Developing secure services for women: Containment at the expense of care? Dr Mary di Lustro Consultant Forensic Psychiatrist Women’s Directorate, Rampton

Developing secure services Developing secure services for women: Containment at for women: Containment at

the expense of care?the expense of care?Dr Mary di LustroDr Mary di Lustro

Consultant Forensic PsychiatristConsultant Forensic PsychiatristWomen’s Directorate, Rampton Hospital & Lead Women’s Directorate, Rampton Hospital & Lead

Clinician for Women’s Services, Arnold LodgeClinician for Women’s Services, Arnold Lodge2525thth June 2004 June 2004

Developing secure services for Developing secure services for women: Containment at the women: Containment at the

expense of care?expense of care? The case for gender specific careThe case for gender specific care The development of the national The development of the national

strategystrategy The evolution of the National High The evolution of the National High

Secure Service for Women and local Secure Service for Women and local developmentsdevelopments

Care versus containment; Therapy Care versus containment; Therapy versus securityversus security

Visions of the futureVisions of the future

The case for gender specific careThe case for gender specific care

Studies of patients detained in high and Studies of patients detained in high and medium security have identified medium security have identified significant gender differences.significant gender differences.

The needs of women are therefore The needs of women are therefore inadequately met in services centred on inadequately met in services centred on the needs of men.the needs of men.

This may account for women being more This may account for women being more commonly readmitted to medium security commonly readmitted to medium security and having longer admissions to secure and having longer admissions to secure care.care.


Women are more likely to:Women are more likely to: Have been transferred from other NHS Have been transferred from other NHS

facilities.facilities. Have a history of fire setting or criminal Have a history of fire setting or criminal

damage, but less likely to have damage, but less likely to have committed a violent or sexual offence.committed a violent or sexual offence.

Have a history of abuse and/or self-Have a history of abuse and/or self-harm.harm.

Have physical ill-health.Have physical ill-health.


Women are more likely to:Women are more likely to: Be admitted for behaviours for which Be admitted for behaviours for which

they were not charged or convicted they were not charged or convicted and be detained under civil sections and be detained under civil sections of the Mental Health Act.of the Mental Health Act.

Have a diagnosis of personality Have a diagnosis of personality disorder, particularly borderline disorder, particularly borderline personality disorder.personality disorder.

National strategies and guidanceNational strategies and guidance

Modernising mental health services. Modernising mental health services. DoH, 1998DoH, 1998

Mental health national service Mental health national service framework. DoH,1999framework. DoH,1999

Safety, privacy and dignity in mental Safety, privacy and dignity in mental health units. DoH, 2000health units. DoH, 2000


Secure futures for women: Making a Secure futures for women: Making a difference. DoH, 2000 difference. DoH, 2000

Endorsed women-centred Endorsed women-centred servicesservices

Mental health services for Mental health services for women women should be available in should be available in hospital and the hospital and the communitycommunity


Tilt Review of security at the high Tilt Review of security at the high security hospitals. DoH, 2000security hospitals. DoH, 2000

““We regard it as inappropriate, We regard it as inappropriate, both both from a civil liberties and from a civil liberties and efficient use efficient use of resources viewpoint, of resources viewpoint, for patients for patients who can be safely who can be safely accommodated in accommodated in less secure less secure conditions, to remain in a conditions, to remain in a high high security setting for lengthy security setting for lengthy periods.”periods.”


Provision of NHS mental health services. Provision of NHS mental health services. Health Select Committee, 2000Health Select Committee, 2000

““We agree that the way forward for We agree that the way forward for women’s secure services must be a women’s secure services must be a completely separate service. We completely separate service. We

urge urge the Department of Health to the Department of Health to bring bring forward and publish a national forward and publish a national strategy strategy to achieve this as a matter of to achieve this as a matter of urgency.”urgency.”


The government’s strategy for women The government’s strategy for women offenders. HO, 2000offenders. HO, 2000

The government’s strategy for women The government’s strategy for women offenders-consultation report. HO, 2001offenders-consultation report. HO, 2001

Women’s mental health: Into the Women’s mental health: Into the mainstream, strategic development of mainstream, strategic development of mental health care for women. DoH, 2002mental health care for women. DoH, 2002

Mainstreaming gender and women’s Mainstreaming gender and women’s mental health: Implementation guidance. mental health: Implementation guidance. DoH, 2003DoH, 2003

Women’s service developmentsWomen’s service developments

WISH (Women In Secure Hospitals) mission WISH (Women In Secure Hospitals) mission statement:statement:

All health and social care partners should All health and social care partners should offer offer “a discrete, gender sensitive women’s “a discrete, gender sensitive women’s service that reflects: the essential service that reflects: the essential differences in women’s social and offending differences in women’s social and offending profiles; their mental distress and complex profiles; their mental distress and complex patterns of behaviour; their care and patterns of behaviour; their care and treatment needs underpinned by principles treatment needs underpinned by principles of empowerment, respect and dignity.”of empowerment, respect and dignity.”


Women patients within the high Women patients within the high secure estate have decreased secure estate have decreased dramatically since 1991, when there dramatically since 1991, when there were 345 women in high secure care.were 345 women in high secure care.

Women’s mental health: Into the Women’s mental health: Into the mainstream recommended that two mainstream recommended that two high secure sites provide care for high secure sites provide care for women patients.women patients.


The implementation guidance of the The implementation guidance of the strategy recommended only one site.strategy recommended only one site.

The emergence of a single national The emergence of a single national provider of high secure care at provider of high secure care at Rampton Hospital followed.Rampton Hospital followed.

The service will provide for only 50 The service will provide for only 50 women patients.women patients.


Challenges for local services Challenges for local services To develop a range of services for women To develop a range of services for women

patients who would have previously been patients who would have previously been considered for high secure care.considered for high secure care.

To ensure that managed clinical networks To ensure that managed clinical networks anticipate the capacities of different anticipate the capacities of different services within that network.services within that network.

To ensure that adequate attention is paid To ensure that adequate attention is paid to the requirement for interface working to the requirement for interface working between services, agencies and settings.between services, agencies and settings.


Local developmentsLocal developments The provision of 20 medium secure beds The provision of 20 medium secure beds

for women patients, with the philosophy for women patients, with the philosophy of providing:of providing:

A holistic, woman-centred approach to A holistic, woman-centred approach to the needs of each individual patient with the needs of each individual patient with the goals of psychological and social the goals of psychological and social integration, in addition to the reduction integration, in addition to the reduction of risk to self and others.of risk to self and others.


Patient GroupPatient Group The service will provide clearly defined The service will provide clearly defined

physical, procedural and relational physical, procedural and relational security for women who cannot be security for women who cannot be managed safely in conditions less than managed safely in conditions less than medium security.medium security.

Many women are likely to have lived Many women are likely to have lived through severe and prolonged abuse through severe and prolonged abuse (physical/emotional/sexual).(physical/emotional/sexual).


Patient GroupPatient Group More than 60% women in secure care More than 60% women in secure care

have been sexually abused during have been sexually abused during childhood, increasing to more than 80% childhood, increasing to more than 80% of those women diagnosed as suffering of those women diagnosed as suffering from a disorder of personality.from a disorder of personality.

These women can be re-traumatised These women can be re-traumatised within the psychiatric system by within the psychiatric system by common institutional practices.common institutional practices.


Patient GroupPatient Group Women may have a history of substance Women may have a history of substance

misuse.misuse. They may suffer from eating disorders.They may suffer from eating disorders. They may experience difficulty in forming They may experience difficulty in forming

trusting relationships.trusting relationships. They may be dealing with the effects of They may be dealing with the effects of

enforced separation from their children.enforced separation from their children. Their presentation may include pervasive Their presentation may include pervasive

anger, depression, mood instability, anger, depression, mood instability, dissociation and anxiety.dissociation and anxiety.


Security arrangementsSecurity arrangements The levels and nature of physical and The levels and nature of physical and

procedural security will not differ significantly procedural security will not differ significantly from the remainder of the medium secure from the remainder of the medium secure service.service.

There will be significant differences in There will be significant differences in relational security provided, defined as:relational security provided, defined as:

The psychological relationship developed The psychological relationship developed between a woman patient and her care team between a woman patient and her care team within contained and fully explained within contained and fully explained boundaries.boundaries.


Importance of relational securityImportance of relational security The quality of relationships is more The quality of relationships is more

significant to women’s feelings of well-significant to women’s feelings of well-being than is generally the case in being than is generally the case in relation to men (Kaplan & Surrey).relation to men (Kaplan & Surrey).

Traditional developmental theories Traditional developmental theories emphasise separation and emphasise separation and independence from others as signs of independence from others as signs of healthy adult maturity. Viewing oneself healthy adult maturity. Viewing oneself in relation to others is interpreted as a in relation to others is interpreted as a sign of immaturity.sign of immaturity.


Importance of relational securityImportance of relational security Such theories deny the positive aspects Such theories deny the positive aspects

of mutuality and sensitivity to others of mutuality and sensitivity to others and the fact that:and the fact that:““the ability to experience, comprehend, and the ability to experience, comprehend, and

respond to the inner state of another person respond to the inner state of another person is a highly complex process relying on a high is a highly complex process relying on a high level of psychological development and ego level of psychological development and ego strength.”strength.”

(Kaplan & Surrey)(Kaplan & Surrey)


Importance of relational securityImportance of relational security The psychiatrist Jean Baker Miller wrote:The psychiatrist Jean Baker Miller wrote:

““Male society, by depriving women of the Male society, by depriving women of the right to its major ‘bounty’-that is, right to its major ‘bounty’-that is, development according to the male development according to the male model-overlooks the fact that women’s model-overlooks the fact that women’s development is proceeding, but on development is proceeding, but on another basis. One central feature is that another basis. One central feature is that women stay with, build on, and develop in women stay with, build on, and develop in the context of connections with others.”the context of connections with others.”


Importance of relational securityImportance of relational security Jean Baker Miller goes on to say:Jean Baker Miller goes on to say:

““Indeed women’s sense of self becomes Indeed women’s sense of self becomes very much organised around being able to very much organised around being able to make and then maintain affiliations and make and then maintain affiliations and relationships. Eventually for many women relationships. Eventually for many women the threat of disruption of connections is the threat of disruption of connections is perceived not just as a loss of a perceived not just as a loss of a relationship, but as something closer to a relationship, but as something closer to a total loss of self.”total loss of self.”

(Miller)(Miller)


Importance of relational securityImportance of relational security This should be considered in This should be considered in

combination with theories that early combination with theories that early abuse, stress and deprivation may abuse, stress and deprivation may result in impaired neurodevelopment result in impaired neurodevelopment (Kolk et al) and changes such as a (Kolk et al) and changes such as a reduced number of opioid receptors reduced number of opioid receptors in the brain.in the brain.


Importance of relational securityImportance of relational security Challenging behaviour is functional and Challenging behaviour is functional and

should be interpreted in the context of should be interpreted in the context of relationships.relationships.

The woman patient’s disturbed attachments The woman patient’s disturbed attachments and interpersonal functioning need to be and interpersonal functioning need to be understood in the context of Miller’s understood in the context of Miller’s comments and the sense of loss that will comments and the sense of loss that will result if a care team attempts to alter them result if a care team attempts to alter them without first seeking to establish less without first seeking to establish less dysfunctional attachments.dysfunctional attachments.


Implications of relational securityImplications of relational security There will be significant challenges to There will be significant challenges to

staff within the service.staff within the service. Staff should have made an active Staff should have made an active

choice to work with women and have choice to work with women and have an understanding of gender issues an understanding of gender issues and empowerment, in addition to and empowerment, in addition to having the requisite clinical skills.having the requisite clinical skills.


Implications of relational securityImplications of relational security There must be regular, systematic There must be regular, systematic

individual supervision for all staff.individual supervision for all staff. There must be opportunities for There must be opportunities for

reflective practice.reflective practice. Confidential stress counselling must Confidential stress counselling must

be available when necessary.be available when necessary. Regular staff appraisal.Regular staff appraisal.


Implications of relational securityImplications of relational security Staff must develop a shared Staff must develop a shared

understanding of the patients’ understanding of the patients’ complex psychopathology.complex psychopathology.

As part of this process staff must As part of this process staff must develop a high degree of self-develop a high degree of self-awareness, that includes awareness, that includes examination of their own core beliefs examination of their own core beliefs and value judgements.and value judgements.


EnhancedEnhanced medium secure services medium secure services The implementation guidance, The implementation guidance,

Mainstreaming gender and women’s Mainstreaming gender and women’s mental health, states that secure services mental health, states that secure services should provide:should provide:““services for the services for the small small number of women, number of women, currently in high secure care, who have currently in high secure care, who have committed severe offences, or who could committed severe offences, or who could not be catered for within existing medium not be catered for within existing medium secure care, but who do not need secure care, but who do not need Category ‘B’ high secure care.”Category ‘B’ high secure care.”


EnhancedEnhanced medium secure services medium secure services The local service development will The local service development will

include provision for some women include provision for some women patients requiring such care.patients requiring such care.

These patients are not envisaged to These patients are not envisaged to require a greater degree of physical require a greater degree of physical security.security.

They will require a greater degree of They will require a greater degree of procedural and relational security.procedural and relational security.


EnhancedEnhanced medium secure services medium secure services This patient group has similar This patient group has similar

characteristics and needs to those characteristics and needs to those already identified, but differs in the already identified, but differs in the following manner:following manner: Level of dependencyLevel of dependency Degree of complexity of needDegree of complexity of need Nature of risk to self and/or othersNature of risk to self and/or others The chronicity in all three of these areasThe chronicity in all three of these areas


EnhancedEnhanced medium secure services medium secure services The provision of services for these The provision of services for these

women will require greater women will require greater resources, largely in respect of staff.resources, largely in respect of staff.

There will also be significantly There will also be significantly greater need for staff supervision, greater need for staff supervision, training and development, reflective training and development, reflective practice and staff support, including practice and staff support, including counselling when appropriate.counselling when appropriate.


Women’sWomen’s medium secure servicesmedium secure services The developing service will accept The developing service will accept

referrals from the prison service and referrals from the prison service and intends to establish a positive relationship intends to establish a positive relationship with the National Offender Management with the National Offender Management Service.Service.

The intention is to provide streamlined The intention is to provide streamlined care pathways for women, wherever they care pathways for women, wherever they are located, ensuring that they receive are located, ensuring that they receive appropriate hospital care.appropriate hospital care.

Care versus containmentCare versus containment

It has been accepted that women It has been accepted that women patients are often detained at levels patients are often detained at levels of physical security greater than of physical security greater than those they actually require.those they actually require.

For many women, they have For many women, they have therefore been subject to a far therefore been subject to a far greater degree of containment than greater degree of containment than necessary, without receiving gender necessary, without receiving gender sensitive, therapeutic care.sensitive, therapeutic care.


In high security the recent In high security the recent expenditure on ensuring the expenditure on ensuring the Category ‘B’ status of the hospital Category ‘B’ status of the hospital estate appears to have promulgated estate appears to have promulgated this state of affairs.this state of affairs.

Much debate has resulted from these Much debate has resulted from these changes and the implied focus upon changes and the implied focus upon containment and security, rather containment and security, rather than care and therapy.than care and therapy.


To some degree this will be To some degree this will be replicated within the new service replicated within the new service developments at the levels of both developments at the levels of both medium and low security.medium and low security.

Much of this provision will take place Much of this provision will take place within existing services and women within existing services and women will de facto be detained at the same will de facto be detained at the same level of physical security deemed level of physical security deemed necessary for men.necessary for men.


If this remains the case, women’s needs If this remains the case, women’s needs will be subjugated by the prioritisation will be subjugated by the prioritisation of physical security needs judged on the of physical security needs judged on the basis of physical security needs of men.basis of physical security needs of men.

Whilst gender specific services may Whilst gender specific services may develop more sensitive and therapeutic develop more sensitive and therapeutic models of care, women may continue in models of care, women may continue in the future to receive a greater degree of the future to receive a greater degree of containment than is absolutely containment than is absolutely necessary.necessary.


A utopian vision of women’s services would A utopian vision of women’s services would include a managed clinical network that include a managed clinical network that incorporates all levels of secure provision, incorporates all levels of secure provision, community mental health services and community mental health services and healthcare provision within the prison estate.healthcare provision within the prison estate.

This managed clinical network should work in This managed clinical network should work in close collaboration with the National Offender close collaboration with the National Offender Management Service and ensure that all Management Service and ensure that all women offenders receive the appropriate women offenders receive the appropriate care, treatment and rehabilitation, rather care, treatment and rehabilitation, rather than containment alone.than containment alone.


““Women do not need permission to Women do not need permission to change tradition, but do need change tradition, but do need support and commitment.”support and commitment.”

Developing secure services Developing secure services for women: Containment at for women: Containment at

the expense of care?the expense of care?Dr Mary di LustroDr Mary di Lustro

Consultant Forensic PsychiatristConsultant Forensic PsychiatristWomen’s Directorate, Rampton Hospital & Lead Women’s Directorate, Rampton Hospital & Lead

Clinician for Women’s Services, Arnold LodgeClinician for Women’s Services, Arnold Lodge2525thth June 2004 June 2004

Documents

Developing secure services for women: Containment at the expense of care? Dr Mary di Lustro Consultant Forensic Psychiatrist Women’s Directorate, Rampton