VOL: 97, ISSUE: 37, PAGE NO: 40
Sheila Mallon, BA, RMN, is a staff nurse at Macmillan Close, NottinghamSheila Mallon, BA, RMN, is a staff nurse at Macmillan Close, Nottingham
Macmillan Close is a community-based, residential rehabilitation unit in Nottingham. It has 12 town houses that accommodate 27 clients. Each has his or her own bedroom and front-door key, and each house has a kitchen, lounge and bathroom. Placements can be long or short-term, depending on need, and there is a crisis, respite and outreach service.
The unit offers men and women aged 18 to 65 a chance to participate in their rehabilitation, make friends, be involved in decision-making and take responsibility for their own lives.
The team's philosophy is based on a client-centred approach, using the Strengths Model of Care (Rapp and Wintersteen, 1989). The focus of this model is what a client can or wants to do, and building on this rather than their deficits.
The 24-hour staff team aims to support people with enduring mental health problems and provide a therapeutic environment. The team seeks to optimise an individual's level of independence, promoting choice and self-determination within realistic boundaries. One house is for women only.
Although 58% of admissions to psychiatric hospitals are women, Gadd (1996) and Owen et al (1996) report that the particular needs and views of women with enduring mental health problems are poorly served by existing services.
The needs of men generally take precedence over those of women, primarily because of the nature of men's problems and behaviour. Women often present with less problematic behaviours: they are less violent, more likely to comply with medication and often have the daily living skills required for independent living that men often lack.
The services available to women are mainly hospital-based provision (acute wards) or medication at home in the care of a GP, who is more likely to treat the woman than refer to other services.
Alarmingly, two-thirds of all NHS psychotropic and antidepressant drugs appear to be prescribed to women. Women are also twice as likely to receive electroconvulsive therapy than men, at the expense of counselling and other services (MIND, 1993).
Research on women with enduring mental health problems has identified that they have specific needs. Invariably these include issues concerned with lack of power, abuse, loss, social isolation and vulnerability.
The psychological costs to women because of their gender are well-documented and researched. For example, older women are least likely to be offered counselling but most likely to be prescribed psychotropic drugs, despite the fact that they are most at risk from side-effects. Ussher (1991) and Gorman (1992) highlight how the effects of marriage, childbirth, caring, poverty, domestic violence and simply being a woman can result in psychological upset. But services are failing to address these underlying causes and, instead, appear to be treating the secondary symptoms.
Male-dominated services are off-putting for women, so staff at Macmillan Close felt it was important to make their services more appropriate and accessible to women. One of the main recommendations of research and service users was the basic need to feel safe in their environment.
Setting up a women-focused service
Before 1992, because of the male-dominated client environment, many women did not see Macmillan Close as particularly accessible or therapeutic. They were reluctant to share a house or bathroom with men, which resulted in a lack of referrals.
To meet women's needs, a three-bedroomed women-only house was set up in 1992. Since then the number of admissions has increased. An audit carried out last year found that the average percentage of female admissions for 1996-1998 was 44% and that 13 of 20 randomly selected women had requested to be placed in the women-only house.
The service has benefited women who have been abused or are in exploitive relationships with men. It has also benefited those who want time away from men and those whose parents or significant others may be unhappy about them coming into a male-dominated environment.
Philosophy of the women's service
Staff at the unit developed a philosophy based on the views of service users and the 1996 Mental Health Act Commission, as well as recommendations on mental health from the Sainsbury Centre for Mental Health (1997).
This approach acknowledges the importance of safety for women within mental health services. Male visitors are accommodated away from the house. No men - and that includes staff - are allowed into the house, apart from workmen, who are escorted at all times by female staff. This ruling can be overturned in emergencies, for example, if there is a danger to self or others and in the event of fire. There is also a written non-harassment policy which applies to all clients.
Women are given a choice of having a female key worker and, if possible when requested, a woman from the multidisciplinary team, such as an occupational therapist or doctor. All women have the option to access this service.
The cornerstone of effective care is establishing a meaningful relationship with clients based on a person-centred, humanistic approach of trust, respect and a genuine interest in the person and his or her needs. Staff on the unit aim to gain a better understanding of each woman and help them to move forward in a supported way, take risks and explore coping strategies.
Clients are encouraged to be involved in writing their own care plans, attending house and residents' meetings, and there is always a service user on the interview panel for new staff.
Women are offered a client-centred package of care, from preadmission to care in the community. They are encouraged to attend women's groups and engage in preadmission work before placement in the unit.
Assessment for care is based on a recognition of the woman's health and social care needs and acknowledges a client's need to be listened to and respected, enabling her to develop a therapeutic relationship with staff. Women have ready access to staff who are familiar and trusted and have an interest and background in women's studies, gender issues or family therapy. The aim is to develop ways of managing mental health problems and support women in identifying coping strategies and recognising prodromal signs. There is access to specialist counselling as well as education and information on diagnosis and medication.
The women are encouraged to be involved in their care planning, evaluation and reviews, and they cook, clean and shop for themselves. Yet it should not be assumed that they are experts in daily living simply because they are women. So, where appropriate, they are supported in dealing with practical problems and the activities of daily living. Building up such skills within a household setting increases confidence and empowers them to take control of their lives - something that is difficult to achieve on a hospital ward.
The unit aims to designate and develop a child-friendly area for families and visitors with children. It also offers a mixed evening club which meets locally in town, weekly activities and groups, and holidays and evenings out for residents. Drop-in sessions on Saturdays are open to former residents and there are user-led activities, sessions for relaxation and art groups. A number of other groups have been set up recently: a drama group, a 'moving on' group, a drug and alcohol group, and a psychosocial interventions group.
The women's group
In addition to the wide range of activities already mentioned, Macmillan Close has a weekly women's group. It is informal, open to former residents and offers women a forum to share their experiences, concerns and problems, helping them to feel less isolated. They are able to discuss freely issues that concern women only and the roles and responsibilities they have in common.
The group also offers women an opportunity to juxtapose their behaviour with their feelings beyond the confines of the unit. In the safe context of a women-only group this can enhance a woman's understanding of which facets of her problems lie within her psyche and need analytical understanding and which are related to the position women hold in a society or culture.
Research cited in Aveline and Dryden (1988) emphasises the value of groups in increasing self-esteem and helping women to regain confidence and enter the social world again.
Staff aim to provide a safe environment within which women are able to support one another and gain strength and confidence through empowerment. It is hoped that their awareness of life choices and the resources available both to them and within them will increase, enabling them to work towards personal goals.
Links with the community
The unit has established links with the local women's centre and women-only accommodation in the community. For example, a closed group that will run for six weeks at the local women's centre is being organised by the community occupational therapy team.
The centre also offers rape counselling and individual counselling, help for Asian women and advice on welfare rights. In addition, it has a lesbian centre and runs courses in assertiveness and confidence-building, self-defence, information technology, and literacy and numeracy skills. Local colleges offer a befriending service for women living in the community.
Staff at Macmillan Close offer women ongoing liaison, advice and practical help, enabling them to access the community they live in and make informed choices on their future, all within a safe environment. The aim is not only to access services in the unit but also those outside, as well as non-mental health services. This will help clients to develop networks they can continue to maintain once they have been discharged.
Women with mental health problems often have limited social networks and may feel socially excluded (Rogers and Pilgrim, 1996).
Women discharged from Macmillan Close who have later been readmitted have indicated that social isolation has contributed to a decline in their mental health. They often find it difficult to participate fully in society: this may affect activities such as going to the cinema, the pub or the fitness centre on their own. Because of their problems, their social networks have often broken down. For those discharged into the community, this can be a frightening time.
To promote social inclusion and the development of these women's social networks, Macmillan Close is working towards becoming a practice development unit in collaboration with Leeds University. It aims to link with two other units in the area to develop the women's service. A monthly club for all the units involved has been set up to share resources and activities. Speakers are invited and a recent night out at a local club was a great success, particularly for women who did not have the confidence to go out in the evenings.
Ultimately we are working towards a user-led service for women so that they can gain more control over their lives, establish social networks that meet their needs and continue to improve the standard of service provision.