Transcript Developing secure services for women: Containment at the

Developing secure services
for women: Containment at
the expense of care?
Dr Mary di Lustro
Consultant Forensic Psychiatrist
Women’s Directorate, Rampton Hospital & Lead
Clinician for Women’s Services, Arnold Lodge
25th June 2004
Developing secure services for
women: Containment at the
expense of care?
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The case for gender specific care
The development of the national strategy
The evolution of the National High Secure
Service for Women and local
developments
Care versus containment; Therapy versus
security
Visions of the future
The case for gender specific care
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Studies of patients detained in high and medium
security have identified significant gender
differences.
The needs of women are therefore inadequately
met in services centred on the needs of men.
This may account for women being more
commonly readmitted to medium security and
having longer admissions to secure care.
The case for gender specific care
Women are more likely to:
 Have been transferred from other NHS
facilities.
 Have a history of fire setting or criminal
damage, but less likely to have committed
a violent or sexual offence.
 Have a history of abuse and/or self-harm.
 Have physical ill-health.
The case for gender specific care
Women are more likely to:
 Be admitted for behaviours for which they
were not charged or convicted and be
detained under civil sections of the Mental
Health Act.
 Have a diagnosis of personality disorder,
particularly borderline personality disorder.
National strategies and guidance
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Modernising mental health services. DoH,
1998
Mental health national service framework.
DoH,1999
Safety, privacy and dignity in mental
health units. DoH, 2000
National strategies and guidance
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Secure futures for women: Making a
difference. DoH, 2000
Endorsed women-centred services
Mental health services for women
should be available in hospital and the
community
National strategies and guidance
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Tilt Review of security at the high security
hospitals. DoH, 2000
“We regard it as inappropriate, both
from a civil liberties and efficient use
of resources viewpoint, for patients
who can be safely accommodated in
less secure conditions, to remain in a
high security setting for lengthy
periods.”
National strategies and guidance
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Provision of NHS mental health services.
Health Select Committee, 2000
“We agree that the way forward for
women’s secure services must be a
completely separate service. We urge
the Department of Health to bring
forward and publish a national strategy
to achieve this as a matter of urgency.”
National strategies and guidance
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The government’s strategy for women offenders.
HO, 2000
The government’s strategy for women offendersconsultation report. HO, 2001
Women’s mental health: Into the mainstream,
strategic development of mental health care for
women. DoH, 2002
Mainstreaming gender and women’s mental
health: Implementation guidance. DoH, 2003
Women’s service developments
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WISH (Women In Secure Hospitals) mission
statement:
All health and social care partners should offer
“a discrete, gender sensitive women’s service
that reflects: the essential differences in
women’s social and offending profiles; their
mental distress and complex patterns of
behaviour; their care and treatment needs
underpinned by principles of empowerment,
respect and dignity.”
Women’s service developments
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Women patients within the high secure
estate have decreased dramatically since
1991, when there were 345 women in
high secure care.
Women’s mental health: Into the
mainstream recommended that two high
secure sites provide care for women
patients.
Women’s service developments
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The implementation guidance of the
strategy recommended only one site.
The emergence of a single national
provider of high secure care at Rampton
Hospital followed.
The service will provide for only 50
women patients.
Women’s service developments
Challenges for local services
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To develop a range of services for women
patients who would have previously been
considered for high secure care.
To ensure that managed clinical networks
anticipate the capacities of different services
within that network.
To ensure that adequate attention is paid to
the requirement for interface working
between services, agencies and settings.
Women’s service developments
Local developments
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The provision of 20 medium secure beds for
women patients, with the philosophy of
providing:
A holistic, woman-centred approach to the
needs of each individual patient with the
goals of psychological and social integration,
in addition to the reduction of risk to self and
others.
Women’s service developments
Patient Group
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The service will provide clearly defined
physical, procedural and relational security for
women who cannot be managed safely in
conditions less than medium security.
Many women are likely to have lived through
severe and prolonged abuse
(physical/emotional/sexual).
Women’s service developments
Patient Group
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More than 60% women in secure care have
been sexually abused during childhood,
increasing to more than 80% of those women
diagnosed as suffering from a disorder of
personality.
These women can be re-traumatised within
the psychiatric system by common
institutional practices.
Women’s service developments
Patient Group
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Women may have a history of substance misuse.
They may suffer from eating disorders.
They may experience difficulty in forming trusting
relationships.
They may be dealing with the effects of enforced
separation from their children.
Their presentation may include pervasive anger,
depression, mood instability, dissociation and anxiety.
Women’s service developments
Security arrangements
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The levels and nature of physical and procedural
security will not differ significantly from the remainder
of the medium secure service.
There will be significant differences in relational
security provided, defined as:
The psychological relationship developed between a
woman patient and her care team within contained
and fully explained boundaries.
Women’s service developments
Importance of relational security
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The quality of relationships is more significant
to women’s feelings of well-being than is
generally the case in relation to men (Kaplan
& Surrey).
Traditional developmental theories emphasise
separation and independence from others as
signs of healthy adult maturity. Viewing
oneself in relation to others is interpreted as a
sign of immaturity.
Women’s service developments
Importance of relational security
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Such theories deny the positive aspects of
mutuality and sensitivity to others and the
fact that:
“the ability to experience, comprehend, and respond
to the inner state of another person is a highly
complex process relying on a high level of
psychological development and ego strength.”
(Kaplan & Surrey)
Women’s service developments
Importance of relational security
 The psychiatrist Jean Baker Miller wrote:
“Male society, by depriving women of the right to
its major ‘bounty’-that is, development according
to the male model-overlooks the fact that
women’s development is proceeding, but on
another basis. One central feature is that women
stay with, build on, and develop in the context
of connections with others.”
Women’s service developments
Importance of relational security
 Jean Baker Miller goes on to say:
“Indeed women’s sense of self becomes very
much organised around being able to make and
then maintain affiliations and relationships.
Eventually for many women the threat of
disruption of connections is perceived not just as
a loss of a relationship, but as something closer
to a total loss of self.”
(Miller)
Women’s service developments
Importance of relational security
 This should be considered in combination
with theories that early abuse, stress and
deprivation may result in impaired
neurodevelopment (Kolk et al) and
changes such as a reduced number of
opioid receptors in the brain.
Women’s service developments
Importance of relational security
 Challenging behaviour is functional and should
be interpreted in the context of relationships.
 The woman patient’s disturbed attachments and
interpersonal functioning need to be understood
in the context of Miller’s comments and the
sense of loss that will result if a care team
attempts to alter them without first seeking to
establish less dysfunctional attachments.
Women’s service developments
Implications of relational security
 There will be significant challenges to staff
within the service.
 Staff should have made an active choice
to work with women and have an
understanding of gender issues and
empowerment, in addition to having the
requisite clinical skills.
Women’s service developments
Implications of relational security
 There must be regular, systematic
individual supervision for all staff.
 There must be opportunities for reflective
practice.
 Confidential stress counselling must be
available when necessary.
 Regular staff appraisal.
Women’s service developments
Implications of relational security
 Staff must develop a shared
understanding of the patients’ complex
psychopathology.
 As part of this process staff must develop
a high degree of self-awareness, that
includes examination of their own core
beliefs and value judgements.
Women’s service developments
Enhanced medium secure services
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The implementation guidance, Mainstreaming
gender and women’s mental health, states that
secure services should provide:
“services for the small number of women,
currently in high secure care, who have
committed severe offences, or who could not be
catered for within existing medium secure care,
but who do not need Category ‘B’ high secure
care.”
Women’s service developments
Enhanced medium secure services
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The local service development will include
provision for some women patients
requiring such care.
These patients are not envisaged to
require a greater degree of physical
security.
They will require a greater degree of
procedural and relational security.
Women’s service developments
Enhanced medium secure services
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This patient group has similar
characteristics and needs to those already
identified, but differs in the following
manner:
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Level of dependency
Degree of complexity of need
Nature of risk to self and/or others
The chronicity in all three of these areas
Women’s service developments
Enhanced medium secure services
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The provision of services for these women
will require greater resources, largely in
respect of staff.
There will also be significantly greater
need for staff supervision, training and
development, reflective practice and staff
support, including counselling when
appropriate.
Women’s service developments
Women’s medium secure services
 The developing service will accept referrals from
the prison service and intends to establish a
positive relationship with the National Offender
Management Service.
 The intention is to provide streamlined care
pathways for women, wherever they are
located, ensuring that they receive appropriate
hospital care.
Care versus containment
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It has been accepted that women patients
are often detained at levels of physical
security greater than those they actually
require.
For many women, they have therefore
been subject to a far greater degree of
containment than necessary, without
receiving gender sensitive, therapeutic
care.
Care versus containment
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In high security the recent expenditure on
ensuring the Category ‘B’ status of the
hospital estate appears to have
promulgated this state of affairs.
Much debate has resulted from these
changes and the implied focus upon
containment and security, rather than care
and therapy.
Care versus containment
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To some degree this will be replicated
within the new service developments at
the levels of both medium and low
security.
Much of this provision will take place
within existing services and women will de
facto be detained at the same level of
physical security deemed necessary for
men.
Care versus containment
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If this remains the case, women’s needs
will be subjugated by the prioritisation of
physical security needs judged on the
basis of physical security needs of men.
Whilst gender specific services may
develop more sensitive and therapeutic
models of care, women may continue in
the future to receive a greater degree of
containment than is absolutely necessary.
Visions of the future
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A utopian vision of women’s services would
include a managed clinical network that
incorporates all levels of secure provision,
community mental health services and
healthcare provision within the prison estate.
This managed clinical network should work in
close collaboration with the National Offender
Management Service and ensure that all women
offenders receive the appropriate care,
treatment and rehabilitation, rather than
containment alone.
Visions of the future
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“Women do not need permission to
change tradition, but do need support and
commitment.”
Developing secure services
for women: Containment at
the expense of care?
Dr Mary di Lustro
Consultant Forensic Psychiatrist
Women’s Directorate, Rampton Hospital & Lead
Clinician for Women’s Services, Arnold Lodge
25th June 2004