Do women need special secure services?

Sex, gender and the carceral: Female staff experiences of working in forensic care with sexual offenders

English high-secure hospitals have contained individuals deemed mentally disordered, and dangerous, since the mid-nineteenth century. With the development of gender sensitive services female patients have been moved out of these institutions into smaller secure settings. Female staff continue to work in high secure hospitals, but are often in a minority in these services. Little is known about how female staff experience the everyday world of work. This paper is based on in-depth interviews with female nurses employed in a unit caring for detained male sexual offenders with a diagnosis of personality disorder. It forms part of a much larger discourse-analytic study of nine patients, with a history of sexual offending, and eighteen mental health nurses, which focused on talk about pornography and criminality. The findings from this project have been previously reported in Mercer and Perkins (2014). This paper demonstrates how patriarchy remains an enduring cultural characteristic of caring for men detained under the Mental Health Act (1983, 2007) because of sexually violent crimes against women and children. It textures the ward environment and the relationships between people who work within it, constructing women as 'outsiders' and producing a masculine culture which leaves female staff feeling vulnerable and at risk. The analytic focus of the paper is concerned with exploring how women experience working in the male-dominated environment of a high-security Personality Disorder Unit (PDU). Three discursive repertoires are identified: the institutional space as male, the impact of working with men detained as a result of sexual offending, and the construction of therapeutic work as a 'job for the boys'. In this world, female staff, as a product of their gender, constructed themselves both as at risk and inviting risk.

The risks, needs and stages of recovery of a complete forensic patient cohort in an Australian state

BACKGROUND

Routine outcome measures are increasingly being mandated across mental health services in Australia and overseas. This requirement includes forensic mental health services, but their utility in such specialist services and the inter-relationships between the measures remain unclear. This study sought to characterise the risks, needs and stages of recovery of an entire cohort of forensic patients in one jurisdiction in Australia.

METHODS

Local expert groups, comprising of members of the forensic patient treating teams, were formed to gather information about the status and needs of all forensic patients in the State of New South Wales, Australia. The expert groups provided demographic information and completed three assessment tools concerning the risks, needs and stages of recovery of each forensic patient.

RESULTS

The cohort of 327 forensic patients in NSW appears to be typical of forensic mental health service populations internationally when considering factors such as gender, diagnosis, and index offence. A number of important differences across the three structured tools for forensic patients in different levels of secure service provision are presented. The DUNDRUM Quartet demonstrated interesting findings, particularly in terms of the therapeutic security needs, the treatment completion, and the stages of recovery for the forensic patients in the community. The CANFOR highlighted the level of needs across the forensic patient population, whilst the HCR-20 data showed there was no significant difference in the mean clinical and risk management scores between male forensic patients across levels of security.

CONCLUSIONS

To the authors' knowledge this is the first study of its kind in New South Wales, Australia. We have demonstrated the utility of using a suite of measures to evaluate the risks, needs, and stages of recovery for an entire cohort of forensic patients. The data set helps inform service planning and development, together with providing various avenues for future research.

Lived experience of working with female patients in a high-secure mental health setting

Women's secure hospitals are often considered to be stressful and demanding places to work, with these environments characterized as challenging and violent. However, the staff experience of working in this environment is not well represented in the literature. The present study is the first to examine the 'lived experience' of seven nurses working in the National High Secure Healthcare Service for Women. Interview transcripts were analysed with the use of interpretative phenomenological analysis, and the findings presented within four superordinate themes 'horror', 'balancing acts', 'emotional hard labour', and 'the ward as a community'. These themes all depict the challenges that participants experience in their work, the ways in which they cope with these challenges, and how they make sense of these experiences. A meta-theme of 'making sense by understanding why' is also presented, which represents the importance for participants to attempt to make sense of the tensions and challenges by formulating a fuller meaning. The findings suggest the importance of workforce development in terms of allowing sufficient protected time for reflection and formulation (e.g. within the format of group supervision or reflective practice), and for staff-support mechanisms (e.g. clinical supervision, counselling, debriefs) to be inbuilt into the ethos of a service, so as to provide proactive support for staff 'on the frontline'.

Evolution of secure services for women in England

Patients detained at high and medium security reveal significant gender differences in the presentation of psychopathology, mental disorder and social and offending profiles. However, secure mental health services in England, like prisons, generally fail to recognise the core importance of the differing biopsychosocial development in women and the impact of life experiences on women's subsequent biopsychosocial functioning. As a consequence, women are often inadequately provided for in services dictated by the identified needs, risks and responsiveness of men. The lack of clinically appropriate facilities for women may account for the increased frequency with which women are readmitted to medium security and for their longer admissions to both high and medium secure care. New tertiary services are developing as a result of the lessons learnt while providing gender-blind care. However, further development is required to ensure that women receive services of the same quality, range and nature of those received by men.

Needs of women patients with mental illness

Women patients suffer from a range of mental disorders similar to those that men may experience. However, there are some striking differences in the prevalence of specific disorders, and in their presentation and management. Some mental illnesses only occur in women. It seems that women patients may have a different experience of treatment, a consequence of differences in their needs and also of the way that health professionals perceive those needs. These differences are embedded in the wider cultural milieu in which we live. There are particular issues for women patients in relation to, for example, childhood sexual abuse, rape and domestic violence. At present, tools to measure needs of individual patients are generally not gender specific.

Psychiatric services for women

The need for specific psychiatric services for women has been debated by many practitioners involved in care delivery and management of women with differing degrees of mental health problems.

Part-time training and working for male and female psychiatrists

Part-time training and working have become popular acceptable options for both male and female psychiatrists, regardless of age. There are a number of reasons for this, the most common being family commitments such as those to children or elderly relatives, but also including personal ill health, wanting to reduce stress and prevent burn-out, wanting to pursue different priorities, portfolioworking or simply trying to achieve a better quality of life. The importance of providing flexible working patterns has been emphasised by the Department of Health (1998) in Working Together – Securing a Quality Workforce for the NHS.

Do men need special services?

The targeting of services to groups with special needs is today commonplace in enlightened public health policies. To list men among the ‘minorities’ in need of such special help might have the semblance of satire. This air of levity is not really reduced by listing male's shorter life expectancy, higher infant mortality and higher rates of natural and unnatural deaths in all age groups (Drever & Bunting, 1997; Kelly & Bunting, 1998).

Women in acute psychiatric units, their characteristics and needs: a review

Aims and method Recent policy guidelines published by the Department of Health highlight the need to develop gender-sensitive psychiatric services. However, very little is currently known about the specific characteristics and needs of female patients entering acute psychiatric wards, particularly psychiatric intensive care units. This article aims to review the current literature on what is known about this group of patients. PubMed, Embase and PsycINFO were systematically searched using a number of key terms. Results A total of 27 articles were obtained. The findings were divided into four categories: admission characteristics, treatment needs, risk management and outcomes after discharge. Gender differences were found in diagnosis and presentation. Clinical implications The differences observed in the reviewed studies suggest that women may have different assessment and treatment needs, and ultimately, different philosophies of care. A dearth of studies in this area indicates that if services are to develop in line with government policies, more research is needed.

Dialectical Behaviour Therapy [DBT] with People with Intellectual Disabilities: A Systematic Review and Narrative Analysis

BACKGROUND

There is mixed evidence regarding the effectiveness of psychological therapies for people with intellectual and developmental disorders. Although systematic reviews have supported the use of dialectical behaviour therapy with people with borderline personality disorder, there are no comparable reviews regarding DBT with people with intellectual and development disabilities.

METHODS

Studies were identified using a systematic approach and were selected if they reported an intervention that included a DBT skills group and then assessed using the Evaluative Method for Determining Evidence Based Practice.

RESULTS

Seven studies reported adaptations and outcomes of DBT for people with intellectual and development disabilities, four of which delivered full DBT programmes with three describing DBT skills groups. All studies were appraised with regard to methodological quality and the adaptations and results examined.

CONCLUSIONS

The findings indicate that DBT and DBT skills groups can be adapted for people with intellectual and development disabilities, but further high-quality research is needed to make conclusions about efficacy and effectiveness.

Women's secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales

BACKGROUND

In England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery.

METHODS

This qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants' views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment.

RESULTS

Evidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women's needs.

CONCLUSION

Future service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women's experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.

A qualitative study exploring female patients' experiences of self-harm in a medium secure unit

This study utilized a social constructivist model and reports upon interviews conducted with five female patients in a medium secure service. Their perception of self-harm is considered. Six themes emerged from the data, 'the traumatized individual', 'interrupted maturation process', 'the hidden experience', 'crossing the line', 'individual and systemic repercussions', 'nascent potential protection'. In addition to the six themes that emerged, we concluded that, although individual perceptions of self-harm varied, commonalities existed across accounts and that individual formulation may assist both patients and staff to gain a personalized understanding, thus, enabling less harmful ways of coping to be established.

The journey from despair to hope: an exploration of the phenomenon of psychological distress in women residing in British secure mental health services

This paper reports the findings of a descriptive phenomenological study that aimed to elicit and describe the experience of psychological distress as expressed by a group of women compulsorily detained within secure mental health services in the U.K. A fundamental objective of the study was to contribute to the existing evidence base that supports the care and treatment needs of this severely traumatized and challenging patient group. We argue that service providers and clinical practitioners could be better informed about the unique care and treatment needs of this severely traumatized and challenging patient group when working with them. A descriptive phenomenological approach developed by Giorgi was used to elicit the lived experiences of 'psychological distress' from a sample of female patients resident within a high secure hospital and an independent medium secure hospital. The findings indicate that a treatment plan which includes a combination of prescribed medication, informal support networks, intensive individual therapy and active engagement in a therapeutic life skills programme can be extremely beneficial. Most notably in helping to reduce the frequency of both internally and externally directed violent behaviour in this vulnerable client group.

Women and firesetting: a qualitative analysis of context, meaning, and development

OBJECTIVES

To explore subjective experiences of women in secure services of their firesetting behaviour, its personal meaning and the factors that contributed to its development.

DESIGN

An interview-based study using Interpretative Phenomenological Analysis.

METHODS

Interviews were carried out with nine women, in medium secure services, with histories of firesetting.

RESULTS

Three overarching but interlinked themes emerged, reflecting a narrative progression from the context of life experiences that preceded firesetting (including subthemes: distressing experiences and isolation from support), through the experience and meaning of the firesetting act (influencing others and getting help, achievement and control, and not thought through), to the individual's current position regarding past actions.

CONCLUSIONS

The clinical implications of the findings are considered in the context of the existing male-orientated firesetting knowledge base and emerging models of service delivery to women in secure settings.

The development of a 'best practice' service for women in a medium-secure psychiatric setting: treatment components and evaluation

The inadequacy of inpatient facilities for women with severe psychiatric and co-morbid difficulties has been repeatedly documented. The establishment of effective therapeutic programmes for women in medium psychiatric facilities is also in their infancy, and little research has been undertaken. This article describes the development of a 'best practice' psychological treatment programme for women with a dual diagnosis. Emphasis is placed on the need to develop further intensive gender-specific services using an established model for effective therapeutic service development. In addition to a detailed description of the group therapy programme, staff training initiatives, methods for ensuring treatment integrity and a methodology for service evaluation is given.

Gender differences in psychiatric diagnoses among inpatients with and without intellectual disabilities

There are few published studies on the relationship between gender and psychiatric disorders in individuals with intellectual disabilities. Adults (N = 1,971) with and without intellectual disabilities who received inpatient services for psychiatric diagnosis and clinical issues were examined. Among individuals with intellectual disabilities, women were more likely to have a diagnosis of mood disorder and sexual abuse history; men were more likely to have a substance abuse diagnosis, legal issues, and past destructive behavior. Gender difference patterns found for individuals with intellectual disabilities were similar to those of persons without intellectual disabilities, with the exception of eating disorder and psychotic disorder diagnoses. Gender issues should receive greater attention in intellectual disabilities inpatient care.

Bordering on insanity: misnomer, reviewing the case of condemned women

In the UK, there have been calls to develop gendered specific mental health services for women in an attempt to ensure privacy and dignity are achieved as and when women come into contact with services. This is a largely rhetorical policy objective. There are more fundamental factors affecting women's experience of mental health services that need addressing. This paper explores these issues in the context of mental health care for women who have been 'given' the diagnosis of borderline personality disorder (BPD). Borderline personality disorder effects 2% of the adult population, 75-90% of those diagnosed being women. This diagnosis continues to present considerable conceptual and therapeutic challenges for all of those involved in mental health services and it remains a categorical label that evokes a wide range of conscious and unconscious responses in mental health nurses. The paper argues that mental health nurses need to recognize the defence mechanisms involved in working with individuals who are often difficult to work with. It is only when mental health nurses can embrace and acknowledge the person in the context of their life, that the pejorative and disabling consequences of the BPD label can be eliminated, ensuring the individual's story is heard and not that which is often a pre-constituted account accompanying this diagnosis.