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
• Womens Directorate, Rampton Hospital Lead
  Clinician for Womens 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 womens
  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 governments strategy for women offenders.
  HO, 2000
• The governments strategy for women
  offenders-consultation report. HO, 2001
• Womens mental health Into the mainstream,
  strategic development of mental health care for
  women. DoH, 2002
• Mainstreaming gender and womens mental health
  Implementation guidance. DoH, 2003

11
Womens service developments

• WISH (Women In Secure Hospitals) mission
  statement
• All health and social care partners should offer
  a discrete, gender sensitive womens service
  that reflects the essential differences in
  womens 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
Womens service developments

• Women patients within the high secure estate have
  decreased dramatically since 1991, when there
  were 345 women in high secure care.
• Womens mental health Into the mainstream
  recommended that two high secure sites provide
  care for women patients.

13
Womens 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
Womens 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
Womens 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
Womens 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/sex
  ual).

17
Womens 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
Womens 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
Womens 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
Womens service developments

• Importance of relational security
• The quality of relationships is more significant
  to womens 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
Womens 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
Womens 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 womens
  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
Womens service developments

• Importance of relational security
• Jean Baker Miller goes on to say
• Indeed womens 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
Womens 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
Womens service developments

• Importance of relational security
• Challenging behaviour is functional and should be
  interpreted in the context of relationships.
• The woman patients disturbed attachments and
  interpersonal functioning need to be understood
  in the context of Millers 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
Womens 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
Womens 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
Womens 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
Womens service developments

• Enhanced medium secure services
• The implementation guidance, Mainstreaming gender
  and womens 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
Womens 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
Womens 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
Womens 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
Womens service developments

• Womens 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, womens 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 womens 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
• Womens Directorate, Rampton Hospital Lead
  Clinician for Womens Services, Arnold Lodge
• 25th June 2004