Resegregating psychiatric wards may protect women: CrossCurrents Winter 2002/03
CrossCurrents
In the late 1960s, when psychiatric institutions integrated men's and women's wards, the prevailing wisdom was that the more
natural, home-like environment would yield therapeutic benefits. Over time, that wisdom has changed with changing circumstances.
Hospital beds have been cut dramatically and psychiatric stays greatly shortened. The average inpatient is more severely ill
than 30 years ago and no longer as heavily sedated by antipsychotics.
Among mental health professionals, there is a growing awareness that mixed-sex wards may place many women - particularly those
most acutely ill - at risk. In the United Kingdom, often a leader in mental health reform, the movement is underway to turn
back the clock and resegregate psychiatric services. Canada may follow suit.
In mixed-sex wards where there are no locks on doors, men sometimes wander into women's rooms at night. Women are often propositioned
for sex. There are reports of drug dealers who roam psychiatric hospitals looking to coerce female clients into having sex
for drugs, says Dr. Mary Seeman, a psychiatrist at the Centre for Addiction and Mental Health (CAMH) in Toronto.
Last spring, the psychiatric ward of a Winnipeg hospital reported two alleged sexual assaults within 10 days. In each case,
the woman and the alleged assailant were inpatients. Another alleged assault occurred in a Toronto hospital several years
ago. Sadly, such incidents are only the most visible part of a widespread problem that mental health professionals around
the world are struggling to address.
Indeed, the prevalence rate for sexual and physical abuse among women with serious mental illness is roughly twice that of
the general population. Numerous studies have found that up to two-thirds of women with mental illness have suffered some
form of childhood abuse, whether physical, sexual or emotional. Rates of revictimization are alarmingly high.
"The vulnerability of women with serious mental illness to sexual and physical abuse has been documented, and we're starting
now to think about why," says Dr. Jean Gearon, assistant professor of psychiatry at the University of Maryland School of Medicine.
Gearon explains that for women with schizophrenia, the nature of the psychopathology itself is a factor. Deficits in recognizing
subtle or even dramatic interpersonal cues combined with poor social problem-solving skills can add up to an inability to
recognize and negotiate their way out of dangerous situations.
While the body of research about the abuse of women with mental illness has grown considerably over the past decade, very
little has focused on the setting of the mixed-sex ward.
In one of the first studies to examine safety in the clinical environment, published in a 1999 issue of the Canadian Journal of Nursing Research (CJNR), 20 women from three institutions in the Greater Toronto Area were interviewed about changes they would like made
to the inpatient environment. Their responses concerning male patients were unequivocal: seventeen women felt unsafe in mixed-sex
units and expressed a desire for segregated areas. Their concerns ranged from distress at a disturbed man screaming in the
room next door to men not being adequately dressed at breakfast to dislike of being touched by male staff.
Clearly, the issue of safety goes beyond the mere prevention of assaults. For some women with a history of abuse, the mixed-sex
ward might be an inherently traumatic environment.
This can be a difficult idea for mental health professionals to accept, as focus groups with clinicians from the settings
involved in the CJNR study revealed. "The first reaction was always, 'Oh, that must have been in one of the other settings,'"
says Dr. Ruth Gallop, associate dean of the Faculty of Nursing at the University of Toronto and co-author of the study.
After the initial disbelief passed, the disparity between clinician and client perceptions of what constitutes safety and
dignity in the inpatient environment came into focus. The study's findings have been used by several inpatient units across
Canada in restructuring their programming, in particular, modifying how night-time checks of clients are carried out.
"The findings reflect the need for clinicians to understand that a history of abuse or trauma is not separate and discrete
from these people's lives," says Gallop. "Finding out about abuse isn't enough if we're not going to use that knowledge to
modify treatment."
The reality is that it is easy for clinicians to become regimented in their practice, according to the CJNR study. Faced with
the daily challenges of client care, it is difficult to step back and reassess the most basic assumptions of the inpatient
environment, while the front-line practitioners most keenly aware of the need for change can feel powerless to effect it within
the hospital hierarchy. Nevertheless, that awareness of the need for change is growing.
"The consensus among most people now who treat women is that it would be better, probably for both men and women, that we
take another look at the old issue of whether wards should be together or not," says Seeman. In Canada, CAMH's women-only
ward is the exception to the rule of mixed-sex facilities.
More than just providing a safe environment, the women-only ward offers advantages for treatment. "If you have a more homogeneous
population, you can specifically treat the issues that women come with, which are not always the same as those that men come
with," says Seeman.
Of course, resegregation by sex is not an all-or-nothing proposition. Women might be offered the choice. Or there might be
women-only areas on mixed wards or women-only groups.
These are among the options that Linda Hughes, nursing director for the Mental Health Program in the Winnipeg Regional Health
Authority (WRHA), believes need to be investigated. The focus, she insists, should not be on resegregation alone, but on the
broader issues of women and mental health.
In this spirit, Hughes has worked in conjunction with WRHA facility program managers, the Canadian Mental Health Association
and a community clinic to develop initiatives that address the problem of abuse and allow women to feel safer on a mixed ward.
Workshops have been held for nursing staff across the region. A poster and pamphlets have also been designed for inpatient
units in the WRHA, to initiate discussions of safety and respect with clients. The Winnipeg Health Sciences Centre is running
a campaign to promote itself as an abuse-free zone.
It is an open question whether such initiatives can make a difference in preventing assaults like those that allegedly occurred
at the Winnipeg hospital, also part of the WRHA. "One of the things we need to do better work on is identifying early in the
admission those people who have a history of being, or who have a potential to be, perpetrators of unwanted sexual activity,"
says Hughes.
At the hospital's request, an external review was undertaken in the first week of June. Its recommendations are pending.
Among psychiatric care professionals, the subject of women-only treatment is very much in the air, with broad support for
the idea of increased access to single-sex care. However, where environmental changes are concerned, there is always the question
of senior management support and funding.
In the United Kingdom, it took not only the support of clinicians but a decade of persistent lobbying by the mental health
charity Mind to bring the matter of resegregating psychiatric services to a political boiling point. At present, the British
government is committed to phasing out mixed-sex wards in 95 per cent of health trusts by 2003, though whether such an ambitious
target can be met is a matter of contention.
In Canada, such sweeping change is not yet on the horizon. "We're in a slightly weak area because we don't have firm research
data," says Dr. Sarah Romans, Shirley Brown Chair in Women's Mental Health Research at the University of Toronto. "We want
comparative trials of women randomly assigned a single-gender ward or a mixed-gender ward, with outcomes. That would be the
hard kind of data that would convince evidence-based management."
Gearon agrees that further research is needed. Currently, efforts to address a history of abuse therapeutically are compromised
by the lack of clinical data about how persons with serious mental illness process trauma. Until this is investigated, mental
health professionals are hard pressed to develop effective interventions to reduce the trauma associated with abuse, and to
prevent revictimization.
"Staff need to become more sensitive to the needs and experiences of women inpatients," says Billie Pryer, manager of CAMH's
Women's Inpatient Unit. "Safety on mixed wards isn't threatened just by perceived possible violence by male inaptients," she
says. "Common staff practices like entering rooms at night need to be adjusted to promote environments that feel safe and
respectful of women."
For clients with a history of abuse, segregation alone is not enough. "I wouldn't just want to do prevention without intervention,"
says Gearon.
Robert Plowman
Centre for Addiction
