Mental health and urban policy

Professor Hugh Freeman Hope Hospital (University of Manchester), Salford, UK

1M. Rutter, 'The city and the child', American Journal of Orthopsychiatry, Vol 51, 1981, pp 610-625.

2S.D. Webb, 'Rural- urban differences', in H.L. Freeman, ed, Mental Health and the Environment, Churchill Livingstone, London, 1985.

The scale and accelerating rate at which urbanization is occurring, particularly in the Third World, presents a monumental problem in the need to provide an acceptable physical and mental quality of life for the inhabitants of these huge urban settlements. So far as bodily health is concerned, its relationship to the s t ructura l env i ronment is now reasonably well u n d e r s t o o d - water supply, sewage disposal, protection from weather, etc - though unpleasant sur- prises such as Legionaire's Disease may still emerge from time to time. But the complex and interrelated causes of those psychological and social pathologies which seem increasingly to accompany mass urbanization have yet to be fully identified; at the same time, urban policy needs to incorporate now what we already understand about them, if even greater human problems are to be avoided in the future.

"Mental health ' can be defined in innum- erable ways - most of them too vague or idealized to be of much practical value. C om m on sense, though, requires it to be used in terms of the levels of emotional symptoms such as anxiety or depression which people report ; if environmental changes in an area resulted in significant

reductions in the levels of these com- plaints, then it would be reasonable to say that the mental health of that popula- tion had improved.

'Social pathology' means significant deviation from prevailing norms of be- haviour, expressed in such forms as delinquency and crime, disordered or broken family relationships, and addic- tions. Most people in any population who behave badly are not psychiatrically dis- ordered, though the exact proport ion who are is unknown; but it appears that communit ies with high rates of mental illness do also tend to show high levels of behavioural deviance and of psychiatric sequelae to crime and social disturbance. This connection has been most clearly identified in the case of children, and Rutter ~ points out that inner city life is associated with an increased susceptibil- ity to a wide range of problems - not only crime and delinquency, but depression, emotional disturbance, educational diffi- culties and family breakdown.

On the other hand, it would not be true to say that urban living as a whole is less healthy in psychiatric terms than life in the country, 2 because as units of analysis, 'u rban ' and 'rural" are too large and too heterogeneous to be meaningful. The characteristics of particular environments

1 06 0264-2751/87/020106-06503.00 ~-9 1987 Butterworth & Co (Publishers) Lid

need to be specified more clearly, if their possible effects on mental health are to be analysed, though this does not mean that conurbations or even regions have no significance from the mental health point of view. Cities do tend to house concentrations of multiply disadvantaged people, who may show poor mental health along with other unfavourable attributes; but it would be quite wrong to extrapolate this picture to whole city populations. 3

There may, . however, be an optimum size beyond which the costs of cities start to outweigh their benefits, resulting in an escalation of levels of social pathology, particularly crime. 4 The sheer size of today's urban settlements may involve what Cappon 5 has called 'the destruction of whatever natural order of territoriality was established by historical and social usage'; for example, Mexico City has already passed the size of any previously known metropoli tan area. From the anthropological point of view, Fox 6 has poin ted out that 'We are certainly evolved to be gregarious, but not in nations of 600 million or in cities of 15 million'.

One of the most important urban processes that is relevant to mental health is redevelopment and residential reloca- tion. In the UK this process began on a large scale after 1918, and resulted in four million homes being built within 20 years, which housed over eight million people, mainly of upper working or lower middle class social status. The density of this new environment was on average about one- third that of the old, so that the urban areas exploded in size; the standard of facilities such as bathrooms and hot water systems was generally much higher.

However, there was a social price to be paid, in that these new residential areas lacked the established kinship and mutual help networks of older communities, while most occupants now tended to place greater emphasis on their domestic privacy, in place of interactions with those living around. At the same time, local building styles and materials were

abandoned, so that traditions and land- marks tended to become submerged and identical streets of 'semis', with their nearby shopping parades, could be found from Land's End to John O'Groats .

In 1938, the description of 'suburban neurosis '7 recorded the stresses which were commonly occurring after removal from more central areas, eg higher ex- penses, social isolation, distance from employment and loss of familiar sur- roundings. Similar findings emerged in 1957 from comparison of a housing estate on the edge of London with an older working class area: s it was suspected that this was partly due to the shock of rehousing and partly to the poor social facilities on the estate, which tended to provoke loneliness and social isolation. The almost unbelievably thoughtless way in which a new housing estate was built in Liverpool without any essential services, but with design faults which made life almost intolerable for so many of its residents, has been described by a doctor who worked there from the beginning. 9

Hansen and Hillier ~° point out that such developments were designed on the assumption that the undesirable features of the old communities could be planned away, and that life would be bet ter in an environment consisting only of adequate housing, together with (eventually) a few essential shops. Here, the planning clich6 of separation of land uses had been fully worked out. But in fact, virtually none of the anticipated benefits of this change

'three million people were relocated from old urban areas in the UK in the period 1955-75'

have been shown to occur: these estates have no meaningful integration into the wider community, and even within them, the layout seems to have provoked more suspicion than sociability.

Although three million people were relocated from old urban areas in the UK in the period 1955-75 (half a million

3H.L. Freeman, 'Mental health in the inner city', Environment & Planning A, Vol 16, 1984, pp 115-121.

4K. Wedmore and H.L. Freeman, 'Social pathology and urban overgrowth', in H.L. Freeman, ed, op cit, Ref 2. 5D. Cappon, 'Designs for improvement in the quality of life in downtown cores', International Journal of Mental Health, Vol 4, 1975, pp 31-47. 6R. Fox, 'Of inhuman native and unnatural rights', Encounter, Vol 58, 1982, pp 47-53. ~S. Taylor, 'Suburban neurosis', Lancet, Vol i, 1938, pp 759-761. eF.M Martin, J.H.F. Brotherston and S.P.W. Chave, 'The incidence of neurosis in a new housing estate', British Journal of Preventive and Social Medicine, Vol 11, 1957, pp 196- 202. 9M. Goodman, paper to conference on 'Unhealthy Housing', University of Warwick, t 986. loj. Hansen and W.E.G. Hillier, 'The architecture of community', Architecture and Behaviour, Vol 2, 1984.

C I T I E S M a y 1 9 8 7 1 0 7

11 p. Willmott, 'Population and community in London', New Society, Vo130, 1974, pp 206-209.

leaving London alone within ten years), hardly any research has been carried out into possible adverse psychological and emotional effects of this process on indi- viduals, or of social effects on the areas they left behind, That such effects might have occurred is very likely, considering that many of the cleared areas were long established communit ies , with a charac- teristic culture of their own and impor- tant social networks which could never be reproduced artificially. It has become increasingly recognized in recent years that the social support derived f rom these networks is of fundamental importance in the maintenance of mental health.

Thus, the demolit ion of a neighbour- hood is not just the destruction of build- ings, but also that of a functioning social system; while 'slum clearance' was a powerful slogan in achieving the removal of old environments , it ignored the fact that most of the social problems found in slums were not directly related to their physical structure. Fur thermore , the re- development process - f rom first plans to reset t lement of all the residents - is usually a long one, during which time people are worried about their future, watch the decay of the familiar neigh- bourhood around them, and may finally be moved against their will to a home they do not want.l~ In this process, the boundar ies and spatial a r rangements which different ethnic or social groups have established over time are wiped out, and with them, often their modus vivendi

with society in general - having predict- ably adverse effects on the social order of cities.

While inner city areas in the UK have been largely emptied of their previously established working class residents, much of the accommodat ion that remained has been r eoccup ied , p r e d o m i n a n t l y by members of minority races or by people with socially marginal characteristics. During this process the nature of large urban communities has changed fun- damentally, and in such a way as to foster the development in many places of major social problems, particularly as it has

coincided with economic decline and deindustrialization.

Dispersal of urban communit ies was promoted first by an assumed desirability of low density (though it had never been shown that high density per se is harm- ful); second bv a belief in a "shortage of land" (though all cities contained enor- mous unused or partly used areas) and third by the assumption that old houses

'Grandiose road developments were also ruthlessly imposed'

should be demolished rather than reha- bilitated (though no evidence existed that this was in fact preferable) .

Grandiose road developments were also ruthlessly imposed on (mainly poor) communit ies , bringing them few if any benefits, but enormous social costs. In tearing apart compact and human scale environments , highways caused the sub- division of urban areas into artificial and now segregated cells, between which movement became very difficult, particu- larly for pedestrians or cyclists. Whereas it is the conventional wisdom that there is never enough public investment to under- take the changes that would be desirable, this was in fact a case not of too little being spent, but far too much: not for the first time, such policies tended to have the opposite effects to those claimed for them.

The U K also carried out probably the world's largest p rogramme of planned new town construction, following a tradi- tion begun early in the century at Letch- worth, Welwyn, Bourneville and Port Sunlight. The most significant feature of these new communit ies was that they embodied a conscious element of social engineering, and were designed to be- come balanced and self-sufficient, rather than merely dormitory areas. Through their choice of residents they were pro- tected from the worst social problems of the inner cities and from the burdens imposed by the elderly and chronic sick -

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though such cases will steadily increase in number with the passage of time.

In general, the new towns were de- signed as multiples of neighbourhood units and it was assumed that these would establish local social values and a positive feeling among residents that they had a relationship towards their unit. However, we have no means of knowing whether or not this formula achieved what was ex- pected of it, because the matter was never investigated. 12 In fact, this huge national investment was accompanied by hardly any interdisciplinary scientific effort to study its human consequences, so that no confident statement can be made as to whether or not it was general- ly worthwhile. Without such information, there is no way of assessing the 'oppor- tunity costs' ie the possible benefits that might have been achieved by spending the same amount of money in different ways. (For instance, was it right to have built Milton Keynes so near to London, rather than making the same investment in the rehabilitation of inner London or Tyneside?)

Many factors have to be included in the balance sheet of new towns, expanded towns, or peripheral housing estates in

'a large proportion of the people who migrated to them did so reluctantly'

the UK; but there can be little doubt that a large proportion of the people who migrated to them did so reluctantly and out of economic necessity - ie they could not find a more central home at a price they could afford. If they had not had to do so, kinship and other social networks would have been preserved, many estab- lished urban communities that no longer exist would have retained a healthy life and much stressful daily travel would not have been necessary.

In the UK and some other countries, one of the foremost urban policies of the post-war period was the construction of high rise residential blocks as a 'quick

technological fix" for the problem of housing shortage. This was carried out in the absence of any systematic enquiry as to what kind of accommodation people wanted, ~3 and in combination with the use of untested industrialized building methods, nearly all of which have proved to be disastrous. There has been little systematic research into the effects on mental health of high rise living for the working class, but the balance of evi- dence suggests that this has been adverse, particularly for families with young children.14 Possible explanations for this effect have been reviewed by Ineichen; 15 they include poor construction and lack of sound insulation, poor maintenance, difficulty in monitoring the surrounding space, difficulties in informal interaction

'an attractive environment will tend to make people generally happier'

between residents, inability to make physical changes to the home, lack of opportunity to particpate in management of the block and unpleasant appearances, inside and out.

Although the relationship between physical surroundings in general and mental health lacks reliable data, it is not unreasonable to believe that an attractive environment will tend to make people generally happier than they would be in an unattractive one. There is evidence, though, that dimly lit and hostile looking constructions which lack the human scale of more traditional environments are likely to make many people feel anxious or afraid - and not without reason, since the danger of harassment or attack is far greater in areas with footbridges, sub- ways, multistorey garages and empty spaces between high rise blocks.

These environments are also lacking in shelter (which is hardly appropriate for the UK climate) and subject to the gusting of high speed winds, causing both physical and psychological stress, particu- larly for those in poor health and for the

12H.L. Freeman, 'Mental health and new communities in Britain', in T.J. Nossiter, A.H. Hanson and S. Rokkan, eds, Imagination and Precision in the Social Sciences, Faber, London, 1972. 13p. Dunleavy, The Pofitics of Mass Housing in Britain, Clarendon Press, Oxford, 1981. 14H.L. Freeman, 'Housing', in H.L. Freeman, ed, op cit, Ref 2.

SB. Ineichen, paper to conference on 'Unhealthy Housing', University of Warwick, 1986.

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160p cit, Ref 1. 17H.M. Choldin, 'Urban density and pathology', Annual Review of Sociology, Vol 4, 1978, pp91-113. ~80. Newman, Community of Interest, Anchor Doubleday, New York, 1980.

Figure 1. Salford: central redevelopment area.

old and very young (see Figure 1). Was any thought given by architects or plan- ners to how a woman pushing a pram, with a toddler in tow, was to cross a footbridge having stairs up and down to it, or get up to a 20th-storey flat when the lifts were out of order?

So far, though, attempts to apply psychiatric knowledge to the social field have rarely produced more than trivial recommendations, and one of the reasons for this relative failure is that efforts tend to be focused at the wrong level - usually one that is far too ambitious. When prevention of psychiatric disorder is dis- cussed, there is a tendency to assume that this must in some way deal with 'basic' causes; yet this involves a naive and simplistic view of aetiology, most of which remains unknown.16

Though there are many practical ways in which society could reduce psychiatric and social pathology, on the basis of existing knowledge and resources, the tendency is to wait for the millennium, mostly because of unproved assumptions that these pathologies are direct express- ions of the harmful structure of society - a view promoted mainly by Marxists.

Progress can in fact only come through scrupulous, painstaking research, based on clear concepts, and through action which is directly related to what has been

scientifically demonstrated. In this pro- cess, the mental health professions could form a useful alliance with those architects and planners who have a genuine concern with the human con- sequences of their activities.

One cause which they might jointly take up would be opposition to the overwhelming preoccupation that plan- ning authorities and local government have had for many years with reduction of urban population density. Choldin 17 has pointed out that 'It is more important to recognise that high density is a basic feature of the urban community and to discover ways in which to organise com- munity life and to build satisfying en- vironments ' .

It is even more important to recognize that relatively high density is actually essential for the positive qualities of towns and cities, such as cultural life and specialized professional services; the low densities of suburbs make these facilities difficult to provide without a degree of car travel which is both environmentally damaging and unjust to the more dis- advantaged sections of society. New- man TM has drawn attention to the way in which suburban communities endlessly reproduce the same relatively low level of collective amenities, while leaving behind 'the decaying remnants of a once rich urban environment ' , in their flight from the pathology of the inner city. A princip- al casualty of this endless process is 'the disappearance of urban life-style'.

While we await more systematic in- formation, in an area that has so far been subject to little scientific enquiry, it would not be unreasonable to maintain that mental health is unlikely to be promoted by incomprehensible urban sprawl, severed by dangerous motorways and full of monotonous blocks standing between unwelcoming spaces. There are also the likely ill effects of population dispersal, such as the time and energy wasted by many millions of people every day in commuting, together with the stress that comes from this frustrating activity. As a consequence, city centres

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are deserted at night and weekends and suburbs empty during the weekdays, causing further undesirable social and psychological effects.

More recently, the construction of orbital motorways around the outer sub- urbs of cities has produced a new genera- tion of suburb-to-suburb traffic, pulling

'these developments tend to create a "suburban gluepot" of new traffic movements'

industry, business and even professional activity out of the central areas. Pro- moted as a solution to urban traffic congestion, these developments tend to create a 'suburban gluepot' of new traffic movements, while accelerating the de- cline of city centres, and making suburb- to-centre public transport uneconomical through loss of passengers - again harm- ing most those with least resources. Thus, those who are multiply disadvantaged become ecologically trapped, unable to work because employment has moved to far suburbs or become strung along motorways.

This dispersal and areal differentiation of human activities also makes the con- trol of deviant behaviour more difficult, since people are constantly on the move (except for the poor and handicapped),

and the unofficial monitoring that neigh- bours and workmates carry out in less complex societies is no longer possible. Instead, a concern for people's mental health would suggest the need to restore to large human settlements the benefits of urbanity - of a social matrix that would provide the environmental structure in which a worthwhile quality of life and work could grow. For instance, much of the old commercial centres of Manches- ter and Liverpool are empty, yet still consist of soundly constructed buildings; to provide the resources to convert these to residential use would be little problem for the UK's institutional investors. The social benefits would be immense, while in the long run even the financial returns might be hardly less favourable than those obtained from present investment policies.

Regrettably, there is so far little sign that such considerations carry any weight. To promote endless urban sprawl, while obliterating communities' landmarks and replacing them with the tasteless impersonality of most present day buildings, seems like a recipe for social disaster in the long run. However, it remains the task of scientific enquiry to demonstrate these dangers in a way that can influence both the political process and the practice of architecture and planning.

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