce readers of Rural and Remote Health to the pertinent theory and findings from three main areas of social geographic research: (i) rural geography; (ii) mental health geography; and (iii) the social geographies of caring - each with the potential to inform recent research efforts in rural mental health. We conclude that rural mental health researchers would benefit from embracing what social geography has to offer.
Rural geography: challenging the notion of the 'rural idyll'
An important aspect of the work of social geographers in understanding rural environments is the view that 'rurality' is a social construction with multiple meanings ascribed to it3. The work of rural geographers has challenged at least two major assumptions often made about 'rural life': (i) that rural residents have a strong sense of community; and (ii) that rural living is closer to nature and, therefore, less competitive and more harmonious than urban living4. These notions are referred to in the rural geographic literature as Gemeinschaft, a standard sociological assumption about the idyllic nature of rural life, and one that has been extensively challenged by the work of social geographers. A major piece of work in this regard was the Rural Life-Styles Research Program in England and Wales in the 1990s, conducted by Paul Cloke and colleagues5. This research program spanned a decade, and its findings are summarized in the 1994 report, Lifestyles in Rural England5.
Qualitative accounts such as those obtained by Cloke and colleagues reveal numerous contradictions to idyllic constructions of 'rurality'. For example, many rural people find it difficult to obtain affordable housing, experience under-employment, low pay, poor-quality jobs and lack of transportation to work. The employment and economic conditions in rural areas is changing - there is higher participation in the workforce by women; poverty and income disparity are increasing. Rural people do link their overall wellbeing to cleaner, fresher air and open spaces; however, they are also concerned by pollution and the effects of agricultural chemicals and pesticides. Mobility and accessibility for rural people is a major concern and the potential for isolation, and hence marginalization, on this basis is very real6.
In summary, the picture of rural life which emerged from a decade of research in England and Wales in the 1990s was one of multiple deprivation and not the popular idyll created by urban mythology or urban policymakers. By 'deconstructing the rural' and re-routing academic discourse through lay discourse, social geographers have been able to shed light on the realities of rural living.
Mental health geography and the dynamics of social exclusion
Another important and relevant aspect of the work of social geographers to rural mental health research is the 'second wave' of mental health geography that took place also in the 1990s7. Whereas, mental health geography's 'first wave' was primarily concerned with the movements of people with mental illness in the post-asylum era, its 'second wave' concerned itself with questions of identity for people coded by society as mentally 'abnormal', and the ways in which they are dealt with by people who identify as being 'normal'8.
Mental health geographers have described 'imagined geographies' of 'us and them' whereby 'us' here in 'our' patch of the world demonise 'them' 'there' in 'their' patch of the world8. These geographies underlie practices of stigma and social exclusion towards people with mental health problems, particularly those with diagnosed mental illnesses. Theoretical explanations for these phenomena borrow from psychoanalytic theory about self-other relations9. However, perhaps of more relevance to rural mental health researchers is the argument that constructions of people with mental health problems as ultimate 'others' have wide-ranging social and spatial implications and legacies, ranging from the historical asylum to the 'body swerve' on the village street10.
An understanding of the dynamics of social exclusion from a social geographic perspective has great potential to inform current efforts in rural mental health research to describe, understand, and ultimately tackle social stigma of mental illness in the rural context. Specifically, it should not be assumed that social stigma of mental illness in rural communities arises out of lack of knowledge or ignorance on the part of rural people. Education about mental illness may not be sufficient to break down stigma when it serves a social distancing function11.
Rural mental health and social geographies of caring
Researchers in the small sub-field of mental health geography have noted that much research takes place in urban contexts, highlighting varied geographies of segregation such as the urban psychiatric ghetto12 and purified suburbs13, with little regard, until recently, of rural geographies of mental health. Since 2000, however, several papers interrogating the social geographies of rural mental health have emerged, ranging from interdisciplinary literature reviews to place-based studies indicating the complex social and spatial relations underlying the experience of mental ill-health in particular localities14-16. Of note is research undertaken in the rural Scottish Highlands by Parr and Philo which critically deconstructed the narrative accounts of 160 users of services, service providers and carers about the realities of living with mental health problems in a remote and rural region17,18. In the case of the Highlands, a specific cultural history of mental health care, coupled with distinctive regional geographies of emotional conduct and expression, contributed to a reluctance to acknowledge mental health issues in everyday social contexts.
While the findings from the work in the Scottish Highlands are too numerous to mention here19, one of the main contributions of this study to rural mental health research is the authors' conceptualisation of rural communities in terms of social proximity and physical distance, and the social phenomena that stem from this17,18. In rural environments community members may be separated by many kilometers, yet they can be considered socially proximate in that they can have an intimate knowledge of each other's lives: the opposite socio-spatial relationship can be evidenced in urban environments where community members tend to be physically proximate yet socially distant. Parr and colleagues referred to this as the 'rural paradox of proximity and distance' and described the ways in which this socio-spatial relationship is responsible for both the silencing of mental health difficulties and the exclusion of people with mental illness in a way that is more pronounced than what occurs in urban areas, precisely because neighbours want to limit social obligations to those with mental health problems in areas with low densities of formal services.
Parr and Philo's work is highly significant to rural mental health research and has particular implications for understanding help seeking behaviour in the rural context20,21. Social geographic factors are also relevant to the utilization of rural mental health services more generally as social visibility, rural gossip networks, fear of social stigma, and self-stigma may deter people with mental health problems from accessing services in rural communities in an on-going way, hence delaying their progress towards recovery22.
Conclusion
The work of social geographers has great potential to enhance current understandings of mental health in the rural context. We have provided a brief introduction to three major areas of work - rural geography, mental health geography, and the social geographies of caring - and believe each of these three areas makes a simple yet salient contribution to the current research agenda in rural mental health1. First, studies in rural geography have deconstructed the notion of the rural idyll and, in so doing, introduce a range of possible social factors that may assist rural mental health researchers to understand relationships between health and place. Second, mental health geography provides a conceptualization of social stigma of mental illness as a distancing phenomenon which have the potential to inform mental health promotion efforts to reduce stigma in rural contexts. Third, the literature on the social geographies of caring in rural communities provides insight into the uniqueness of rural culture, particularly in terms of social proximity, and has implications for the provision of mental health care to rural populations.
We hope that this piece acts as a timely reminder that health research is a multidisciplinary effort. As rural mental health researchers, there is much to be gained from looking outside the disciplines in which we were originally trained to find new ways to synthesise and extend knowledge for the benefit of rural communities.
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