VOL: 98, ISSUE: 04, PAGE NO: 40
Jennifer Newton, PhD, MA, and Georgie Parry-Crooke, BA, AdvDipCounselling, are senior lecturer/researchers in community care, University of North LondonJennifer Newton, PhD, MA, and Georgie Parry-Crooke, BA, AdvDipCounselling, are senior lecturer/researchers in community care, University of North London
The secure psychiatric services have been in the news regularly over the past year, particularly the need for reform of the three special hospitals - Broadmoor, Rampton and Ashworth. Current provision is thought to be particularly unsuitable for women (Department of Health, 2000).
The ratio of men to women in the three hospitals is more than five to one. In regional secure units it is not unusual for a lone woman to be placed with a group of 15 male patients. It can be argued that too many women are cared for in these settings: most do not need the level of security provided (Box 1). Furthermore, the service is inevitably designed mainly to meet the needs of men, and cannot easily provide the support required by women, many of whom have been abused by male family members.
In response to proposals to reconfigure the secure mental health services, Women in Secure Hospitals (WISH) felt it was important to ensure that the views of women patients were heard. The charity commissioned the University of North London to consult with these women and sent the results of this consultation to the Department of Health and regional commissioners of secure psychiatric services. WISH also evaluated the consultation process itself (Stafford, 2001). This has demonstrated that it is possible to gain meaningful feedback by talking to women patients. WISH argues that women patients should be consulted regularly about their care. The results have implications for nurses who remain the major providers of day-to-day care.
Fifty-six women patients gave their views (46 in high security hospitals, 10 in medium security units). Most met researchers for a one-to-one interview, though one group of six met together and four supplied comments in writing.
The women were asked what was good about life in secure care and what they would like to change. They discussed daytime activities, treatment and care, rules, relationships, and mixing with men. Their account (Parry-Crooke et al, 2000) makes fascinating, if sometimes uncomfortable, reading. It concludes that the system too often fails to help women to take responsibility for and control over their difficulties.
On the whole, the women had relatively modest and realistic expectations about how their situation could be improved.
Some women in high security settings described depressingly empty days: breakfast, medication, lie on your bed, lunch, sit about, an hour of occupational therapy, sit about, tea, medication, bath, music, television, then bed. Not surprisingly, they liked to 'get off the ward' as much as possible and enjoyed mixing with teachers from 'outside'. They liked to be able to choose women-only activities, but the choice of whether or not to participate at all was also important.
Key nurses who make time to talk and keep promises
Key nurses were the usual choice of person to discuss problems with. Comments about them ranged from very positive to extremely critical. Positive relationships were those where the woman found the staff member accessible and approachable, trusted them to maintain confidentiality and believed they would keep promises. Conversely, in poor relationships the woman tended to feel that she was treated like a prisoner, with little or no respect, and was disbelieved. The staff member was perceived as inaccessible, insensitive and inattentive.
Protection from male patients
Although mental health lobby groups have argued strongly against mixed-sex psychiatric wards, women do not necessarily want all aspects of provision to be separate. In fact, most preferred mixed settings for daytime and evening activities.
However, this came with a huge caveat. They wanted to be treated with respect and to feel safe. They needed to be able to choose - to have the option, for instance, of using the gym when men were not present. And when in a mixed-sex environment, they wanted to feel protected from harassment and intimidation. But this was frequently not their experience. In medium security mixed settings the situation could be particularly difficult, leading to negative consequences for the women.
'There's 16 of them and they dominate. I'm always having to stand up for myself and then I explode. The staff then say I'm violent and threatening.'
While male patients were sometimes seen as a problem, male staff were more often valued and, in some circumstances, increased the women's sense of safety. Some women also said that male nurses were supportive key workers. However, they cited instances where it was inappropriate for male nurses to work with women patients - for example, in conducting room searches and placing women in seclusion.
Meaningful care-plan objectives
When asked about their care plans, the women rarely described a jointly agreed set of objectives related to their needs, nor jointly formulated strategies to achieve them. In fact, just 32 of the 56 women knew that they had a care plan and even fewer had been involved in its development or review. Only two had seen their care plan and had a copy.
More often than not, women had several plans related to single problems, which were not clearly linked to an overall set of aims. As one woman explained, people can have care plans for 'dieting, cutting up, being abusive ... I had one for my Walkman and my diet, but I don't know how they get drawn up ... They say you make your own care plan. They say it's like building bricks. It didn't feel like that to me.'
The women also observed that care plans had some specific goals, but no detail on how to achieve them.
'The aim for me is to minimise or cut down on self-harm, the objective is for me not to do it and then I sign it. It doesn't say how you're going to do it. The nurse does it, we're not asked, then we read it and sign it. If it's not signed, it still goes ahead, but that goes against you as they say you are not complying with your treatment.'
There were similar issues about the aims, focus and provision of therapy not being agreed with the women. Many wished to focus on early experiences such as sexual abuse or their reasons for self-harm. They described how the focus was more likely to be their index offence. Agreeing to therapy was, for some women, an issue of compliance linked to discharge and requests to see a female therapist were not always agreed.
Treatment choice and information
The women's lack of involvement was compounded by the poor information provided. Two-thirds were taking medication, but many did not know what it was, how long they might need to stay on it, or what side-effects to expect. The possibility of talking therapies was discussed with most of the women, although fewer than one in three were seeing a therapist. Many had been told there would be a wait of months or years.
Care plans that are not linked to rewards or punishment
The women in medium security units did not find their care plans very useful and were dismissive about them. In high security care, plans were frequently viewed as the embodiment of rules, as well as non-negotiable checklists of behaviour and activities related to compliance and possible rewards.
One woman described being put on medication after years without taking it because her discharge depended on successful drug therapy. Therapy was frequently linked with sanctions to force compliance. Most frequently, the perceived cost for non-compliance for the women was delayed discharge.
'I have psychotherapy once a week. It's hard. I don't want to have it but I need to have it to leave.'
In fact, the control of the women seemed to militate against them developing control over their lives. One woman's comment echoed the views of many:
'We're expected to behave like adults but we get treated like children.'
Clear, understandable and consistent rules
Several women were unclear about the rules, saying that they sometimes changed with no explanation and varied between wards.
'I didn't get told about the rules. I don't know how you get to know about them. I just try to be good.'
'We were told that if you abuse the staff you have to go to bed at 10.30. When I challenged the nurses, they just said it was a new rule.'
These two comments came from women in high security hospitals, who were well aware of the pressures on staff and the fact that some of them had difficulty adjusting to the recent requirement to provide 24-hour care. Before 24-hour care came into being the women's movements, access and activities were restricted during the night. They commented that opportunities to negotiate or change the rules at ward meetings, or in relation to care plans, were rare. More often it was considered impossible to influence the rules.
A place of safety
In summary, the women consulted were asking for very basic improvements: to feel safe, have a trusted confidante, choice, participation in decision-making and to be treated with respect. Their comments about all aspects of their lives in secure settings, particularly high security hospitals, suggest that feelings of powerlessness are likely to be reinforced by the way they are treated and the pressure to behave like 'good girls'.
- Women in Secure Hospitals (WISH), 18 Borough High Street, London SE1 9QG; tel: 020 7407 5191; e-mail: firstname.lastname@example.org