Developing secure services for women: Containment at the expense of care

1. 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

2. Developing secure services for women: Containment at the expense of care? 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

3. The case for gender specific care 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.

4. 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.

5. 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.

6. National strategies and guidance Modernising mental health services. DoH, 1998 Mental health national service framework. DoH,1999 Safety, privacy and dignity in mental health units. DoH, 2000

7. National strategies and guidance 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

8. National strategies and guidance 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.”

9. National strategies and guidance 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.”

10. National strategies and guidance The government’s strategy for women offenders. HO, 2000 The government’s strategy for women offenders-consultation 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

11. Women’s service developments 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.”

12. Women’s service developments 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.

13. Women’s service developments 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.

14. Women’s service developments Challenges for local services 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.

15. Women’s service developments Local developments 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.

16. Women’s service developments Patient Group 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).

17. Women’s service developments Patient Group 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.

18. Women’s service developments Patient Group 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.

19. Women’s service developments Security arrangements 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.

20. Women’s service developments Importance of relational security 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.

21. Women’s service developments Importance of relational security 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)

22. 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.”

23. 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)

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. Women’s service developments Enhanced medium secure services 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.”

30. Women’s service developments Enhanced medium secure services 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.

31. Women’s service developments Enhanced medium secure services This patient group has similar characteristics and needs to those already identified, but differs in the following manner: Level of dependency Degree of complexity of need Nature of risk to self and/or others The chronicity in all three of these areas

32. Women’s service developments Enhanced medium secure services 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.

33. 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.

34. Care versus containment 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.

35. Care versus containment 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.

36. Care versus containment 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.

37. Care versus containment 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.

38. Visions of the future 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.

39. Visions of the future “Women do not need permission to change tradition, but do need support and commitment.”

40. 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