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Women with learning disabilities
Women with mild to moderate learning disability may face special problems in their adjustment to motherhood and meeting the needs of their developing child. Primary care, maternity services and specialist mental health services undertake joint assessment and management where appropriate.
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http://www.powerofbreathing.com/breathing/joined.aspx?afl=73291 Women’s Mental Health:
Into the Mainstream
Strategic Development of
Mental Health Care for Women
Flower to earth
by Christine Daddy
Art is how I express myself and this picture is in memory of a friend who suffered with mental health
problems. It is a celebration of her life.
Christine Daddy’s work was featured in Art Works in Mental Health, an exciting National Exhibition of
original work created by people who have been directly or indirectly affected by mental ill health. Covering
a spectrum of painting, drawing, photography, writing, sculpture, pottery and ceramics, the exhibition was
designed to enhance and promote understanding of mental health issues that affect us all in some way.
To view all the art works submitted visit www.artworksinmentalhealth.co.uk
Women’s Mental Health:
Into the Mainstream
Strategic Development of
Mental Health Care for Women
3
Foreword .................................................................................................................. 5
Section 1
Mainstreaming women’s mental health .................................................................... 7
1.1 Consultation ............................................................................................................. 8
1.2 The policy context .................................................................................................... 9
1.3 The wider government agenda .................................................................................. 9
Section 2
Understanding women’s mental health ................................................................... 12
2.1 Mental ill health in the general population ............................................................. 12
2.2 Risk and protective factors for mental health .......................................................... 12
2.3 Groups of women who may be vulnerable to mental ill health ............................... 16
Section 3
Mental health care for women ............................................................................... 22
3.1 What is provided now............................................................................................ 22
3.2 Models of care ...................................................................................................... 22
3.3 What women say .................................................................................................... 23
Section 4
Developing gender sensitive mental health care ..................................................... 26
4.1 Gender sensitivity ................................................................................................... 26
Section 5
Gender sensitivity: Underpinning values and principles ........................................ 28
5.1 Involving and listening to women ........................................................................... 28
Section 6
Gender sensitivity: Organisational development .................................................... 30
6.1 Workforce development .......................................................................................... 31
6.2 Governance ............................................................................................................. 32
Section 7
Gender sensitivity: Planning, research and development ....................................... 33
7.1 Assessment of need.................................................................................................. 33
7.2 Commissioning....................................................................................................... 34
7.3 Research and development ...................................................................................... 35
Section 8
Gender sensitivity: Services – general principles .................................................... 37
8.1 Workforce issues...................................................................................................... 37
Contents
Section 9
Gender sensitivity: Service delivery ........................................................................ 40
9.1 Individual assessment and care planning ................................................................. 40
9.2 Care and treatment ................................................................................................. 45
9.3 Consultation/liaison................................................................................................ 46
9.4 Advocacy................................................................................................................. 47
Section 10
Gender sensitivity: Service organisation – non-specialist mental health services ... 49
10.1 Health promotion programmes............................................................................. 49
10.2 Primary care .......................................................................................................... 49
10.3 Women-only community day services (includes proposed service specification).... 50
10.4 Employment services............................................................................................. 55
10.5 Supported housing ................................................................................................ 56
Section 11
Gender sensitivity: Service organisation – specialist mental health services .......... 58
11.1 Community services.............................................................................................. 59
11.2 In-patient and other residential settings ................................................................ 60
11.3 Secure/forensic services (includes proposed service specification) .......................... 63
Section 12
Services for specific groups of women .................................................................... 73
12.1 Services for women with experience of violence and abuse.................................... 73
12.2 Services for women who self-harm ........................................................................ 76
12.3 Services for women with personality disorder........................................................ 80
12.4 Services for women with dual diagnosis with substance misuse............................. 84
12.5 Services for women with perinatal mental ill health .............................................. 85
12.6 Services for women with eating disorders .............................................................. 88
12.7 Services for women offenders with mental ill health ............................................. 90
Appendix 1
Terms of reference and membership of advisory groups ........................................ 93
Appendix 2
Consultation questionnaire .................................................................................... 96
References ............................................................................................................... 97
4
Women’s Mental Health: Into the Mainstream
5
The needs of women are central to the government’s programme of reform and investment in public
services and to our commitment to addressing discrimination and inequality. Modernising mental
health services is one of our core national priorities.
There are differences in the family and social context of women’s and men’s lives, the experience and
impact of life events, the presentation and character of their mental ill health and consequently their
care and treatment needs. These differences must be understood by policy makers and those planning
and delivering services. Mental health care must be responsive to these differences.
Women’s Mental Health: Into the Mainstream highlights that women make up over half of the general
population, play a significant role in the workforce and assume the major responsibility for home
making and for the caring of our children and other dependent family members. At the same time,
many women experience low social status and value. Social isolation and poverty are much more
common in women, as is the experience of child sexual abuse, domestic violence and sexual violence.
The complex interplay of all these factors can have a major impact on women’s mental health and have
wider repercussions as a result of the multiple roles that women adopt in our diverse communities.
Women’s Mental Health: Into the Mainstream emphasises the importance of listening to women. Their
voice is highlighted throughout the document together with examples of services across the country that
are genuinely empowering women and responding to their needs.
We must take heed of what women are saying. They want to be listened to, their experiences validated,
and most of all to be kept safe while they recover from mental ill health. They want importance placed
on the underlying causes and context of their distress in addition to their symptoms, support in their
mothering role and their potential for recovery recognised.
The implementation of the Mental Health National Service Framework enshrines these principles in
that the expertise and experience of service users should be at the heart of planning and delivering
mental health services, with holistic assessment and care planning and an emphasis on hope and
recovery. Gaining more insight into the needs of women will contribute greatly to closing the gaps
between national mental health policy and local implementation.
Jacqui Smith
Minister for Mental Health
Foreword
7
Women make up over half of the general population, play a significant role in the workforce and
provide the majority of the care for our children and other dependent family members. The
consequences of women’s mental ill health affect more than the individual, reflecting these multiple
roles. Mental ill health in women, as in men, is common. It differs however in both presentation and
character. Currently, much mental health care is not organised to be responsive to gender differences
and women’s needs consequently may be poorly met. It is for these reasons that a strategic approach to
the development of mental health care for women is necessary. This consultation document forms the
foundations for this work.
The changes needed to develop mental health care that is genuinely sensitive to gender will have to be
systematic and sustainable. This will require both generating greater understanding of the issues and
further commitment to the development of user-focused services. It will be best achieved by gender
becoming integral to existing systems, such as those for service planning, delivery and evaluation.
That is, by becoming a mainstream issue.
The aim of this consultation document is to provide information, to generate discussion, and to outline
a direction to help achieve a mainstream approach to gender in mental health service organisation and
delivery. It covers services for adults of working age, in line with the Mental Health National Service
Framework (MHNSF)1. Many of the principles, however, are relevant to all age groups and to men as
well as women.
This document has been developed:
• with advice and support from two expert advisory groups, comprised of practitioners,
managers, policy staff and service user representatives (see appendix 1 for terms of reference
and membership);
• building on the work undertaken to produce the report Secure Futures for Women: Making
a Difference2, which was informed by a series of listening panels across the country;
• through visiting and meeting a range of services and individuals – examples of ways of working
positively with women are included throughout the document;
• using quotes by women themselves, to help bring alive the issues as they see them – these were
derived from a number of sources, including a service user listening event, a consultation
exercise with women in secure services and a survey of views on women’s mental health
services;
• by holding a working conference on the development of secure care for women, which was
attended by a wide range of stakeholders.
The overall remit of the expert advisory groups was to help produce “a framework for the delivery of
comprehensive, high quality, mental health services that meet the needs of individual women”. This should:
• acknowledge and address the links between the social and economic context of women’s lives,
their mental health and support/treatment needs;
• address specific issues related to gender, race, age, class, disability and sexual orientation;
Section 1
Mainstreaming women’s mental health
• ensure women’s safety, privacy and dignity;
• engage with women service users on a partnership basis;
• tackle the impact of organisational culture on the delivery of high quality services.
This consultation document is comprised of the following sections:
• Section 1 introduces the document and the policy context in which mental health services
are being developed;
• Section 2 outlines specific issues for women’s mental health, including the links between
poverty, child sexual abuse, domestic violence and the impact of caring and mothering
on mental health;
• Section 3 describes what is known about mental health care for women, including what
women think of services;
• Sections 4, 5, 6 and 7 introduce the ideas and actions needed to achieve change in services
to make them more sensitive to gender and the needs of women in particular, covering
underpinning principles, organisational development, planning, research and development;
• Sections 8, 9, 10 and 11 describe the development of gender sensitivity in the delivery of
mental health care for women, in particular secure care and community day services, areas
in which the government has already made specific commitments;
• Section 12 describes mental health provision for specific groups of women.
Key issues and consultation points are summarised at the end of each section.
We acknowledge that there is some duplication of information between sections, but have tried to
create sections that are self-contained, so that the reader can use them individually without too much
cross-referencing.
Further copies of this document and/or the summary version can be obtained either from the internet
at www.doh.gov.uk/mentalhealth or free of charge from the Department of Health, P.O. Box 777,
London SE1 6XH, tel 08701 555 455, fax 01623 724524, email doh@prolog.uk.com.
The publication of this document, which will be circulated to a wide range of stakeholders, will be
followed by a three-month formal consultation period. Written comments are invited (see appendix 2)
and a number of consultation events will be held around the country. These events will involve service
users, carers, practitioners, managers, commissioners and policy makers.
Following consultation, service specifications for women-only community day services and women’s
secure care will be published in the Mental Health Policy Implementation Guide. A strategic
implementation plan will also be developed outlining key actions, with indicators against which
improvements will be measured, in priority areas identified during the consultation period. However it
is envisaged that this detailed consultation document will have a long term use as a valuable resource for
commissioners and providers in planning and delivering appropriate mental health services for women.
1.1 Consultation
8
Women’s Mental Health: Into the Mainstream
Modernising Mental Health Services3 and the Mental Health National Service Framework describe how
mental health care in general should improve and develop. The NHS Plan4 makes the commitment
to reduce inequalities and develop a comprehensive health service designed around the needs and
preferences of individual patients, their families and carers, which will respond to the different needs
of different populations. Women are one such population.
In March 2001, the then Minister for Mental Health, John Hutton, announced the development of
a strategy for women that would:
“pull together issues of concern for women across the Mental Health Framework and NHS
Plan and link with work of other government departments; ensure that women are listened to
and their views translated into real change; and value the contribution made by the voluntary
sector, who currently provide valuable services for women in crisis ....”
This would build on the existing commitments to mental health services for women:
• mixed-sex accommodation to have been removed in 95% of NHS trusts by 2002;5
• women-only community day services developed in every health authority by 2004 (NHS Plan);
• development of a strategy for women’s secure care, with women being a high priority for
moving out of high secure care into more appropriate services.6
The development of this strategy sits within an overall commitment to address inequalities in the
delivery of mental health services and to tackle discrimination and disadvantage. Other strands
of positive action include the development of a strategy to address the needs of people from black and
minority ethnic groups and a strategy for people who are deaf.7
The National Institute for Mental Health in England (NIMHE) has been created to assist frontline
health and social care staff implement policy and improve outcomes for people using mental health
services. NIMHE’s equality programme “will develop to embrace the implementation of specific actions
from the strategies for black and minority ethnic communities and for women”.8
The ultimate aim of modernising mental health care is to ensure that the needs of the individual are
addressed with respect and an understanding of diversity,* and that inequalities are tackled.
Meeting the needs of women is central to the government’s programme of reform and investment in
public services. In 1999, the government launched a unique Listening to Women9 exercise. A series of
road shows, a postcard campaign and meetings with women’s groups heard from over 30,000 women.
Physical and mental well-being was identified as the most important issue facing the country. Women
said that they wanted quality health care and reliable information about health for themselves and the
people they care for. The delivery of health and education services appropriate to women’s needs is a key
priority for the Government.
1.3 The wider government agenda
1.2 The policy context
9
Women’s Mental Health: Into the Mainstream
* ie. gender, race, culture, religion, age, disability and sexual orientation
Violence was also identified as a key issue in Listening to Women. The publication Living without Fear 10
provides information and guidance on tackling violence against women. It set goals for reducing
violence, providing a better environment for a healthy family life and encouraging the development
of multi-agency partnerships to improve support to women who experience violence.
The Government is developing and implementing preventative strategies to reduce domestic violence
and repeat victimisation, to provide support for victims and their children and to ensure that the
criminal justice system’s response to domestic violence is appropriately robust. This is an ongoing
programme of work, which is working towards a focused national strategy to address domestic violence.
Five priority areas for action have been identified:
• early intervention in the cycle of violence and abuse by health practitioners (Department of
Health);
• enhanced civil and criminal justice interface when dealing with cases where violence is alleged
(Lord Chancellor’s Department);
• increasing safe accommodation choices for women and children fleeing domestic violence (the
Office of the Deputy Prime Minister);
• education and awareness raising on the prevalence and social unacceptability of domestic
violence (Cabinet Office and Department for Education and Skills);
• ensuring appropriate police and Crown Prosecution Service (CPS) response to all incidents of
domestic violence (Home Office and CPS).
The Government has also made a commitment to reduce offending by women. The Strategy for Women
Offenders11 was published for consultation in 2000 and the results of that consultation were published
in a report in September 200112. The key messages from the Consultation Report are being fed into the
development of the Women’s Offending Reduction Programme, a Home Office-led initiative which is
being launched towards the end of 2002.
The Women’s Offending Reduction Programme promotes an holistic response to the range of factors that
impact on women’s offending including mental and physical health, housing, experience of abuse,
caring responsibilities, education and employment. The aim is to strengthen links between the various
departments, agencies and organisations that are responsible for these areas, to ensure that integrated
policies, programmes and spending partnerships are developed to meet the specific needs and
characteristics of women offenders. There is a clear need to establish links between the Women’s Mental
Health Strategy and Women’s Offending Reduction Programme (see section 12.7 on services for women
offenders with mental ill health).
The Department of Health and Prison Service Strategy for Developing and Modernising Mental Health
Services in Prisons13 outlines how mental health care for prisoners should be improved and monitored.
Maternal health will be addressed in the National Service Framework for Children. The aim of this
framework will be to ensure that childbearing women, children and young people develop healthy
lifestyles and have opportunities to achieve optimum health and well-being, within the context of high
quality preventative and treatment services.
A new integrated policy and funding framework for support services and accommodation will be
introduced in 2003, outlined in Supporting People.14 This will place the funding and development
of supported housing for vulnerable groups, including people with mental ill health and victims
of domestic violence, on a more secure and co-ordinated basis. It will also encourage the delivery
of support in ordinary housing as well as in specialist schemes.
10
Women’s Mental Health: Into the Mainstream
The government has undertaken a cross cutting review of the role of the voluntary sector in
service delivery. The Review makes a series of recommendations to strengthen the working relationship
between government and the voluntary and community sector in pursuit of world class public
services.15 The voluntary sector plays a key role in providing mental health support for women.
11
Women’s Mental Health: Into the Mainstream
12
Understanding the nature and causes of mental ill health in women is essential to the development
of mental health care sensitive to their needs. This section describes:
• the major differences in the occurrence of mental ill health between women and men;
• the factors that are thought to be important in the causation of mental ill health and those that
may be protective;
• groups of women who may be vulnerable to mental ill health.
Studies in the general population suggest that the overall prevalence* of mental illness does not differ
significantly between women and men. For specific disorders, however, clear gender differences emerge.
Anxiety, depression and eating disorders are more common in women, substance misuse and anti-social
personality disorders are more common in men.16 There are also gender differences in the way in which
women and men present with mental ill health.
Most studies suggest that depression and anxiety are at least one and half to two times more common
in women.17 In contrast, mental illnesses, such as schizophrenia and bipolar affective disorder, do not
show such clear gender differences in incidence† and prevalence.18 Rates for probable psychosis in
the UK general population are estimated at 0.5% for women and 0.6% for men.19 There is some
indication that schizophrenia may have an earlier onset and a more disabling course in men.20,21
A significant proportion of women experience post-natal depression and some post-partum psychosis
(see section 12.5 on perinatal mental ill health).
There are various risk factors known to relate to mental ill health. These include socio-economic,
physiological and psychological factors. In addition, women’s mental health is affected by experiences
of child sexual abuse, domestic violence, sexual violence and rape. The interplay of these factors
and their interactions are complex and not yet fully understood.
Research into the impact of protective factors that mitigate exposure to risk is in its infancy. The role
of family ties, positive parenting experiences, social networks, self-esteem, environmental factors
(such as housing and having meaningful ways in which to occupy time) are all likely to play a part.
It is clear however that gender, like socio-economic status, shapes individual opportunities and
experiences across life and consequently creates differences in exposure to risk and protective factors.22
2.2 Risk and protective factors for mental health
2.1 Mental ill health in the general population
Section 2
Understanding women’s mental health
* Prevalence: the total number of cases of a disorder in a group of people at a point in time, or if specified, over a period in time.
† Incidence: the number of new cases of a disorder in a group of people at a point in time or, if specified, over a period of time.
2.2.1 Socio-economic factors
Deprivation and poverty are strongly linked to the prevalence of mental ill health in communities.
Psychosocial health in women seems to be particularly strongly related to socio-economic status. This
suggests that the impact of inequalities in health between socio-economic groups may be different for
women and men and that consequently gender specific policies are needed to address them.23
Poverty
Gender inequalities in income and wealth, in combination with women’s role as mothers and carers,
make them particularly susceptible to poverty. It has been estimated that two thirds of adults living in
the poorest households are women. A similar percentage of adults dependent on income support are
also women.24 Women are much more likely than men to live in poverty, particularly if lone parents
or in later life. Poverty is associated with mental ill health.
Employment
Nearly twice as many women (30%) than men (16%) of working age are economically inactive, and
nearly twice as many men (60%) than women (35%) are in full-time paid employment.25 The majority
of women in paid employment are employed part time, half are in the low paid clerical, retail and
personnel sectors. This contributes to women’s vulnerability to poverty.
Unemployment is associated with mental ill health. The impact of unemployment on women and men
seems to be different, some studies showing a less negative effect on women. This may reflect gender
differences in expectation of work and the role of women within the family.
Women’s work in the family
Women provide the majority of care for children and other family dependents. In some cases, women’s
work in the family is their reason for being categorised as ‘economically inactive’. Studies have found
that women who work, whether part time or full time, generally also undertake the majority of the
housework and childcare.26 The tension and stress inherent in having competing, and often
unsupported, multiple roles and responsibilities as mothers, homemakers, carers and partners may have
an adverse effect on women’s mental health. The low societal status and value placed on women’s roles
in the family and workforce and the potential negative impact on a woman’s sense of self-worth may
also contribute to mental ill health.
2.2.2 Physiological factors
Increased prevalence of depression in women may be in part explained by the impact of hormonal
and reproductive changes. Hormone levels are known to influence mood, at its most extreme seen in
pre-menstrual dysphoric disorder.* Women are also vulnerable to developing mood disorder during
pregnancy and in the postnatal period. Mental disorder is a significant cause of maternal mortality27
(see section 12.5 on services for women with perinatal mental ill health).
Physical ill health
Physical ill health is known to be associated with mental ill health. In women and men, emotional wellbeing
is a strong predictor of physical health.28 People with chronic physical ill health are more at risk
of mental ill health, particularly depression. People with mental illness are more likely to have physical
illnesses such as cardiovascular disease and respiratory complaints.29
13
Women’s Mental Health: Into the Mainstream
* Pre-menstrual dysphoric disorder: a mental disorder in which there are marked changes in mood associated with the menstrual cycle.
One of the symptoms of mental illness can be ‘somatisation’. This is a process by which psychological
problems are expressed as bodily or physical complaints. Somatic complaints are two to three times
more common in women. There may also be cultural differences in presentation of psychological
problems. Consequently, it is important to be aware of the possible physical manifestations of
psychological disorders as well as the effects on physical health of psychological problems (eg stress,
muscular tension and headaches).
2.2.3 Psychological factors
Life events
There is a well-described association between major life events and mental ill health.30 It seems that
certain types of events are more likely to be associated with specific disorders: events involving loss, such
as bereavement, being associated with depression and events associated with threat, associated with
anxiety. Although generalisations can be made about specific types of events, it is the meaning of those
events for the individual, and their psychological resilience, that is likely to be important in determining
whether mental ill health ensues. Moreover, the meaning of events may differ for an individual at
different points in their life. It may be repetition of certain types of events, for instance of violence and
abuse, which is of particular importance or the association of certain events with other types of adversity.
Social isolation
Social isolation is associated with mental ill health. Women are more vulnerable to social isolation than
men because of:
• higher levels of poverty;
• lone parenthood;
• lack of mobility – women are more likely than men to be dependent on public transport, they
are less likely to be able to drive or to own a car;31
• longer life expectancy, women are more likely to live alone and in poverty in their later years
than men;32
• fear, many women in cities are afraid to go out alone at night.33
Findings of research presented to the Royal College of Psychiatrists annual conference in 2002
illustrates the relationship between these factors and their association with mental illness in women
bringing up children on their own.34 This study found that lone mothers are three times more likely to
be depressed than any other group of women. There was a correlation between mental illness and high
rates of material disadvantage: most of these women were not employed, the majority lived in rented
housing and two thirds had no access to a car.
It is important to note that there are also protective factors for women in that they tend to have better
social networks than men. Positive views on one’s social networks and/or having confiding relationships
can counteract social isolation and protect mental health.
Emerging work on the concept of social capital* may help to link these issues. A gendered view of social
capital will help to address long standing gender inequalities and gender blind policy making. These can
systematically disadvantage women and erode the limited social capital available to them, thus
compromising their mental health.35
14
Women’s Mental Health: Into the Mainstream
* Social capital is a broad term that embraces the level of trust, reciprocal relationships, community and civic participation in a particular
locality.
2.2.4 Experiences of violence and abuse*
Women are at a greater risk of violence and abuse than are men. This applies both in childhood and as
adults. There is a substantial body of research which links women’s experience of child sexual abuse and
domestic violence with long term mental illness and also with physical and sexual health problems.36,37
Important issues are that violence and abuse against girls and women:
• are more common than is generally realised;
• can have a significant impact on physical and mental health;
• are often not disclosed (especially in the case of women who are young, disabled, old and some
minority ethnic groups).
The high levels of child sexual abuse and domestic violence suggest that these may relate to the high
prevalence of depression in women (see section 2.1 on mental ill health in the general population,
section 9.1 on assessment and care planning and section 12.1 on services for women who experience
violence and abuse).
Child sexual abuse
Prevalence rates for child sexual abuse vary in community studies depending on the definitions used
i.e. penetration, any sexualised physical contact or non-contact, inappropriate sexual behaviour. There
is a consensus amongst researchers that there is substantial under-reporting. This will have an impact
on the rates reported for boys as well as girls.38
Studies suggest that child sexual abuse is relatively common. Estimates from across the international
literature suggests that 7–30% of girls and 3–13% of boys may be affected.39,40 Higher rates are reported
in some studies, particularly if non-contact abuse is included.41,42 Most studies suggest that women are
up to 3 times more likely to have been abused than men are. Intra-familial abuse is more common
amongst girls. Research is consistent in identifying men as the abusers in about 95% of cases regardless
of whether the victim is female or male.43,44
Not all people who experience child sexual abuse report later problems, however there are many studies
that report an association with an increased risk of mental disorder and psychological problems such as
self-harm, depression, anxiety, somatisation, difficulties in inter-personal relationships, eating disorders,
drug/alcohol abuse and problems with parenting.45,46,47 Women in contact with mental health services
have experienced significantly higher rates of child sexual abuse than other women and than men
(see section 9.1 on assessment and care planning). Child sexual abuse may be associated with a range
of other childhood adversity, including physical and emotional abuse and domestic violence. Further
research is needed to help in identifying those who will be at greatest risk of later problems.48
Domestic violence
Domestic violence has been defined by the Crown Prosecution Service:
“The term domestic violence shall be understood to mean any violence between current or
former partners in an intimate relationship, wherever and whenever the violence occurs.
The violence includes physical, sexual, emotional or financial abuse.”
Accurate rates are difficult to ascertain, given the extent of under-reporting. Research suggests that
between 18 and 30% of women experience domestic violence during their lifetime. Most research has
focused on violence perpetrated by men on women, which is estimated to account for 80 to 95% of
domestic violence. Domestic violence occurs in same sex relationships and can also be perpetrated by
women.49,50,51 It accounts for 25% of all violent crime and two out of five murders of women in
15
Women’s Mental Health: Into the Mainstream
* Throughout the document, the term ‘violence and abuse’ refers to child sexual abuse, domestic violence, sexual violence and rape.
England and Wales are by partners/ex-partners.52 The majority of women with experience of domestic
violence do not report it to anyone. It is estimated that women on average experience 35 episodes
before seeking help. Survivors frequently turn to non-statutory agencies such as Women’s Aid, Victim
Support and other voluntary sector service providers. Although all women face difficulties getting help,
these difficulties may be greater for some groups of women, particularly black and Asian women, older
women, lesbian women and those with a disability.53
Women have twice the risk of experiencing domestic violence whilst they are pregnant.54
The experience of domestic violence was disclosed voluntarily to a health professional in 12% of
maternal deaths in the UK.55 This is likely to be an underestimate, as violence is not routinely
asked about.
Women who experience domestic violence report more depressive symptoms, are at greater risk of
suicide and make greater use of mental health services than women in the general population.
At least 750,000 children a year witness domestic violence. Nearly three quarters of children on the
“at risk” register live in households where domestic violence occurs. It is thought that children are most
vulnerable to abuse and long-term adverse effects when domestic violence co-exists with parental mental
illness or problem alcohol/drug use.56
Sexual violence and rape
Large-scale studies on rape and sexual assault are rare and definitions for inclusion vary. The research
that does exist shows that, in developed countries, between 14–40% of women have experience of
sexual violence. Many of the perpetrators are known to the woman.
Findings of the 2000 British Crime Survey57 on the extent of sexual victimisation of women, since the
age of 16, indicates that around 1 in 10 women have experienced some form of sexual victimisation,
including rape, and approximately three quarters of a million women have been raped on at least one
occasion (highlighting that these figures are likely to be under estimates). ‘Strangers’ are only
responsible for 8% of rapes. Women are most likely to be:
• sexually attacked by men they know in some way (partners 32% and acquaintances 22%);
• raped by ‘current partners’ (45%).
Research suggests that there is a link between the experience of sexual violence and mental ill health in
both women and men.58
An understanding of the risk factors associated with mental ill health allows identification of groups of
women who may be vulnerable to mental ill health. Whilst most women within such groups will not
suffer mental ill health, the recognition of vulnerability to illness is one step towards increasing the
chances of detecting and managing it effectively and appropriately (see section 9.1 on assessment and
care planning).
2.3.1 Women who are mothers and/or carers
The vast majority of the running of households, i.e. cooking, shopping etc. and of caring for children
and dependent adults is carried out by women.59 Forty percent of women spend over 50 hours a week
caring for someone living with them.60 This, in conjunction with women’s position in the labour
market, means that they are more likely than men to live more home and community based lives.
2.3 Groups of women who may be vulnerable to mental ill health
16
Women’s Mental Health: Into the Mainstream
Women with children
The Health and Lifestyle Survey suggested that the most important factor associated with the mental
well-being of married women was the age of their youngest child.61 Women with children under five
were particularly likely to have poor mental health, especially if a lone parent.
It is likely that the interaction of socio-economic factors, in conjunction with being at home with
children, puts low-income women at greater risk of mental ill health than those better off. Lone parents
are likely to have low income or to be reliant on state benefits; most lone parents are women.62 Lone
mothers, however, appear to have poor psychosocial health even after controlling for income,
employment status and occupation.63 In the UK Psychiatric Morbidity Survey a lone parent mother was
three times as likely as a lone parent father to have non-psychotic mental illness.64 Women with
generalised anxiety disorder* were particularly likely to be lone parents.
Young women who are mothers are at risk of socio-economic disadvantage and consequently mental ill
health. Teenage mothers have an increased risk of adverse outcomes for themselves and their children.65
Estimates suggest that one in seven girls leaving local authority care are either pregnant or already
mothers.66 Looked after children are generally at an increased risk of developing mental ill health in
later life.67 This will relate to the experiences of abuse and neglect that brought them into the care of
local authorities as well as, for some, negative experiences while being looked after.
Research suggests that parental mental ill health can have a major impact on children. Some estimates
suggest a third to two thirds of children will be adversely affected.68
Other caring responsibilities
There are around 6 million carers in the UK, over half of these are women, the majority in the 45–64
age range.69 Caring for dependent adults or disabled children can have a significant impact on mental
health.
Carers of people with dementia show high levels of mental ill health, particularly those that feel
burdened, such as younger carers, those not receiving regular help and if the person with dementia has
behavioural problems.70
Caring for a person with learning disabilities can place considerable strain on carers and families having
an impact on emotional well being, financial resources and relationships.71 The majority of people with
learning disabilities and many of their families are poor. Carers of adults with learning disabilities report
40% more health limiting problems than the general population.72 This is of particular importance as
the number of elderly carers increases.
Carers providing substantial amounts of care face financial hardships. They find it difficult to combine
the care they provide with paid employment.73
2.3.2 Older women
Social isolation and poverty are more common in older women than in men. Women are more likely
than men to be reliant on state pensions: less than half the numbers of elderly women than men have
personal or occupational pensions.74 Women are more likely to experience bereavement in old age, their
partners dying earlier than they do. Their increased life expectancy also means that they are more likely
to experience institutional care with its attendant loss of independence and role.
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Women’s Mental Health: Into the Mainstream
* Generalised anxiety disorder: an anxiety disorder in which the person experiences unrealistic or excessive worries which last over long
periods of time, months or years. (In distinction to panic attacks where the feelings are short lived).
Overall, even allowing for the increasing prevalence of dementia with age, mental ill health is more
common in older age groups. This is particularly true for depression.75 Depression is more common
among older people with physically disabling conditions.76 Women are more likely than men to suffer
from disability resulting from restriction in mobility and self-care.77 It is not unusual for depression to
be missed in older people, the ageing process being blamed for changes in mood or social functioning.
2.3.3 Women from black and minority ethnic groups
The interrelationship between gender, culture and ethnicity is poorly researched in terms of its impact
on mental health and well being. The interplay between gender and power is made more complex
when taken in conjunction with culturally traditional gender roles, particularly for young women
from minority ethnic groups growing up in a westernised society. In addition, racism, the impact of
immigration with potential loss of family and social networks, language barriers, uncertainty over the
future and social isolation can all have a detrimental impact on mental well being. Many individuals
from minority ethnic groups have these negative experiences alongside socio-economic adversity such
as poor housing, poverty and unemployment.
Despite the research limitations there are indications of important differences in mental health and
illness between different ethnic groups.78,79 Of particular concern with respect to women are:
• suicide, self-harm and eating disorders amongst Asian adolescent girls;80,81
• post-traumatic stress disorder and other mental illness, together with experience of
torture/abuse, in some groups of refugees and asylum seekers.82
2.3.4 Lesbian and bisexual women
There are few studies that report prevalence figures for either the size of the population of women who
define themselves as lesbian or bisexual or that look specifically at their mental health. Estimates are
likely to be low given that lack of understanding, prejudice and discrimination mean that many would
prefer to keep their sexual preferences hidden. Estimates of prevalence of same sex relationships vary
from 2–12%. Women’s pathways and choices concerning their sexuality are influenced by many factors
in their lives.
Women who do not define themselves as heterosexual may have added stressors in their lives given
the degree of stigma prevalent in society. These experiences may contribute to poorer mental health.
Studies suggest that there are higher rates of mental ill health amongst the non-heterosexual community
including anxiety, depression, and substance misuse.83,84
2.3.5 Transsexual women
The prevalence of transsexuality* in the general population is not accurately known. Published figures
are likely to be underestimates for reasons of prejudice and lack of understanding. Current estimates of
biological men with gender identity disorder (1:10–12,000) far exceed the number of biological women
(1:40,000–50,000).85 Transsexual women and men experience stigma and discrimination that may
contribute to poorer mental health.
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Women’s Mental Health: Into the Mainstream
* Transsexualism, also know as gender dysphoria, is an overwhelming desire to live and be accepted as a member of the opposite sex to
that allocated at birth. The condition is usually accompanied by a sense of discomfort with one’s physical body and a wish to go
through a process known as transition, in which hormonal treatment and surgery align the body with the sense of gender identity
experienced by the brain. Gender dysphoria is a recognised medical condition for which NHS and private treatment is available.
2.3.6 Women involved in prostitution
Women involved in prostitution have experienced high levels of violence and abuse as children and as
prostitutes. Many misuse drugs/alcohol, have little or no access to primary care and may experience
homelessness. They also either live in fear of losing custody of their children or have to deal with
the loss of their children. Subject to severe discrimination, research suggests high levels of mental
ill health.86,87,88
2.3.7 Women offenders
The relationship between mental ill health and offending is complex. It is clear however that women in
prison have high levels of mental ill health, some women using mental health services have histories of
offending behaviour and women’s offending patterns differ substantially from those of men.
Broad differences between women and men’s offending include:89
• men commit more crime than women; less than 5% of the prison population are women;
• men start their criminal careers at an earlier age than women (8% of women and 34% of men
have a criminal record by the age of 40) and are more likely than women to have lengthy
criminal careers (>10 years – 3% of women and 25% of men);
• women are more likely than men to commit acquisitive crimes e.g. shoplifting, fraud (60% women
prisoners, just over 30% men) and are less likely to commit arson, violent or sexual offences;
• women are more likely than men to say that financial hardship, particularly in relation to
children, contributed to their crime (41% v 25%);90
• there has been a dramatic increase in the number of women in prison compared to men which
continues to rise, particularly for drug and acquisitive offences (between 1993 and 2000, the
average women’s population increased by 111.5% compared to a 42% increase for men);
• women in prison have experience of high levels of violence and abuse as children and as
adults.91,92
The offending profiles of women and men in secure mental health services also differ from each other
and from the broad differences outlined above (see section 11.3 on secure/forensic services).
Mental ill health in prisoners
Exact prevalence figures are difficult to ascertain given the differences in reported rates between the two
major research studies in UK prison populations (which used different research methodologies).93,94 It is
clear that mental ill health is common, often co-exists with substance misuse and that remand prisoners
have higher levels of mental ill health than those in the sentenced population.
Overall, the following differences between women and men are reported. Women are:
• twice as likely as men to have received help for a mental/emotional problem in the 12 months
before entering prison (40% v 20%);
• less likely than men to receive a diagnosis of anti-social personality disorder, although more
likely than men to have a diagnosis of borderline personality disorder;
• more likely to have severe mental illness;
• twice as likely as men to have symptoms associated with post-traumatic stress disorder;
• more likely than men to have a history of self-harm, particularly in those with high scores for
probable mental disorder.
Although further research is needed, it is likely that mental ill health makes a substantial contribution
to offending behaviour in women.95,96,97
19
Women’s Mental Health: Into the Mainstream
2.3.8 Women with learning disabilities
In all age groups of people with learning disabilities, there is an increased prevalence of psychiatric
disorder and behavioural disturbance over that found in the general population. In many cases mental
ill health remains undetected owing to lack of understanding on the part of carers and professionals,
together with potential difficulties in communication. Concurrent physical ill health may make
diagnosis more difficult and the effects of medication may obscure the clinical presentation of
mental illness.
Many risk factors, known to contribute to the development of mental illness, occur more frequently in
people with learning disabilities. These include sensory impairments, communication difficulties, low
self-esteem, stigma, abuse, low levels of social support, poor coping skills and chronic ill health.
Estimates of co-existing mental illness and/or behavioural disorder in adults with learning disabilities
vary from 14.3 to 67.3%. If challenging behaviours are excluded then rates found fall dramatically.98
The pattern of ill health is somewhat different to the general population. Higher rates of substance
misuse and affective (or mood) disorders are found in the general population.99
People with learning disabilities suffer high levels of sexual, physical and emotional abuse. This applies
to those living in their own homes and to those in residential care.100 It has been estimated that 1,400
adults with learning disabilities are reported as victims of sexual abuse in the UK each year. This is
likely to be an underestimate of the actual number of cases.101
2.3.9 Women who misuse alcohol and/or drugs
There are known gender differences in alcohol and substance misuse. In the general population men are
more likely to misuse both. There seems however to be greater social stigma attached to women
misusing substances, particularly alcohol. This may lead to women’s problems being missed or ignored,
with consequent difficulties in accessing services. In addition, as women are more likely to be lone
parents, fear of loss of custody of children may also mean that their substance misuse problems remain
hidden for longer and therefore present later.
Both women and men who misuse alcohol or drugs are at a high risk of having mental disorders.
The nature of the relationship between the two conditions is complex and may take any of the
following forms:
• mental illness precipitating or leading to substance misuse;
• substance misuse worsening or altering the course of mental illness;
• substance misuse leading to psychological symptoms;
• substance withdrawal leading to mental ill health.
Examination of the gender differences in the nature of these relationships is limited and most research
comes from the US. Women in touch with substance misuse services are significantly more likely than
men to have experience of the following:102,103,104,105
• violence and abuse;
• poor physical and psychological health, particularly anxiety and depression;
• suicidal thoughts and attempts.
20
Women’s Mental Health: Into the Mainstream
Consultation Question
• Are there other groups of women who should be considered as particularly vulnerable to mental
ill health?
Key Messages
• Mental ill health is common in women and men.
• There are significant gender differences in type and presentation of mental disorder and in the
prevalence of risk and protective factors.
• Understanding the nature and causes of mental ill health in women, and how these differ from
those of men, is essential to the development of mental health care that is responsive to women’s
needs.
• An understanding of the risk factors associated with mental ill health allows the identification of
groups of women who may be vulnerable to mental ill health e.g. women who have experience
of violence and abuse, women with caring responsibilities and women offenders.
21
Women’s Mental Health: Into the Mainstream
22
This section describes what we know about mental health care for women. This information is derived
from a variety of sources including surveys of mental health services, evaluations of specific models of
provision and research that asks women what they think about services.
The majority of mental health care for women is provided by generic, mixed-sex services. Some services
provide women-only sessions or specific activities for women and others provide dedicated women-only
services. We currently do not have a comprehensive picture of the levels and types of services that are
specifically for women. The Department of Health’s comprehensive mapping of mental health services
(website www.dur.ac.uk/service.mapping_2001_02.pdf) asked some specific questions about womenonly
provision. The 2001 survey suggests that there is tremendous variability across the country.
Current information suggests that:
• approximately a fifth of day hospitals and a quarter of day centres provide women-only sessions
– in some local implementation team (LIT) areas all these facilities provide women-only
sessions, in others none do;
• a few areas provide women-only acute in-patient and/or secure services – the majority of acute
units provide single-sex sleeping accommodation, toilet and bathing facilities;
• few employment schemes have women-only sessions.
As is often the case, it is likely that such variation is as much determined by historical factors as specific
differences in the need of the population served.
An earlier UK survey of women and mental health services received over 500 nominations of projects
demonstrating good practice.106 The majority of these were not exclusively for women and many were
in the voluntary sector. A wide range of needs were addressed including counselling services, supported
accommodation, services for women with experience of violence and abuse or for those who self-harm.
The voluntary sector provides the vast majority of women-only community day centre or day services.
These services may not always be described as mental health services (by commissioners, the women
using them, or the wider community), however they address many of the mental health care needs of
women who use them (see section 10.3 on community day services).
Published research comparing different models of care that specifically address women’s needs is limited.
It is therefore difficult to be sure which model/s of provision provide the most effective or appropriate
mental health care for women.107,108 There have been serious criticisms of some aspects of mixed gender
care, particularly acute in-patient, community residential and secure care.109,110,111,112,113 Concerns often
relate to safety, women patients being vulnerable to intimidation, coercion, violence and abuse by other
patients, visitors, intruders or members of staff.
3.2 Models of care
3.1 What is provided now
Section 3
Mental health care for women
“I and a number of women I know have had very bad experiences on mixed wards.
A friend of mine was raped and I was harassed to death by men and the staff never
intervened. The staff think that women being there will make the men behave better and
that if men behave badly it’s the fault of the women. I would have thought that if you see
a seriously ill woman being harassed, you ought to stop it…. Now when I feel very
depressed, I stay with a friend. The situation in the hospital was so awful, I’d never
go back there – you can’t be ill in peace.”
Studies suggest that it may be having a choice between mixed-sex and single-sex provision that is
important to women.114,115 Research on the effects on women of mixed-sex acute in-patient care is limited.
There are few large-scale surveys that ask women specifically what they think of, or want from, mental
health care. There is, however, a significant body of small scale research which collectively repeats
consistent and compelling themes expressed by women service users, survivors and carers.116,117,118
This evidence should be given equal consideration alongside more formalised research/data as it
emerges. To emphasise the importance of involving and listening to women, service user views are
incorporated throughout this document in the form of italic quotes.
Generally women say, when asked, that they experience women-only services as safe services and more
attuned and responsive to their needs. In addition to their fundamental right to be ‘kept safe’, women
say they want services that:
Promote empowerment, choice and self-determination
Women express an overwhelming sense of ‘not being listened to’, that their life experiences, views and
needs are not validated or responded to.
“Women are thought unreliable witnesses of their own lives and experiences.”
“There’s a ‘there, there, dear’ attitude. People don’t take us as being credible – you’ve got the
double bind of being women and ‘mentally ill’.”
“I am fed up with everyone running my life for me, doing my thinking for me, giving me
their opinions about who I am.”
Women say medication is often the only option on offer with little information about side effects. They
want greater access to ‘talking treatments’, complementary therapies, learning new strategies, developing
new skills and alternatives to hospital admission when they are acutely ill.
Women say it is important to them to choose the gender of their key worker (doctor and therapist)
which is often denied them, and the opportunity to develop ‘sensitive, appropriate relationships’ with staff
committed to partnership.
Place importance on the underlying causes and context of women’s distress in addition to
their symptoms
Women say they want recognition that their psychological vulnerability is not rooted in their ‘biology’
but in the context of their lives: their sense of powerlessness, lack of social status/value and life
experiences of violence and abuse that they have survived or are surviving.
“Psychiatry on the whole demonstrates limited understanding of the social impact of
poverty, sexism, racism, parenting issues, sexual abuse and violence on women’s lives …
All account for much mental distress but a sticking plaster approach never addressed the
issues so distress just recurs.”
3.3 What women say
23
Women’s Mental Health: Into the Mainstream
Address important issues relating to women’s role as mothers, and the need for
accommodation and work
Women want staff to be sensitive and responsive in supporting them to care for their children,
recognise their fear of ‘losing’ children due to their mental distress or their potential desire to have
children if they are not already mothers.
“Women’s needs often get ignored because of the mantra ‘the needs of children are
paramount’. In practice, this seems to mean that the woman herself doesn’t matter. I think
these services desperately need to become more ‘woman’ friendly, with the idea that women
are entitled to support to keep their children. This is likely to be a more effective way
of helping children in the long run.”
Women express concern over the lack of childcare facilities in all settings, and of friendly visiting areas
within residential settings that would help them to maintain contact with their children.
Women want access to a range of safe accommodation options and welcome services that support and
enable them to start, retain or return to meaningful employment.
Value women’s strengths and abilities and potential for recovery
Women say that too much attention is focused on their problems and difficulties and not enough
importance placed on the positive aspects of their lives, and their ability to survive painful experiences.
“To get services, you need to provide a worst case scenario. Rather they should say ‘how can
we help you benefit from this service. What do we need to do to support this woman to be
independent, to meet her potential and to enable her to participate and get support in the
wider community’.”
Mental Health Media has produced a video (funded by the Department of Health) – What Women
Want, Mainstreaming Women’s Mental Health to dovetail with the National Women’s Mental Health
Strategy process. It features a number of women service users talking about their mental health
problems and experiences with positive reference to specific mental health settings that they feel
have been truly responsive to their needs and why. A training booklet accompanies the video.
Purchase price incl. pp: £74.95 (standard price)
£44.95 organisations with 10 or fewer fulltime employees
Contact Mental Health Media, telephone 020 7700 8171, email info@media.com, www/mhmedia.com
24
Women’s Mental Health: Into the Mainstream
Consultation Questions
• What information, if any, should be collected on the provision of women-only/women focused
services?
• How should good practice in the provision of mental health care for women be disseminated?
Key Messages
• Most mental health care for women is provided in mixed-sex environments.
• There is significant variation across the country in the provision of women-only
sessions/services.
• The voluntary sector is the leading provider of women-only community day services.
• There has been serious criticism of mixed-sex in-patient care in relation to women’s safety from
violence and abuse.
• Women who have used women-only services speak highly of them.
• Women express an overwhelming sense of ‘not being listened to’.
• Research evidence for the effectiveness of women-only versus mixed-sex service provision
is lacking.
25
Women’s Mental Health: Into the Mainstream
26
Mental health policy has increasingly emphasised the centrality of service users – their needs, their
experiences and choices – and has encouraged working in partnership with them in order to deliver
appropriate services. Key issues that influence individuals’ experience of the world – gender, race,
religion, culture, class, sexuality, disability, age – must therefore be incorporated into service planning,
delivery and evaluation. Turning these aspirations into action is challenging, as organisational and
individual values and behaviours will need to be addressed and changed.
Gender describes those characteristics of women and men that are socially determined, as opposed
to sex, which is genetically and biologically determined. The Beijing Platform for Action (1995)
gave this definition:
“The term gender refers to the economic, social, political and cultural attributes and
opportunities associated with being male and female. In most societies, men and women differ
in the activities they undertake, in access and control of resources, and in participation in
decision-making. In most societies women as a group have less access than men to resources,
opportunities and decision-making.”
Gender is thus fundamental to our sense of who we are, the roles we adopt, the way in which we
perceive others and in which they perceive us.
The development of gender sensitive services is described in the following sections:
• underpinning values and principles (section 5);
• organisational development (section 6);
• planning, research and development (section 7);
• services – general principles, delivery and organisation (section 8, 9, 10 and 11);
• services for specific groups of women (section 12).
The issues outlined should be considered by all organisations involved in planning, delivering and
evaluating mental health care to ensure that they are sensitive to gender and the needs of women.
Addressing gender should be an integral activity and not an afterthought. It will not be possible to
address the needs of women and men equitably, appropriately and effectively if gender is not considered.
Within this it is of course important to continue to recognise the important differences between
individual women:
“Each woman is different. Each woman’s pain has its own history, its own roots – and its own
solution… We must stop treating women as an homogeneous group, expecting one solution
for all, one analysis for all. We do not need either to celebrate or deny difference, whether
between women, or between women and men. We share a lot as women, but as individuals we
cannot be subsumed under some category, some all-encompassing label that predicts that our
experiences will all be the same. Each woman’s experience is still unique to her.”119
4.1 Gender sensitivity
Section 4
Developing gender sensitive mental
health care
It should always be the individual that is seen, but within a view that is informed by an understanding
of diversity issues, such as gender, race and culture. There are experiences that will be common to many
women and some that will only be shared by those from specific groups, such as women from a
particular minority ethnic group or lesbian women.
4.1.1 Gender specific services
One aspect of ensuring that service planning and delivery is sensitive to gender is to understand that
there is a need to provide gender specific, or single-sex, services in some instances. Some services will by
their nature be entirely, or predominantly, women-only such as perinatal mental ill health and eating
disorder services.
When a women-only service is developed the reasons should be explicit and criteria for its usage
developed. Reasons for women-only developments include:
• the expressed preferences of women to ensure choice is available;
• specific gender, cultural or religious needs;
• the generation of a safe environment which has particular relevance for specific groups of
women, such as those with experience of male violence and abuse, those with sexually
disinhibited behaviour, older women or lesbian women.
In services that are women-only, in particular in-patient and other residential services, explicit decisions
about the appropriateness, or not, of mixed-sex activities should be made (see section 11.2 on in-patient
services and section 11.3 on secure/forensic services). These decisions should be dictated by the needs of
the women, their stage in recovery and their capacity to make informed decisions about their safety and
welfare (see section 9.1.7 on risk assessment and section 11.3 on secure/forensic services).
Key Messages
• Gender is a key issue that influences an individual’s experience of the world and therefore gender
issues should be incorporated into research, service planning, delivery and evaluation.
• To turn these aspirations into action, organisational and individual values and behaviours need
to be addressed and challenged.
• It is also important to continue to recognise the uniqueness of the individual.
• To ensure that service planning and delivery are sensitive to gender, there is a need to provide
single-sex services in some instances.
27
Women’s Mental Health: Into the Mainstream
28
The Mental Health National Service Framework makes a clear statement of the principles that should
inform the planning and delivery of mental health services across all settings (Figure 1). Many of these
principles fit in with the increasing emphasis on a recovery-based model of mental health care. Recovery
is about mental health care creating an optimistic and positive environment for all people who use it,
enabling them to take an active role in improving their lives, increasing their independence and taking
their full place in society.
As generic principles these are equally relevant to women and men, in mixed and in single-sex settings.
It is in their application that gender issues should be addressed. This requires gender awareness and
understanding across organisations and service settings, in conjunction with consulting and listening to
women. Ways in which organisational awareness and understanding can be encouraged are described in
this and the following sections.
The process of involving and listening to women should be fundamental to all service planning,
delivery and evaluation. Policy development, service planning, individual care, commissioning and audit
all need to include the voice of women themselves.
A broad spectrum of women need to be included, from all parts of the community, as well as those who
are existing service users or carers. There is inevitably a wide range of mechanisms through which
consultation and involvement can be encouraged. It is only through using a range of techniques that
representativeness will be gained. Specific consultation exercises for hard to reach groups, such as
women from rural areas or some black and minority ethnic groups who live very home-based lives, may
5.1 Involving and listening to women
• involve service users and their carers in planning and delivery of care;
• deliver high quality treatment and care which is known to be effective and acceptable;
• be well suited to those who use them and non-discriminatory;
• be accessible so that help can be obtained when and where it is needed;
• promote their safety and that of their carers, staff and the wider public;
• offer choices which promote independence;
• be well co-ordinated between all staff and agencies;
• deliver continuity of care for as long as this is needed;
• empower and support their staff;
• be properly accountable to the public, service users and carers.
Figure 1: Mental Health National Service Framework Principles
Section 5
Gender sensitivity:
Underpinning values and principles
be necessary. Practical issues also need to be considered e.g. the provision of childcare, the timing
of meetings and the safety and accessibility of meeting venues. Making use of existing meetings and
venues, such as those for parent and toddler groups may be helpful.
It may also be necessary to provide information, interpreting or training to help women be involved
in processes that may be unfamiliar or daunting for them.
The establishment of patient advice and liaison services (PALS) in every NHS trust and primary care
trust will help to provide new ways for women to influence decision making. They will be a source of
information and feedback to NHS staff and have the potential to be a powerful lever for organisational
and cultural change.
Key Messages
• Gender issues should be addressed in the application of the principles enshrined in the Mental
Health National Service Framework.
• Involving and listening to women should be fundamental to all service planning, delivery and
evaluation.
29
Women’s Mental Health: Into the Mainstream
30
It is unlikely that genuinely gender sensitive services can be planned or delivered by organisations that
have not acknowledged and addressed gender issues as a fundamental part of their organisational
culture. An understanding of the essential inter-relationship between the organisation, the practitioner
and the service user and the impact of gender is needed.
The way in which mental health care will be experienced by women will reflect the structures and
processes involved in planning services, as well as their actual experience at the point of delivery. It is
important therefore that gender is addressed in both commissioning and provider organisations.
The government’s modernisation agenda is underpinned by recognition of the need for changes in
organisational culture and delivery of care. Critical areas include:
• partnership working and a reduction in hierarchy;
• choice and autonomy for service users and carers;
• transparency – both for service planning and clinical care;
• valuing evidence-based services;
• focusing on outcomes, as opposed to inputs and outputs;
• increase in integrated and mainstream services and reduced specialisation and service insularity;
• valuing information systems;
• supporting the workforce, both clinical and management;
• valuing non-professional and volunteer staff;
• involvement of staff groups in major redevelopment;
• meaningful service user and carer involvement and inclusion in service planning.
Addressing these issues will help to generate user-focused services and increase staff engagement with
service planning and evaluation. Acknowledging, analysing and also addressing inequalities in power
relationships within organisational structures and processes will facilitate gender sensitivity:
• acknowledging the ways in which power can be abused to the detriment of women service
users and staff and the potential role of the organisation in retraumatisation of the
service user;*
• analysing organisational issues, such as untoward incidents, with an understanding of the
dynamics of power and gender;
Section 6
Gender sensitivity:
Organisational development
* Retraumatisation: This refers to the reawakening and re-experiencing of previous negative life experiences, such as child sexual abuse.
This can occur in response to a variety of stimuli or events, including those that may be well intended. Organisational, and even
therapeutic processes, that are experienced as oppressive can act in this way, such as restraint procedures or close quarters constant
nursing observation A related phenomenon is re-victimisation where the experience of past abuse can produce the tendency for a
sufferer to develop/seek out inappropriate or further abusive situations/relationships.
• applying the same values and principles to the organisation as to the delivery of patient care,
ensuring that gender, alongside other inequality issues, is addressed in all organisational
structures and processes e.g. harassment policies should apply equally to interactions between
patients, between staff and between staff and patients.
Organisational principles such as these are thought to help generate a culture for evidence-based
practice: valuing people, being service user centred, having continuing education, clear role delineation
for staff, effective teamwork, clear leadership, routine use of audit and regular peer review.120 These will
help to create organisations that develop knowledge about what constitutes best practice and effective
mental health care for women.
An aware, informed and competent workforce is essential if gender sensitive services are to be provided.
An understanding of the following issues is therefore necessary for all staff involved in planning,
delivering and evaluating services – policy makers, clinicians, managers and researchers:
• the economic and social context of women and men’s lives;
• the interplay between gender and other inequality issues such as race, culture, ethnicity and age;
• differences in the prevalence of risk and protective factors for mental health between women
and men;
• differences between women and men in presentation and pathways into services and differences
in treatment needs and responses;
• the relationship between gender and power inequalities and how this may affect individual
patients, staff and the organisations in which they work or are cared for.
The level of detail required will differ depending on the roles and responsibilities of the individual
employee, however all staff need a general understanding of these issues and therefore they should be
addressed in all core training in mental health.
6.1.1 Leadership
Leadership within organisations should make a clear commitment to addressing gender issues.
Modelling gender sensitive behaviours and relationships will be essential. Managerial and clinical
practice styles need to demonstrate that staff, as well as patients, are valued. Practical ways of leading by
example and addressing gender include:
• collaborative/partnership working styles, particularly between clinicians and managers, across
professional and organisational boundaries and with service users;
• devolution and transparency of decision making;
• family friendly employment policies including job shares, carers leave, term-time contracts,
child care facilities, generous maternity and paternity leave entitlements;
• being seen to value roles traditionally taken by women, such as secretarial and administrative
support or catering;
• helping employees to have an appropriate work/life balance;121
• not tolerating bullying, sexual or racial harassment and by having robust policies for dealing
with these issues.
6.1 Workforce development
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Women’s Mental Health: Into the Mainstream
Clinical Governance: Quality in the new NHS sets out the Government’s programme of modernisation
and achievement for the NHS.122 Clinical governance provides a “framework within which local
organisations can work to improve and assure the quality of clinical services for patients”. In mental health
care, given the necessity of multi-professional, multi-agency input into service planning and delivery, it
is particularly important that governance and quality issues are addressed across health and social care
and in conjunction with other agencies such as housing and the criminal justice system (see section
7.3.1 on service evaluation).
Governance arrangements should formally include gender and other inequalities. Some of the ways in
which this can be achieved are:
• ensuring women’s involvement in all aspects of service planning, delivery and evaluation;
• including gender and other dimensions of inequality in training programmes;
• developing a culture of evidence-based practice with respect to gender;
• developing quality and monitoring standards that refer to gender, such as choice of key workers
and treatment interventions;
• addressing gender and diversity in annual clinical governance reports.
Key Messages
To provide gender sensitive services:
• Gender issues should be acknowledged and addressed as a fundamental part of organisational
culture and the inter-relationship between the organisation, the practitioner and the service user.
• An aware and informed workforce is essential.
• Leadership in organisations should make a clear commitment to address gender issues.
• Clinical governance arrangements should include gender and other inequalities.
Positive practice example
North West Region Secure Commissioning Team has produced a comprehensive set of Standards
for Women in Secure Services. These standards cover policy and practice development and are
linked to clinical governance indicators. The values that underpin these service standards are
described by the Commissioning Team as ‘sensitivity to gender, race and culture and the
empowerment of women patients’. Many of the issues addressed are pertinent to non-secure
service settings. Local providers have been asked to identify five key areas from the standards for
initial development. Networking, participatory workshops and positive practice directories are
supporting this process.
Contact Pat Edwards/Carol Elford, telephone 0151 920 5056, email carol.elford@southsefton-pct.nhs.uk
6.2 Governance
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33
The principle from the Mental Health National Service Framework that “all mental health services must be
planned and implemented in partnership with local communities and involve service users and carers” should
underpin service planning.
The new arrangements under Shifting the Balance of Power 123 give primary care trusts (PCTs) the lead in
assessing need and commissioning health services. NHS trusts will continue to provide services,
working within delivery agreements with PCTs.
Local councils have been required, since April 2000, to develop Best Value performance plans. These
plans offer a framework to help councils improve the way they deliver services and implement the
Government’s modernisation agenda.
The assessment of need is a starting point for service planning and should be part of a dynamic set of
processes, not an isolated piece of work. Need is not static, it may change over time, projections of
future need should also be assessed.124 Other essential processes related to needs assessment include:
• Resource mapping: A picture of the services providing mental health care for women
(structures, staff, skills) and how much is spent on them is needed. In order that information
collected is comparable across different areas, clear definitions of services and interventions
are also needed;
• Determination of unmet need/gaps in services for women and the linking of this information
to service planning.
Four approaches to needs assessment are described.
7.1 Assessment of need
Positive practice example
North Staffordshire Combined Healthcare Trust has undertaken a radical reconfiguring of specialist
mental health services: nearly 50% of acute in-patient beds relocated into community based mental
health resource centres and a new build for hospital based services. The process of strategic change
was informed by a service user focus (with equitable gender balance) with service user monitoring
groups in each aspect of the service now that it is fully operational. A joint process was established
between the Trust, Community Health Council and service users to monitor implementation of the
Safety, Privacy and Dignity Guidance. A Women’s Forum is also being developed to involve key
staff and managers, voluntary sector representation and service users in joint monitoring of service
provision in relation to the needs of women.
Contact Jenny Crisp, telephone 01782 275135, email jennifera.crisp@nsch-tr.wmids.nhs.uk
Section 7
Gender sensitivity:
Planning, research and development
7.1.1 Epidemiological research
Epidemiology describes the occurrence of illness/disease in a population and can provide an estimate of
the likely numbers in need. Information can be gathered by:
• applying the results of research to a local population, allowing for relevant differences between
the research and local populations, for example in ethnicity or deprivation;
• local surveys may be useful for certain groups such as women refugees, where there is relatively
little published research.
7.1.2 Key informants
The views of a variety of individuals/groups can help define need and benefits of services. This includes
clinicians and service planners as well as women service users and carers (see section 3.3 on what women
say and section 5.1 on involving and listening to women). Views can be obtained through, for example,
individual or group interviews using structured or semi-structured questionnaires or focus groups.
7.1.3 Analysis of service usage
Data is collected on aspects of service usage that is considered a proxy for need. The information can be
compared with data from other services, particularly those that cover similar populations. This makes it
is essential to collect service usage data by gender, ethnicity etc. This can help to identify groups who
are not in touch with services such as homeless women, women in rural areas, or women from certain
minority ethnic groups.
7.1.4 Aggregating data from the direct determination of need in individuals
If standardised measures are used, then aggregate data from individuals can produce an overall picture
of need. Similarly, if care plans are detailed and robust enough, aspects of their information can be
collated to provide a picture of local need.
When assessing need and planning services all aspects of service provision should be seen within the
context of the whole system, so that a comprehensive system of care can be developed. Inevitably the
need for any one component e.g. in-patient beds or day-care will be a function of levels of need and the
available range of services. For example, high levels of in-patient bed usage reflects the need for more
beds only if the patients occupying those beds are all considered to be appropriately placed.
With the move to primary care trust commissioning, it will be important to maintain robust
arrangements for commissioning specialist services such as secure care or in-patient eating disorder
services, ensuring appropriate population size and commissioning expertise. PCTs will be expected to
act collaboratively to ensure that the right level and quality of service is available to their populations.
Strategic health authorities will have a role in ensuring that this happens.
A group, led by the National Director for Mental Health, has been set up to encourage the
development of specialised mental health services and to ensure that they become increasingly available
to the whole population.
7.2 Commissioning
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Women’s Mental Health: Into the Mainstream
7.2.1 The voluntary sector
The voluntary sector can bring many strengths to service delivery:
• a close understanding of, and working relations with, client groups or communities;
• a greater likelihood of engaging hard to reach groups;
• an ability to adapt to the changing needs of client groups;
• an ability to deliver on health and social care objectives.
Despite this it has been acknowledged that, whilst the work of the voluntary sector in mental health
services is clearly of immense value, individual organisations find medium or long term planning
difficult because of the uncertain nature of the funding system. In some cases a lack of year-on-year
support has led to valuable services folding or reducing provision.125
In addition, evidence from Best Value reviews suggests that this sector is often overlooked.126 As the
voluntary sector plays a significant role in providing women’s mental health care, health and local
authorities will need to enter into longer-term contractual agreements and apply the same principle to
their voluntary sector service agreements as they are required to do in their NHS and social care
agreements. An emphasis on partnership working will place increasing demands on the voluntary sector
and stretch their capacity to deliver. Commissioners should recognise this, and allow sufficient
additional resources to meet these demands.
There are similarities in the health care needs of all women as well as important differences between the
sexes and between individual women and men. There is some evidence to suggest that there is gender
bias in research; women may be excluded from studies for inappropriate reasons.127 It is essential that
gender is a key study variable if a better understanding of the differences in the mental ill health of
women and men, and the effectiveness of different interventions, is to be gained.
There are many unanswered questions. Broad areas for future research include:
• differences between women and men of the impact of risk and protective factors in the
generation of mental illness and disorder;
• interaction of gender with other factors such as race, ethnicity and culture and the impact on
mental health and illness;
• looking at the way in which social capital may be linked to mental health and illness in women
and men;
• clearer understanding of the differences in help-seeking behaviour of women and men and
how these differences impact on the determination of rates of mental ill health;
• testing whether current research instruments, particularly risk assessment tools, are equally
appropriate in both women and men;
• determining the effectiveness of treatment interventions in both women and men;
• studying in more depth the differences in the way in which the criminal justice system, health
and social services treat mentally disordered women and men;
• determining whether there are advantages across a broad range of outcomes, both clinical and
service user defined, in delivering mental health care in women or men-only environments.
7.3 Research and development
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Women’s Mental Health: Into the Mainstream
The Mental Health Research Network, under the auspices of NIMHE (National Institute for Mental
Health in England) will provide the infrastructure to support high quality mental health and social care
research that places the needs of service users, families and other carers at the centre of research.
7.3.1 Service evaluation
Given the general lack of information about gender and mental health care, service planners and
providers need to ensure that all service evaluation takes account of gender. This means that:
• in all settings service monitoring, audit and research data should be collected, analysed and
presented by gender;
• local audit is carried out of issues where gender is considered a concern e.g. serious incidents,
observation practice, prescribing eg of benzodiazepines, use of electro-convulsive treatment
(ECT), seclusion and control and restraint;
• where single-sex environments are established their impact should be evaluated. Evaluations
should include service user views and whether there are demonstrable differences between
mixed and single-sex environments in objective measures of mental health.
Consultation Questions
• Are there examples of good practice with respect to gender sensitive/gender specific service
planning, commissioning or evaluation?
• Are there specific research questions relating to gender and mental ill health that should be
considered?
Key Messages
• Local service planning should be informed by needs assessment processes that involve a range
of women.
• Information from a number of different sources and approaches to needs assessment should be
used.
• The importance of the voluntary sector in provision of mental health care for women should
be reflected in robust commissioning arrangements that ensure the financial sustainability
of voluntary sector services.
• Service evaluation and research should incorporate gender as a key variable in analysis and
presentation.
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Women’s Mental Health: Into the Mainstream
37
The way in which services are organised and delivered has a direct effect on the service user’s experience.
This section discusses general principles and is followed by sections on service delivery (the process of
care) and on service organisation (the structural components of care).
The following principles should apply across all service settings:
• access to a same sex member of staff;
• access to a female doctor for physical healthcare;
• physical examinations to be undertaken by a female member of staff or with a female
chaperone present;
• a female member of staff present if restraint is used;
• access to women-only therapy groups, particularly for issues such as violence and abuse;
• access to women-only social activities;
• acknowledgement of caring responsibilities through provision of childcare facilities, transport
and flexible appointment times for example.
Adapted from Safety, Privacy and Dignity Guidance128
Applying these principles gives women greater choice and addresses safety issues.
Service users and carers should be engaged throughout the whole process of workforce planning,
education, training and recruitment. A user-centred approach is fundamental to the work being taken
forward by the Mental Health Care Group Workforce Team, in response to the Government’s
Workforce Action Team Report on workforce issues for mental health services. The following sections
build on the general workforce issues outlined under organisational development (refer page 30). More
specific gender sensitive training and staff support for mental health care practitioners is described.
8.1.1 Training
The fundamental gender issues that need to be incorporated into training programmes have already
been outlined (refer page 31). In addition to these, training for mental health practitioners should
address the following in order to foster positive, user-focused and consequently gender sensitive
working practices:
• listening skills;
• being non-judgmental, empathic and respectful;
• understanding and managing people with complex problems, who may be difficult to engage
and constantly test boundaries, not treating them as a nuisance or using labels, such as
personality disorder, to exclude them from services;
8.1 Workforce issues
Section 8
Gender sensitivity:
Services – general principles
• the importance of consistency and continuity of care from staff and staff as role models,
particularly when dealing with patients who may have had few positive role models in their lives;
• risk assessment processes underpinned by a clear understanding of the gender differences in risk
to self and others;
• a range of risk management skills including de-escalation techniques, the use of therapeutic
relationships to create security, appropriate use of time-out and safe restraint procedures.
To create a gender aware workforce these issues will need to be thoroughly integrated into the
qualifying and post-qualifying training of all mental health practitioners.
Core competencies with respect to gender in secure care have been developed, as has a training course
for practitioners working with women in secure environments (see below).129
8.1.2 Staff support
All workforce development plans should include the structures and processes for providing staff
support. For these to be sensitive to gender the following should be acknowledged:
• a majority of the workforce will be women;
• many of the life experiences of women patients are common and are therefore likely to be
shared by a significant number of the workforce e.g. violence and abuse or bereavement;
• similarly disorders such as depression, substance misuse and eating disorders, because they are
common in the general population, will also be/have been experienced by a significant number
of the workforce;
• if these issues are unaddressed/unresolved they can cause stress for the practitioner, have
a negative impact on the development of therapeutic relationships or, at worst, a detrimental
impact on the service user’s chances of recovery.
Ways of providing staff support include:
• access to regular, systematic supervision;
• opportunities for reflective practice to acknowledge the tension between understanding and
putting limits on extreme behaviours e.g. self-harm and to help practitioners to deal with
personal rejection and refusal of care;
• out-of-hours crisis support and confidential counselling services;
• regular staff appraisal to identify both high achievers and those who need additional
development and support.
Positive practice example
The Gender Training Initiative (a joint initiative between the University of Liverpool and WISH),
funded by the Department of Health, was established to develop gender awareness training for
multi-disciplinary staff working with women patients in secure mental health settings. The principal
aim of the training is to develop staff understanding of issues involved in working with women
patients in secure settings and thereby contributing to the overall improvement in provision. The
course is administered by the Tizard Centre, University of Kent, Canterbury and is available for multidisciplinary
staff teams working with women in secure settings, prisons and adolescent secure units.
Contact Carey Sellwood, telephone 01227 827863, email c.sellwood@ukc.ac.uk
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Women’s Mental Health: Into the Mainstream
Consultation Questions
• How should gender and other dimensions of inequality be addressed in training for mental
health practitioners?
• Are there examples of good practice in the provision of training or staff support processes that
address gender and other dimensions of inequality?
Key Messages
• Access to women staff, women-only interventions and an acknowledgement of women’s caring
responsibilites, need to be addressed in all settings providing mental health care.
• Training for mental health practitioners should be informed by an understanding of gender
issues and address specific issues such as violence and abuse and self-harm.
• Staff support programmes should be underpinned by the understanding that mental ill health
and other experiences may be shared by practitioner and patient, and they should address the
potential impact this may have.
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Women’s Mental Health: Into the Mainstream
40
This section covers issues related to the way in which services are delivered and includes assessment and
care planning, care and treatment interventions, consultation and liaison and advocacy. It does not
attempt to provide a comprehensive overview, but to highlight issues that specifically relate to gender.
Assessment and care planning take place in all settings, whether a GPs surgery, a day centre or an inpatient
ward, although the terms are more often associated with specialist mental health provision.
Fundamental to user-focused delivery of mental health care is a whole person, individual assessment of
need and the development, in partnership with the service user, of a care plan to address those needs.
This process is formalised as the Care Programme Approach (CPA) in specialist mental health services.
Recent care co-ordination guidance makes explicit that the service user’s needs must be central and that
gender should be taken into consideration:130
“Care plans should focus on users’ strengths and seek to promote their recovery. Recognising,
reinforcing and promoting service user strengths at an individual, family and social level should
be an explicit aspect of the care plan. Care plans should recognise the diverse needs of service
users, reflecting their cultural and ethnic background as well as their gender and sexuality, and
should include action and outcomes in all the aspects of an individual’s life where support is
required, e.g. psychological, physical and social functioning.”
The focus on service users’ needs and own recovery goals is reiterated in The Journey to Recovery.131
Care plans should incorporate what service users say works for them, such as support networks of
friends and families.132
“To regain control over our lives we need to be active, assertive and strong. Our concern is
that, all too often, treatments encourage inactivity, passivity and compliance.”
The following should be key components of assessment and care planning:
• experience of violence and abuse;
• caring responsibilities;
• social and economic support;
• physical health;
• ethnicity and culture;
• dual diagnosis with substance misuse;
• risk assessment and management.
Care planning should address factors that cause social exclusion, as well as those that improve mental
health. Inevitably the two are intimately linked.
9.1 Individual assessment and care planning
Section 9
Gender sensitivity: Service delivery
9.1.1 Experience of violence and abuse
“Clinicians generally ask patients about abuse experiences if they have some reason to suspect
abuse … research underscores the discrepancy between the alarming numbers of people who
are physically and sexually abused and the relative lack of attention that is given to these topics
in taking routine psychiatric histories.” 133
“The links between mental ill health and previous experience of sexual abuse are well known
but persistent findings suggest that the issue of sexual abuse receives little attention in mental
health services; indeed, it is common for coping mechanisms to be misinterpreted as symptoms
of pathology, and assessments are often made which ignore the context of abuse, thereby
perpetuating the problem.”134
Research suggests that women using mental health services often have histories of violence and abuse
in child and/or adulthood. Although many of the studies are small, figures of over 50% are not
unusual.135,136,137 In secure settings this figure is even higher.138
The level of awareness of violence and abuse appears low amongst mental health professionals, women
are rarely asked about such histories.139,140 Where survivors of violence and abuse have been asked about
their feelings with respect to disclosure, they say they want to be asked/wished they had been.141,142
By not initiating exploration of abuse staff may:
• confirm a person’s belief in the need to deny the reality of their experiences;
• leave unexplored a significant factor affecting an individual’s mental health, thus compromising
the capacity for recovery;
• unwittingly engage in a process of retraumatisation (see page 30 for definition).
There are of course many reasons why staff may not address issues of violence and abuse, not least that
they may have been subject to abuse themselves (see section 8.1.2 on staff support) or do not know what
to do if it is disclosed (see section 12.1 on services for women with experience of violence and abuse).
9.1.2 Parenting and caring responsibilities
Women’s parenting and caring responsibilities deserve specific consideration for the following reasons:
• The impact of the loss, or threat of loss, of a woman’s caring role, particularly with respect to
her children, may lead to women not seeking help, not reporting abuse or underplaying
symptoms. This may result in their self-esteem being undermined or in the generation of
mental ill health.143 Women need sensitivity and support “to care for their children rather
than pathologising/judging them negatively”;
• At least 30% of adults in touch with mental health services have dependent children and
the majority of women service users. The consequences to the children of interventions/
treatments should be considered;144
• Approximately a quarter to a third of parents whose children are known to children’s services
may experience mental ill health;
• Some women with mental ill health are cared for by their children.
There is an important inter-agency component to the assessment of children and families in
need, including the education and criminal justice systems, as well as health and social care.
Government guidance highlights the impact of parental ill health on families and an assessment
framework for working with children and families in need has been published.145,146
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Women’s Mental Health: Into the Mainstream
By taking a family or systems approach to mental health the following understandings will be facilitated:
• parental mental illness affects children;
• mental illness can affect parenting and parent-child relationships;
• parenthood can precipitate and influence mental illness.
Women as carers for people with mental ill health must also be considered in assessment and care planning.
This is highlighted in care co-ordination guidance:
“The process of the CPA is clearly intended to deliver care to meet the individual needs of
service users. However, those needs often relate not just to their own lives, but also to the lives
of their wider family. The CPA should take account of this, in particular the needs of children
and carers of people with mental health problems, and must comply with the Carers
(Recognition & Services) Act 1995 and the National Service Framework standard on caring
for carers.” 147
9.1.3 Social and economic support
A commonly mentioned barrier to recovery is the benefits trap and low income.148
For those on enhanced CPA, the written care plan must show the action needed to secure
accommodation, employment/education/training or other occupation and appropriate entitlement to
welfare benefits. This should be in place by March 2002 and be extended to all those on CPA by 2004.
All assessment and care planning should take into consideration the individual’s socio-economic
situation. It has been shown that addressing housing for example, is a prerequisite for engagement of
some service users in services. Housing need for women may be hidden; they may be staying with
family/friends or be trapped in accommodation with abusive partners.
Care plans should also include daytime activity addressing service users’ needs and wants rather than
gender stereotypes. There is some evidence to suggest that women may be expected to improve self-care
and domestic skills, whereas men are expected to find employment.149
“Work, leisure pursuits and education were not considered as important for women
as for men and were rarely accorded the same priority in women’s care plans.”
9.1.4 Physical health
The Mental Health National Service Framework highlights the need for improvement in physical health
care for people with mental illness. This needs to be addressed across health care settings, in both
primary care and specialist mental health services.150,151 Health promotion interventions are not well
provided for those with mental illness.152 This is despite high rates of smoking, obesity, poor diet and
lack of exercise in those with mental ill health.153,154 Women who have experienced violence and abuse
may not participate in health screening programmes.155 The risk of sexually transmitted disease and
unintended pregnancy should also be considered.156,157,158
“Our physical healthcare needs are important and should not be subsumed
under our mental health label.”
Assessment and care planning should therefore include:
• GP details (attempts to find one if not registered) and attendance at other primary care
services;
• cervical smear and mammography history;
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Women’s Mental Health: Into the Mainstream
• appropriate questions for asylum seekers and refugees to determine immunisation status and
presence of other diseases e.g. TB;
• need for dental care;
• details of last menstrual period and contraception (and pregnancy test if indicated).
Oral contraceptives and pregnancy will have an impact on choice of medication, if required.
Women should be counselled, or directed for counselling, about appropriate contraception and
the potential risks of medication on pregnancy.
The care plan should address physical health issues, even if it is limited to providing help/support to
enable the woman to access mainstream services.
9.1.5 Ethnicity and culture
Assessment and care planning must recognise that for some minority ethnic groups negative experiences
with respect to their race or culture are common. The experience of racism was said to be a significant
barrier to recovery by a quarter of respondents in a recent MIND survey.159 Services are not always
sensitive to cultural needs: food, language, personal hygiene and spiritual needs are not always
understood. This, in addition to potential racial abuse by other service users or staff, can exacerbate
mental ill health.
“An Asian woman was scolded by staff for not bathing… The woman didn’t wish to use a
bath while she was menstruating because of her beliefs but nobody took the time to realise
or educate themselves that this was the reason and help her to find and use a shower.”
In situations where a woman does not speak English care should be taken if family members are used as
interpreters. Issues such as domestic violence may remain hidden if an independent person is not used.
9.1.6 Substance misuse
Substance misuse and mental ill health commonly occur together, women may hide their addiction,
due to social stigma and/or fear of loss of children, and are more likely than men to abuse prescription
drugs. These issues should be taken into consideration in assessments (see section 2.3.9 on women who
misuse alcohol and/or drugs and section 12.4 on services for women with dual diagnosis).
Positive Practice Example
In the Bolton, Salford and Trafford MH Partnership practice nurses, working in the Edenfield Centre
and the high dependency unit on the Prestwich site, offer general and specific health services to
patients. On admission patients are given a ‘health’ history interview including current acute and
chronic health problems. These are incorporated into care plans, alongside advice on a healthier
lifestyle, in conjunction with the patient and their primary nurse. Practice nurses also liaise with
general hospitals in the event of planned or emergency treatment. Specialist health care includes
pre-treatment counselling for patients commencing Clozapine, continuing support and monitoring
of side effects through a weekly ‘Clozapine Clinic’.
Contact Ian Maule, telephone 0161 772 3597, email imaule@edenfield.bstmhp.nhs.uk
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Women’s Mental Health: Into the Mainstream
9.1.7 Risk assessment
Risk assessment for women and men will have much in common, but should acknowledge
gender difference. Research on risk assessment and management often does not include gender analysis.
As yet there is no clear research evidence to determine whether current risk assessment instruments
are appropriate for women or whether gender specific ones should be developed.160 In general, it is
important to assess offending/ dangerous behaviours within the family and social context of a service
user’s life in order to make a judgement about dangerousness to the public, staff and/or other service
users. Also important, particularly for women, is the differentiation between active suicidal intent and
other acts of self-harm (see section 12.2 on services for women who self-harm).
The vulnerability of a patient to abuse should also be part of risk assessment and management.
Similarly, an assessment of the potential for a patient to act as an abuser should be made. This is of
particular relevance in mixed-sex settings/activities or to assessments of those in single-sex settings
when deciding about the appropriateness of mixed-sex activities.
9.1.8 Sexuality
It is important that mental health practitioners do not make assumptions or value judgements regarding
women’s sexual identity, sexual behaviour and/or the choices they make regarding their sexuality. Women
may feel that their sexuality is ignored, denied or frowned upon. They may be subject to frank abuse.
“We are judged by our sexual behaviour – we are asked about our sexual behaviour when
it clearly doesn’t relate to anything. There is the pathologising – if you are a lesbian you are
pathologised, if you are having a lot of sex that is pathologised, or if you are not having sex
that is also pathologised. To lesbians: ‘ Are you sure you are a lesbian?’.”
Irrespective of a woman’s sexual orientation, respect and sensitivity should be accorded at all times. The
Royal College of Nursing has produced guidance “to develop and promote good nursing practice in mental
health by assisting nurses to meet the needs of all who identify themselves as lesbian, gay or bisexual”.161
Addressing the needs of transsexual women appropriately may present particular challenges for services.
Individuals should be treated in the gender role in which they present and addressed appropriately
ie she/her. If a transsexual woman passes convincingly in her chosen role there may be few difficulties
but if she is, perhaps, early on in transition and still has male physical characteristics, this could be
distressing for other patients. Equally, female to male transsexuals may feel at risk in male wards. In
such circumstances alternatives to admission to hospital or sensitive provision in the in-patient setting
should be considered.
Positive practice example
North Warwickshire Primary Care Trust has developed a Mental Health Services Equality Initiative
to improve the sensitivity of existing services for service users who are gay, lesbian, bisexual or
transgendered. The project offers both one-to-one and group work for service users (in conjunction
with a service user’s key worker), advice and training for staff and a group for gay and lesbian staff
to provide support and identify issues that the Trust needs to address e.g. harassment, homophobia.
The project also works closely with non-health organisations such as the police and education.
Contact Christine Trethowan, telephone 024 7664 2200, email christine.trethowan@nw-pct.nhs.uk
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Women’s Mental Health: Into the Mainstream
Services should provide a range of services to respond to individuals diverse needs: social, therapeutic
and creative activities, self-help, practical support, medication and psychological interventions. In a
recent survey, nearly half the people who said they felt recovered or were coping, said support from
mental health services first helped their recovery; 42% said support from family and friends first helped,
42% said psychiatric drugs, 38% said talking treatments, 31% said GP services, 20% said spirituality/
religion and 11% said alternative therapies. Over a third of respondents, however, said that mental
health professionals and a lack of choice in treatments had hindered their recovery.162
This section does not attempt to be a comprehensive overview of approaches to care and treatment, but
to highlight some important issues with respect to women.
9.2.1 Medication
There is good evidence for the effectiveness of a range of medication in the treatment of mental illness.
User research, however, often highlights a perceived over reliance on medication.
“There is a limited supply of ‘talking therapies’ available in the NHS. High dependence of
GPs and psychiatrists on prescription medication that is ineffective on its own without
other support or life style changes … Doctors education in more holistic practice should be
increased …Help women reclaim the immense wealth of intuitive health knowledge they
have got from each other.”
For women there are some specific issues that should be considered with respect to prescribing:163
• women are more likely than men to be prescribed psychotropic drugs, particularly
antidepressants, anxiolytics and hypnotics. This is likely to be the result of an interplay of
factors; the response to higher levels of depression and anxiety in women, higher levels of helpseeking
behaviour by women, views on gender and mental illness and consequent prescribing
behaviour of clinicians;
• women may require lower doses of drugs than men;
• weight gain with some drugs is problematic;
• some psychotropic drugs alter the effectiveness of oral contraceptives;
• some psychotropic drugs may have a damaging effect on foetal development and are
contraindicated in pregnancy, others are required at lower doses in pregnancy, some are
excreted in breast milk.
9.2.2. Psychological therapies
A wide range of psychological therapies is available and there is evidence for the effectiveness of some.164
Within the NHS, psychological therapies are provided by different professional disciplines. Some
therapists have generic roles providing therapy as an integral part of care programmes within mental
health teams, and others provide stand alone services. Psychological therapies are also provided by the
voluntary sector e.g. community based therapy centres, day services. Women service users clearly want
more access to a range of ‘talking therapies’ and less reliance on medication.
9.2 Care and treatment
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Women’s Mental Health: Into the Mainstream
The Department of Health recommendations on treatment choice in psychotherapy and counselling165
include the following:
• Psychological therapy should be routinely considered as an option when assessing mental
health problems. Medication may be the treatment of choice in an individual case but it should
not be the only option considered;
• Patient preference should inform treatment choice, particularly where research evidence does
not indicate a clear choice of therapy;
• Effectiveness of all types of therapy depends on the patient and the therapist forming a good
relationship.
When psychological therapies are provided, gender inequalities in society which impact on women’s
mental health needs should be acknowledged, particularly those aspects of women’s lives that can create
dependence and powerlessness (see section 2 on understanding women’s mental health). Therapeutic
interventions therefore need to be based on the principles of empowerment, partnership and giving
women a sense of control over the pace and movement of the therapeutic process.
There is an acknowledged shortfall in the availability of a range of psychological therapies. Planned
developments in primary care aim to address some of this (see section 10.2 on primary care). Work
being taken forward by the Mental Health Care Group Workforce Team will examine issues relating
to the delivery of psychological therapies across the whole system of mental health care.
9.2.3 Complementary therapies
Complementary therapies, such as aromatherapy and reflexology, are often highly valued by women
service users and are increasingly available, alongside more traditional approaches. Formal evaluation
of effectiveness is often lacking. Some effectiveness evidence is available for hypericum or St John’s
Wort, exercise and meditation.166,167,168 More research with larger study numbers over longer periods
of time is needed.
Specific work is needed to ensure that, at a population level, there are no gaps in service provision and
that consultation and liaison about individual clients can occur with relative ease. There are a number
of mechanisms that may help achieve this:
• agreed process for referrals;
• agreed standards for referral;
9.3 Consultation/liaison
Positive practice example
The Women’s Therapy Centre in Islington, London is a major voluntary sector provider of both
individual and group psychoanalytic psychotherapy for vulnerable women. Women present with
a multiplicity of problems including experiences of child sexual abuse, domestic violence, eating
problems, substance misuse, bereavement/loss, depression and psychosis. Over 50% are from
black and minority ethnic communities and therapy is provided in several languages. Clients are
seen on a self-referral basis with a sliding scale of fees.
Contact Ann Byrne, telephone 0207 263 7860, email a.byrne@womenstherapycentre.co.uk
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Women’s Mental Health: Into the Mainstream
• named responsibility at both clinical and managerial levels for ensuring development and
review of consultation and liaison structures and processes;
• development of information systems shared across agencies.
Formal agreements between specialist mental health service providers and the following may be of benefit.
• Primary/secondary care providers: shared care issues e.g. prescribing costs, drug monitoring,
physical health screening and monitoring, family planning, the relative roles of primary and
secondary care in management of severe mental illness and less severe disorders;
• Non-statutory services e.g. residential homes, level of service provided to them, training
provided etc;
• Sub-specialities within mental health services – defined responsibilities are particularly
important at the boundaries of services. The following are groups that merit specific
consideration: people with learning disabilities, early onset dementia, brain injury,
personality disorder and substance misuse, and 16–19 year olds;
• Obstetrics and gynaecology: prevention, detection and management of perinatal mental ill
health, psychosexual and other gynaecological disorders which may have a significant
psychological component;
• Medical and surgical specialities: the organisation of hospital liaison psychiatry services and the
management of somatisation;
• Accident and emergency departments: management of crisis, particularly self-harm.
Gender and other dimensions of inequality should be taken into consideration when advocacy services
are established.
The White Paper Reforming the Mental Health Act 169 made a commitment that people subject to the
new mental health legislation will have a right of access to specialist mental health advocacy. The
Department of Health commissioned the University of Durham to undertake a study of mental health
advocacy services to assist it in developing and implementing this proposal for new mental health
legislation. Their report: Independent Specialist Advocacy in England and Wales: Recommendations
for Good Practice, has how been presented to the Department of Health and has been published with
a series of questions. The report can be accessed at www.doh.gov.uk/mentalhealth/advocacy.
Positive practice example
The North West Secure Commissioners commissioned WISH (Women in Secure Hospitals) to
provide and evaluate a pioneering, gender specific advocacy service for women patients detained
at Ashworth Hospital, Merseyside that aims to protect vulnerable women, give them a stronger
voice and promote their rights. This requires ‘an awareness that women have been rendered silent
over long periods of time and finding a voice is not easy’. To ensure maximum access, the service
is provided flexibly and in response to the needs identified jointly by the women and advocacy
workers. Initial types of advocacy offered are the encouragement of self-advocacy, ‘one to one’
representation, group advocacy and support to ward based community meetings.
Contact Kate Noble, telephone 0151 471 2639, email wishnw@freenet.co.uk
9.4 Advocacy
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Women’s Mental Health: Into the Mainstream
Consultation Question
• Are there other aspects of service delivery that should be considered to ensure that gender, and
women’s needs in particular, are addressed?
Key Messages
• Individual assessment and care plans should address gender difference and include the following:
experience of violence and abuse, caring responsibilities, social and economic situation, physical
healthcare, ethnicity and culture; dual diagnosis with substance misuse, risk assessment and
management.
• It is important that mental health practitioners accord women respect and sensitivity at all times
with regard to their sexuality.
• Practitioners need to be aware of and address gender in all care and treatment ie social,
therapeutic and creative activities, self-help, practical support, medication, psychological
therapies and complementary therapies.
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Women’s Mental Health: Into the Mainstream
49
Mental health promotion programmes are a vital part of local planning.170 Issues pertinent to women
include:
• Improving the health of women of childbearing age may also improve the physical and mental
health of the next generation.171 Providing support to women with young children, through
parenting programmes or schemes such as Sure Start, can have a beneficial effect on maternal
and child mental health and child development;
• A number of groups of women are at high risk of mental ill health (see section 2 on
understanding women’s mental health) and should therefore be specifically considered in local
health promotion plans. These should include women with experience of violence and abuse;
• Reducing social isolation and poverty. This will have an impact on women and men, however
programmes should take into account gender difference, such as women’s need for improved
public transport and childcare facilities.
Most mental ill health, mainly depression and anxiety, will be seen and managed in primary care.
10.2.1 General practice
Studies suggest that, on average, GPs detect about half of the people with mental illness (according to
screening questionnaire) that present to them.172 What in actuality ‘detection’ represents is complex and
relates to both GP and patient factors. There is also considerable variation between individual doctors.
There is relatively less research on detection by other primary care practitioners.173,174 Detection is
affected by the way in which patients present their problems. Generally, the combination of physical
complaints and mental ill health, common in women, impedes recognition of the latter.175
Specific issues for women (see also section 9.1 on assessment and care planning) include:
10.2 Primary care
Positive practice example
The Mothering Project at The Maya Centre, Islington works holistically to improve the quality of
parenting for children whose mothers are living with multiple deprivation, may have experienced
violence, sexual abuse, abandonment or neglect in childhood and who are unlikely to approach
traditional mental health services. A six-month programme of support may include individual
counselling, group work, parenting skills training and dance/movement therapy.
Contact The Maya Centre, telephone 0207 281 2673, email maya.centre@virgin.net
10.1 Health promotion programmes
Section 10
Gender sensitivity: Service organisation –
non-specialist mental health services
• recognition and appropriate treatment of depression (including postnatal depression), anxiety
and eating disorders, such as increased availability of psychological treatments and appropriate
use of antidepressants/anxiolytics;
• detection and management of issues/conditions that often remain hidden – self-harm,
substance misuse and experience of violence and abuse;
• review of long-term prescribing, particularly of benzodiazepines;
• access support services, such as benefits or housing advice.
Specific work is underway which will help to achieve improvement in these areas. New graduate
primary care workers will have a role in the provision of brief interventions, mental health promotion
and providing information about other services. The development of ‘Gateway’ workers will help to
improve the interface between primary and secondary care. Further information can be obtained from
the website: www.doh.gov.uk/fastforward.
10.2.2 NHS Direct
In 2001/02, NHS Direct received a total of approximately 7 million calls and between 6 to 8% were
logged as mental health calls. Many calls are about children (approximately 40% of the total calls
received). NHS Direct provides a non-stigmatising way for women to access mental health information
and, at the same time, to raise any physical healthcare needs. This is an opportunity which could be
further developed.
A partnership has been developed with voluntary sector mental health helplines. Gender and other
diversity issues are being addressed as part of this process.
The listening panels that contributed to Secure Futures176 identified the need for on-going community
support, including access to self-help groups, for women mental health service users. The panels heard
that women “dip into services” to get help while trying to hold the family together. The document
highlights evidence of how crucial community support is, not only for existing service users, but also
for women recovering from mental ill health and in helping to promote mental health and well-being.
Women-only services are highly valued by the women that use them. They can provide a nonstigmatising
source of support and inspiration for a wide range of women. Some women speak
of the sense of social isolation that they feel when they are at home with families, especially if they
are struggling with mental ill health. Many acknowledge the value of meeting with other women to share
10.3 Women-only community day services
Positive practice example
In response to a growing number of patients with depression, the Regis Primary Care Group
in West Sussex collaborated with a voluntary sector partner, United Response, to develop an initial
pilot mental health project. It is based in two GP practices which serve diverse communities.
A skilled mental health support worker is employed by United Response. She provides patients,
predominantly women, with a practice-based intervention. She talks to patients about their
symptoms, works with them on identifying individual coping strategies, monitors medication and
acts as a link between patients and GPs. The aim is to enable individuals to maintain normal
activities of daily living and access community support e.g. local self-help groups.
Contact Mary Doran, telephone 01243 837906, email Mary.Doran@united-response.co.uk
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Women’s Mental Health: Into the Mainstream
concerns and experiences. By encouraging creativity, participation, learning and relaxation these services
can help women increase their self-esteem and develop individual coping and protective strategies.
“I’m struggling to leave the house – the staff and women at the Day Centre understand. If I
make it down on my own, they make me feel good. If I can’t make it some days they come
round for me. It’s helping.”
“Safe spaces for women to meet and share, give and receive support, learning groups,
activity groups, creative expression groups, information and skills exchange.”
“It makes you realise that it’s not you alone – there are others who have it as bad if not
worse and they are getting through. It gives me hope.”
10.3.1 NHS Plan commitment
To help develop community support for women’s mental health and well-being the NHS Plan
made a commitment that “by 2004, services will be redesigned to ensure there are women-only day centres
in every health authority”.
However, it has become clear that concentrating on women-only day centres, in their conventional
sense, would not provide sufficient flexibility to allow local services to address the differing needs of
women in different locations. So the emphasis of the NHS Plan target has been changed from day
centres to day services.
Local health and social care communities should develop services to ensure that a range or network of
women-only community day services is available to meet the local needs of women. The way in which
these services will develop is likely to be different across the country, depending on existing local
provision and need. For example there may be a need for different approaches in rural settings, and for
the provision of “outreach” or out-posted services to reach socially isolated women
Currently the majority of women-only day centres are provided by the voluntary sector.*
They provide a range of support that address women’s mental well-being. However, many of them are
not perceived as mental health services by the services themselves or by the women who use them. They
are used by a variety of women, including those with mental ill health. Service development should
build on these services, where they exist.
An outline service specification for women-only community day services is described on page 54.
Voluntary sector day centre services will form part of this provision, but should not be the sole focus.
The final service model for women-only community day services will be described in the Mental Health
Policy Implementation Guidance.
10.3.2 What will these services do?
The aim of service development should be to promote mental health and to help prevent mental ill
health or relapse by supporting women in their own homes and communities.
The services should be non-stigmatising and allow open access. They should provide a range
of services/activities dictated by local needs, such as counselling, drop-in facilities, educational
opportunities e.g. parenting/health promotion, self-help groups, complementary therapies, information
and advice services. They may be provided in a range of settings.
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Women’s Mental Health: Into the Mainstream
* Women@Centre Network directory, available from Keighley Women’s Centre, 01535 681316.
“To women seeking help, a source both directly and indirectly of opportunities in their
communities that could benefit their health … information, opportunity, support, effective
treatments for body, mind and spirit … to teach women directly about health and
opportunities to improve theirs.”
10.3.3 Who will use these services?
These services have the potential to help a range of women:
• those with existing mental illness who receive support from mental health services;
• women recovering from mental ill health;
• survivors of difficult or abusive experiences, who would benefit from on-going support;
• women in the community who would benefit from advice and support to maintain good mental
health (links should be made to the development of local mental health promotion strategies)177.
“We have a laugh, share our troubles. I don’t know what I’d do without my friends and the
staff at the Centre.”
In particular, returning to home and the community after being in hospital can be a difficult time –
adjusting to “normal” living, and resuming caring responsibilities and parenting roles. Support at this
time is crucial and guidance on the Care Programme Approach (CPA), Effective Care Co-Ordination,
emphasises that care co-ordination should facilitate access for individual service users to the full range
of community supports. CPA plans must ensure continuity of care and should foster good links
between community care and support services for patients while in hospital.
Women-only services may also be particularly appropriate for women who are reluctant to access
mainstream services as they find them inaccessible, culturally inappropriate, frightening or in other
ways not appropriate to their needs. Similarly there are some women who feel that mainstream services
have “failed” them.
10.3.4 Planning, commissioning and provision of services
Commissioners and planners need to build on existing provision identified through service mapping,
and develop and support women-only community day services services to meet the needs of women
in their communities. This will involve:
• understanding, uncovering and addressing the “hidden”needs of women in needs-based
planning and commissioning systems (see section 7.1 on assessment of need);
• consulting with local women and organisations;
• building on good practice and existing women-focused services;
• strengthening partnerships with voluntary sector organisations (including provision such as
women’s refuges, etc) in planning and delivering services;
• acknowledging the contribution to women-only provision made by the voluntary sector and
put in place longer term funding arrangements to ensure stablility and sustainability of such
service provision;
• addressing training needs at all levels to ensure that service commissioners and providers are
aware of issues around gender.
In considering levels of funding and contractual arrangements with voluntary organisations,
commissioners and planners should also address the need for:
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Women’s Mental Health: Into the Mainstream
• robust systems for internal and external supervision;
• management systems that sustain and support staff working with complex client groups;
• the evaluation of effectiveness of services – with the use of outcome measures and feedback
from women using these services.
Positive practice examples
The “Staying Out” Project, developed by Sefton Women’s Advisory Network (SWAN) provides
specific support for women who have experience of repeated admission to acute in-patient care.
Commended by the North West Health Challenge Awards 2001, the project is designed to
minimise the effects of mental ill health, maximise the potential for self-worth and positive
achievement and reduce social isolation. Established in September 1999, the project is funded
by the Health Action Zone until September 2002.
Contact: Ann Crotty, telephone 0151 933 3292, email swan-centre@3tc4u.net
Dosti (friendship) is a multi-faith women’s support project, based at Stockhills Day Centre in
Leeds, run by and for Asian women of all ages. It provides a crèche and transport. Women have
access to counselling, advice, advocacy and support (including at times of crisis) in their first
language and can take part in a range of activities e.g. creative sessions, complementary therapies
and cultural events. Dosti focuses on issues that impact on Asian women’s mental health including
extended family and family pressures, domestic violence, arranged and forced marriages, socioeconomic
problems, bereavement and postnatal depression. At Dosti ‘we are promoting good
mental health, challenging barriers that prevent women getting help and bring women together
to share experiences and gain strength from each other’.
Contact Manjula Prasad, telephone 0113 279 3836
Calderdale Well Woman Centre has provided a service ‘run by women, for women’ since
1985 which comprises support, information, advice and opportunities on an open access basis.
The underlying philosophy is holistic ‘that acknowledges the effects of deprivation, loss, abuse
or discrimination on our overall mental and physical well being’. The Centre strongly encourages
and supports women to become involved at all levels within the organisation.
Contact Clare Hyde, telephone 01422 360397, email wellwoman@tesco.net
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Women’s Mental Health: Into the Mainstream
Service design principles
Women-only community day services should:
Who is the service for?
This policy initiative aims to provide community support for women who have a range of
experiences and needs with an emphasis on those who:
Flexibility at local level is essential to ensure that individual community day services reflect the
specific needs of local women e.g. who are socially isolated, are experiencing depression and anxiety.
What will the services provide?
A range of provision, for instance:
How will the services be accessed?
By a number of means, which may include:
• open access
• drop-in
• outreach services for those women for whom
access to services is problematic
• referral from primary care or mental health
services
• educational programmes
• therapeutic interventions and activities
(individual and group)
• self-help groups
• crisis support
• information
• workshops and activities
• complementary therapies
• are mothers living with a serious mental
illness
• are suffering from postnatal depression
• self-harm
• are surviving abuse and violence
• need a women-only setting
(particularly for cultural reasons)
• be staffed by women
• aim to promote self-esteem and empowerment
• be flexible and responsive – to the range
of women’s needs and at times that are
convenient for them
• be safe and confidential
• allow open access
• be supportive and welcoming
• have an holistic approach to health and
well-being
• use appropriately trained staff and volunteers,
with mental health focused training
programmes for volunteers and paid workers
• take account of women’s parenting
responsibilities, e.g. consider the need for
crèche or childcare facilities
• be accessible to all women by taking account
of diverse needs of race, culture, religion,
age, disability, sexual orientation, where they
live and their caring responsibilities
• maintain strong links with primary care,
community mental health teams and other
voluntary/statutory agencies
Outline service specification for women only community day services
This specification should be considered in conjunction with the sections describing the development
of gender sensitive services (see sections 5 to 11).
A range of employment opportunities should be provided to ensure that the needs of service users for
daytime activity are met. The Department of Health has commissioned the Institute for Applied Health
and Social Care Policy to undertake a project to:
• map and evaluate existing employment schemes nationally;
• highlight examples of good practice;
• make recommendations on how mental health services can best engage with employers;
• consider development of standards for mental health services.
Currently, few schemes are specifically for women. Schemes need to address gender differences in
educational backgrounds, employment histories and childcare requirements.
Positive practice examples
Milton Keynes MIND provides a Supported Training and Employment Placement Scheme (STEPS)
for around 100 new service users per annum. A training officer leads on the needs of women
service users and the ratio of women to men on the STEPs scheme is approximately 50:50. Around
40% of service users move on each year to take up formal training or employment opportunities.
A parallel project is based on a local housing estate with vulnerable young mothers – a toy library
has been established jointly with the group and provides valuable work experience (a need
identified by the women).
Contact Phil Green, telephone 01908 630939, email STEPS@mindsteps.freeserve.co.uk
As part of Pentreath Industries based in Cornwall, Now 2, provides intensive support to women
who have or who are recovering from mental ill health. It gives trainees the chance to receive
individually focused training and employment support in a safe and empowering environment.
Now 2 responds to many women’s preference for women-only training as they experience low
self-esteem and self-confidence following traumatic life events. It works on the premise that
meaningful activity is central to community development and, by raising public awareness, issues
of stigma and discrimination can be tackled.
Contact Louise Knox, telephone 01727 850565, email louise@pentreath.co.uk
10.4 Employment services
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Women’s Mental Health: Into the Mainstream
Addressing accommodation needs is a key part of assessment and care planning. The development
of a range of supported housing options in the community should be part of the development
of comprehensive services. A shortfall in accommodation options can cause delays in discharge from
hospital and discharge to placements at higher levels of security than needed (see section 11.3 on
secure/forensic services).
Local strategic planning should address the need for women-only safe, supported housing for women
who have experience of violence and abuse and accommodation that will accept children.
One of the primary factors in enabling women to leave violent men is the availability of crisis housing.
Violence and the fear of violence add an extra dimension to a woman’s housing needs. In many cases
not only are they losing their family home, but they also have to deal with all the emotional, financial
and legal issues involved in disentangling from a relationship. These issues are likely to be even more
difficult to cope with where there are children involved or the person fleeing violence has special needs.
In addition those fleeing violence do so suddenly, their departure precipitated by a crisis. For all these
reasons, many women fleeing violence need not only safe and secure accommodation but also focused
and appropriate support to help them rebuild their lives.
“What most distinguishes the violence women experience compared to that experienced by
men, is the likelihood of the violence being perpetrated by someone they know and, usually,
someone they should be able to trust. If the idea of having a home encompasses living in a
place that affords physical and psychological security, then a child or a women experiencing
violence in her own home is in a very real sense, homeless.”
Jill Astbury, University of Melbourne,
“Gender and Mental Health”
The Department of Environment, in co-operation with the Department of Health and the Women and
Equality Unit has commissioned research into the provision of accommodation and support for
households experiencing domestic violence in England.
10.5 Supported housing
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Women’s Mental Health: Into the Mainstream
Positive practice examples
Stonham Housing Association is committed to reducing the impact of homelessness and social
disadvantage through provision of specialist supportive housing. One example is Watershed
in Cheltenham that provides a safe environment for women with mental health difficulties and
who have the capacity to live communally: ‘Swindon’ for six single women and ‘Prestbury’
accommodating four single women and their children (to enable them to retain their parental
rights) Women stay ‘as long as they need to’, progressing towards independent living in
the community.
Contact Ros Payne, telephone 01242 522544
Missing Link Housing Association based in Bristol provides a range of safe and supported
accommodation for single women with mental health needs. Short term shared housing,
permanent tenancies in self-contained flats with extensive floating support, a resettlement service
for rough sleepers, a counselling outreach scheme for vulnerable homeless women and drop-in
for all women who use Missing Link services. Hallmarks of the service are personalised support,
women’s empowerment, service user involvement in the setting of service standards and an
holistic approach to meeting women’s needs.
Contact Carol Metters, telephone 0117 925 1811, email mlink@globalnet.co.uk
AZADEH Community Network (formerly Petrus) provides self-contained flats with permanent
tenancies for women with a long history of mental health problems to enable them to sustain
independent living and reduce their admission to acute in-patient care. Typically women have
experienced institutionalised care, removal of their children, child sexual abuse, domestic violence
and received a borderline personality disorder diagnosis. AZADEH adopts a multi-agency approach
to providing each woman with an integrated package of support including a 12-hour daily drop-in
facility and on-call home based support.
Contact Emnet Araya, telephone 0151 728 7272, email Emnet.Araya@novas.org
Queen Mary’s Hostel in central London, provides accommodation for 57 homeless women, aged
18–93, mainly those with enduring mental health problems, some with a dual diagnosis and a
few younger women with a borderline personality diagnosis. Severe life disruptions are common
including abuse/violence, family breakdown and the loss of children. The staff team operates a key
worker system in addressing residents’ mental ill health (including appropriate referral to specialist
mental health services), physical healthcare needs, practical concerns and encouraging their
involvement in local activities. The ethos is characterised by “a strong recognition of the women’s
strength to survive, a great sense of compassion for the women and wanting them ‘here’ ”.
Contact Lorraine Miller, telephone 0207 976 6338, email lmiller@echg.co.uk
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Women’s Mental Health: Into the Mainstream
Consultation Questions
• Are there models of good practice with respect to the provision of primary care services for
women?
• Is the model of provision for community day services described in this document sufficiently
coherent to allow services to be developed?
Key Messages
• Mental health promotion is a vital part of local planning and should address specific issues for
women.
• Primary care services will see the majority of mental ill health in women.
• Practitioners, and the services they provide, need to have access to appropriate training, support
and a range of interventions to ensure that depression, anxiety, eating disorders, self-harm,
substance misuse and experience of violence and abuse are detected and appropriately dealt with.
• Women-only community day services should be developed, building on existing good practice,
to ensure that a range of provision is available locally.
• Local strategic planning processes need to address the need for women-only safe and supported
housing that can also accommodate women’s children.
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Section 11
Gender sensitivity: Service organisation –
specialist mental health services
The Mental Health National Service Framework describes a range of services that are needed to deliver
effective and appropriate mental health care. The spectrum of care needed is the same for women and
men, but all services should consider how they address gender and identify the need for single-sex
provision. This section does not cover all aspects of specialist mental health care, it concentrates on
residential and in-patient care, including secure care, where consideration of women’s specific needs are
particularly important.
Resources have been allocated to increase the number of assertive outreach teams, crisis resolution/home
treatment teams and establish early intervention in psychosis services in order to increase the number of
community-based settings. The Mental Health Policy Implementation Guide178 states that these services
should be sensitive to the needs of both women and men.
Positive practice examples
Turning Point’s Gwydir Project in Cambridge provides intensive and tailored community support
to people with severe mental illness on a referral basis from community mental health teams.
By operating a co-working system, the team has sufficient flexibility to offer clients a range of
open-ended interventions depending on their needs. The emphasis is on relationship building,
developing clients’ community/social networks and enabling them to access other relevant services.
On average, the team works with 2:3 women:men clients.
Contact Chris Rowlands, telephone 01223 516511, email gwydir.project@dial.pipex.com
Oakley Square in central London is one of the few women-only hostels nationally for women with
mental ill health. It accommodates eight women providing a service for women who have been
discharged from secure care and women using local mental health services who are at risk of
becoming ‘revolving door’ service users. The hostel provides 24-hour supported care with a
minimum of two staff day and evening and one overnight. It aims to provide a stepping stone
towards greater independence and to support women in developing requisite life skills. Residents
are actively encouraged to participate in community-based activities, educational courses and
voluntary work as well as ‘community life’ at the hostel.
Contact Gerdy Grafendorf, telephone 0207 388 1112, email admin@oakley.equinoxcare.org.uk
11.1 Community services
Current guidance on Safety, Privacy and Dignity states that residential settings should provide single-sex
accommodation, toilet and bathing/washing facilities, a women-only lounge in ‘new build’ mental
health units and, wherever possible, in existing units. It also suggests that access to single-sex secure
outside space would be beneficial and that women should have access to women-only therapy groups
and social activities. To facilitate implementation, the Guidance states that “an officer at a senior level
within the Trust is appointed to have responsibility for women’s safety”.179
Given what is known about acute in-patient care and the needs of women patients in particular, acute
services “should provide a self-contained women-only in-patient unit” as outlined in the Mental Health
Policy Implementation Guide, Adult Acute In-patient Care Provision. (Also see section 4.1.1 on gender
specific services.) In secure settings, single-sex units should be the norm (see section 11.3 on
secure/forensic services).
In women-only residential/in-patient environments, the gender mix of staff should be specifically
addressed. Some women value an environment with all women staff and others value contact with male
staff who maintain professional boundaries and do not impinge on their privacy and dignity. The
potential for male staff to provide positive role models for patients is important.
“Male nurses and doctors using touch without asking, even just a touch on the arm can be
totally unacceptable if you have been abused.”
“Even though there are female-only areas – male nurses are still able to go in there – 2/3 of
us were talking about being raped earlier in our lives and the idea of any man being
in your sleeping, living, washing area is very intimidating and threatening.”
Many services adopt a policy of having no more than 30% male nursing staff. It may be more difficult
to achieve a similar gender balance for other professions; offering a choice of the gender of key workers
should be the norm.
In all residential settings appropriate facilities for family visiting should be developed. Ideally, this
should be provided:
• in an area that is off the ward/main patient area, so that family members, in particular
children, do not have to go through this space;
• in a homely space with appropriate toys/books for a range of ages of children;
• with access to tea/coffee, toilet and baby changing facilities away from patient areas.
11.2 In-patient and other residential settings
Positive practice example
The Ashcroft Project in Norfolk provides a high support community service for women with
long-term mental health needs. The service includes a:
– residential unit for ten women in the main house, plus four bungalows as move on facilities;
– housing scheme comprising six flats supported on a daily basis by two support workers;
– day service for women living in the community as well as for Ashcroft residents.
The three principles underpinning the Project are trust (providing a safe environment in which
trusting, non-judgmental relationships can develop), healing (enabling women to get in touch with
their painful feelings and work on healthier ways of coping) and independence (building women’s
self-confidence and making links with the outside world).
Contact Heather Robinson, telephone 01953 605191, email theashcroftproject@care4free.net
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Women-only crisis houses
The Mental Health National Service Framework refers to the development of crisis houses as a possible
alternative to admission. The models that exist are varied, some are women-only, and there is little
comparative research. However recent evaluations indicate that women-only crisis houses are highly
valued by many women residents because they feel safer and more comfortable in an all-women
environment than on mixed hospital wards. Women also said that staff were readily available, easy to
talk to and supportive and that they derived valuable support from other residents.180,181
Positive practice example
Anam Cara Crisis House in Birmingham was set up in 1997, in conjunction with the local Home
Treatment Service, to provide an alternative to hospital admission for women and men (in practice
working primarily with women) and a ‘sister’ women-only crisis house, Celine, opened in 2001.
Both houses work on a ‘hope and recovery model’ and use a range of complementary therapies.
The ethos is resident-led and staff are regarded as ‘recovery guides’ who use their experience of
mental health problems and recovery to help residents to recover.
Contact Helen Glover, telephone 0121 686 1592, email helenglover@bigpond.com
Examples of reconfigured acute in-patient services
Two years ago, Linfield Mount Hospital, Bradford reviewed its acute in-patient care services which
was compliant, at that time, with the guidance on Safety, Privacy and Dignity. The acute in-patient
care service was reconfigured to provide four self-contained single-sex units (two for men and
two for women), together with single-sex external areas, as it was considered the only means of
guaranteeing the safety and protection of women patients. A visitor’s recreation centre within
the service enables patients to mix, receive their visitors and spend time with their children.
Contact Des Crowley, telephone 01274 363164, email des.crowley@bcht.northy.nhs.uk
At South Staffs Healthcare NHS Trust, their 50 bed acute service includes a self-contained
three bed women-only unit that also enables women on the mixed-sex units to access a womenonly
lounge and smoking room.
Contact Chris Holley, telephone 01785 257888, email chris.holley@ssh-tr.nhs.uk
In London, both the Homerton Hospital in Hackney and the Royal Free Hospital, Hampstead have
acute services comprising two mixed-sex units and one self-contained women-only unit and, in
both services, demand exceeds the capacity of the women-only units.
Contact Stephanie Boag, Helen Boyle Ward, Royal Free Hospital, telephone 0207 830 2739
Contact Brigid Redmond, Mermaid Ward, Homerton Hospital, telephone 0208 510 8998/8214
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Women’s Mental Health: Into the Mainstream
We came in with our soul
Trapped, discouraged, alone
Pain, sadness and sorrow
But we the women of courage
Will leave this house with
Love, understanding and friendship
But most of all hope to reach
For the moon, the stars and
That which is life
“My gratitude is impossible to verbalise, I found a place of sanctuary and peace.”
Residents, Women’s House
“I think the fact that Drayton Park is women only is really, really important because a lot
of women have had problems with men in the past being beaten up or whatever, and then
to have to go into an environment where you’re around nutty men, it is ridiculous, that’s
why I think Drayton Park is really important.”
“It’s just a much nicer environment in which to cope with any kind of crisis. Going into
hospital is just such an undignified and degrading, horrible feeling. And in many cases it
makes it worse and took me a lot longer to recover.”
Residents, Drayton Park
Positive practice example
Drayton Park in Islington provides an alternative to hospital admission for up to twelve women
and four children. The service is informed by the views and experiences of women service users
and the staff working with them. The House offers women a stay of up to four weeks, 24-hour
support and a range of service options/treatments. The service works closely with local services
to ensure continuity of support after women leave. Women residents assume full parental
responsibility for their children. The staff team aims to be as supportive as possible and sessional
crèche workers are available up to six times per week. Beacon Service
Contact Shirley McNicholas, telephone 0207 607 2777
Positive practice example
The Women’s House in Croydon aims to provide a safe, supportive and therapeutic environment
for eight women with enduring mental health problems who are in acute crisis. It offers 24-hour
care and support to women who might otherwise be offered an informal admission to hospital or
to pre-empt the need for hospital admission. The staff team comprises women nurses and care
assistants plus input from a woman psychiatrist. The service philosophy enshrines a commitment to
working in ways that demonstrate respect, sensitivity and valuing difference amongst women
residents and staff.
Contact Penny Cutting, telephone 0208 660 8676
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There are significant differences in the presentation of mental disorder, social and offending profiles
between women and men in secure care. As a consequence, women’s needs are poorly met by being the
minority in a system of secure care primarily designed for men. Women are often placed in levels of
physical security greater than their needs: they are generally less of a risk to the public, are less likely to
abscond and are more likely than men to have been transferred from other NHS facilities, than from the
criminal justice system (often owing to their self-harming or assaultative behaviour towards staff ). Lack
of appropriate facilities for women may be one of the reasons that they are more likely than men to be
readmitted to medium security and often have longer lengths of stay (in medium and high secure care).182
Most studies of gender difference in secure care are of patients in high and medium security, there is
relatively little research on those using low secure care. The major differences between women and men
in secure care are outlined below. Women are much 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. Estimates suggest that at least 70% of women in high
secure care may have histories of child sexual abuse and over 90% self-harm;
• have physical ill health, 25% of those in high secure care have significant physical health needs;
• be admitted after 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.
Women are always in the minority. 14% of the high secure population and approximately 16% of the
medium secure population.183
Current provision
There has been regular, criticism of current secure care provision for women, including by the Mental
Health Act Commission, the Health Select Committee, WISH and NACRO.
Women in secure care have also raised significant issues with respect to the limitations of current care:
“There’s sixteen of them and they dominate. I’m always having to stand up for myself and
then I explode. The staff then say I’m violent and threatening.” (about medium secure care)
“No-one has ever discussed why I did my crime, to try and understand why I did it.
I’d like someone to talk to.”
“Men get away with it. If women do something they get a harder time.”
“I was severely abused as a child so I do not want to go and talk to a sixty year old man.”
The conclusion of an in-depth patient consultation exercise with women, predominantly in high secure
care, stated that:
“Their stories revealed a shared belief that the dream of discharge could best be achieved
by toeing the line rather than fully addressing the causes of their distress. With little
responsibility or choice over their daily lives or futures:
We’re expected to behave like adults but we get treated like children.”184
11.3 Secure/forensic services
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Women’s Mental Health: Into the Mainstream
There are few NHS secure services dedicated to women, although their number is increasing. A survey
in 2000 estimated that only 3% of medium secure NHS beds and 26% of independent sector beds
were designated women-only.185
Needs assessment exercises across all levels of in-patient care show significant levels of inappropriate
placement.
“There is currently a significant mismatch of mental health services and mental health needs.
There are too few medium secure and intensive care beds and a shortfall in supported
accommodation in the community, including those staffed 24 hours per day.” 186
This is particularly true in secure care, especially in high security.
“Surveys in secure units indicate patients placed inappropriately in levels of security which are
higher than needed. There are gaps in medium secure provision, especially long stay medium
secure provision, in local intensive care provision, in long stay low secure accommodation and
in a number of supported community places, including day-care. These shortfalls result in
delayed discharge and transfer, put extra pressure on local in-patient services, and hinder the
effective use of resources.” 187
Moreover, not only is it clinically inappropriate for many women to be cared for in the level of security
that they currently find themselves in, this also raises significant concerns about human rights and
resource wastage:
‘‘We regard it as inappropriate, both from a civil liberties and efficient use of resources
viewpoint, for patients who can safely be accommodated in less secure conditions to remain in
a high security setting for lengthy periods.” 188
Research estimates for the proportion of women inappropriately placed in secure care vary and can
be difficult to interpret given the lack of appropriate discharge placements. There are significant gaps in
provision of longer-term low secure and high support community residential facilities for women.
This led to the Government’s commitment to women being a high priority group for movement out of
high secure hospitals under the NHS Plan and to the commitment to develop a strategic approach to
women’s secure services.
Money, made available for the accelerated discharge of high secure patients subsequent to the
publication of the Tilt Report, has been allocated to the development of new secure services for women
across the country. This will allow an additional group of women to move out of high secure care over
the coming years.
Definitions of security
Secure in-patient services are provided in a number of different settings and commonly divided into
high, medium and low secure care. Until now, high secure care for women patients has been provided
by all three specialist hospitals, Broadmoor, Ashworth and Rampton. However, when category B
perimeter security becomes synonymous with high secure care, the facility at Ashworth will no longer
be suitable for this purpose and will close in 2004.
Given this, it is probably unhelpful to think about developing services within the confines of nonexistent
definitions of levels of security. It is perhaps more helpful to think about security with respect
to the needs of the client group and specific aspects of the built environment, organisational processes
and staffing; environmental, procedural and relational security.
• Environmental security:
Perimeter security: the nature and height of perimeter fences i.e. measures to prevent
absconcion.
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Women’s Mental Health: Into the Mainstream
• Internal security:
The design and lay out of the care environment, some of which hinder escape e.g. air-lock
entry systems, secure windows and alarms and others which reduce the potential for injury
e.g. safety glass, secured furniture, absence of ligature points and materials that could be used
for self-harm.
• Procedural security:
Organisational polices and processes that help:
– maintain a safe and therapeutic environment e.g. limiting use of lighters and policy on
cutlery use/kitchen use and possessions;
– contribute to preventing absconcion;
– prevent entry/possession of contraband and such as weapons, alcohol and drugs. e.g. entry
procedures for visitors and mail checks.
• Relational security:
This is a function of the nature and quality of the therapeutic relationships between patients
and staff. It partly reflects the staff/patient ratio, partly specific policies relating to staff/patient
interaction (such as the way in which increased observation is managed) and partly the training
of, and interventions provided by, the staff group.
It is accepted that in order to provide a secure, therapeutic environment, in which staff, public and
patient safety is addressed, women generally need high levels of skilled relational and procedural, rather
than environmental, security.
11.3.1 A model for the development of women’s secure services
This section describes an approach to the development of services to more appropriately meet the needs
of women, given what is known about the current limitations of women’s secure provision. In keeping
with the development of all mental health care, a systems approach to development should be taken.
This is essential as the provision of high quality, comprehensive care is as much about the processes of
care as it is about settings. The dynamics of the system will determine the nature and quantity of the
service elements required.
For example the lack of appropriate care for women at lower levels of security has led to inappropriate
placements in high secure hospitals. Similarly, if community staff are not skilled in dealing with issues
such as abuse, self-harm or in providing psychosocial interventions, hospital admissions are more likely.
The need for any one part of a system of care will be determined by the capacity of other parts, in
particular the capacity for working at the interfaces between services, settings and agencies. This can
help to prevent admission to secure care e.g. early intervention services or consultation/ liaison services
from secure care to other services.
An outline service specification for women’s secure services is described on page 69.
The future of high secure care
The size of the population of women in high secure care has reduced. It is likely that it will reduce
further over the coming years:
• as women’s services at lower levels of security are developed, women will be transferred out of
high secure care;
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Women’s Mental Health: Into the Mainstream
• the development of women’s services at lower levels of security should reduce the demand for
new admissions into high secure care;
• there are only a very small number of women who need category B security.
As numbers reduce it becomes unfeasible to continue to provide women’s high secure services on three
sites. From 2002 women’s high secure services will be provided from two of the three high security
hospitals only.
The following section describes the development of women-only secure services that provide for a range
of security needs outside category B high secure services. The principles outlined will, however, apply
equally to the high secure hospitals as to other levels of secure care.
A dedicated, integrated secure service
Women’s therapeutic and safety needs are unlikely to be met in mixed wards. Women’s secure services
should be provided in single-sex units, alongside the development of women specific programmes of
care. Given women’s needs for security are predominantly for relational and procedural security, making
a distinction between medium and low secure care, particularly for longer-term care is probably
unnecessary. (This does not apply to local short-term psychiatric intensive care.) This approach is likely
to create a critical mass of patients which will facilitate the development of:
• women-only therapeutic, occupational, educational, social and leisure interventions/ facilities;
• women-only secure outside space;
• a range of in-patient settings for a range of needs e.g. intensive care, challenging behaviour,
remand assessment, rehabilitation and personality disorder;
• a dedicated, appropriately skilled staff group with capacity for cross-cover and development
of specialist skills;
• a stable staff group which will encourage consistency in practice and the development
of therapeutic relationships;
• easier movement of patients across levels of security;
• the ability to move staff/patients, if conflict between individuals makes this a useful option;
• improved links between high secure care and lower levels of security, through shared posts,
for example.
The physical design of the unit/s should take into account the primary need for relational security:
• wherever possible environmental security should be provided by the built environment, rather
than perimeter fences;
• unit lay out should be such that zonal observation is a realistic alternative to high levels of one
to one, or more, nursing;
• crisis suite/s i.e. bedroom, day and bathroom areas that are separate, or can be separated off
as an alternative to a seclusion room;
• quiet area/s;
• child/family visiting areas (see page 60);
• small unit size, probably no more than 12 beds.
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Services will however probably need to be large enough to support at least two multi-disciplinary teams, to
allow adequate numbers of staff to provide specialist cover for times of additional need/holidays etc.
The development of integrated women’s secure services is likely to benefit from being in proximity to
other mental health services. This would help to ensure a range of facilities, adequate open space and
the potential back up of extra staff in times of additional need. It also would allow mixed-sex activities,
if and when appropriate.
Clear policies on mixing between women and men patients should be developed. These should cover
relationships between patients, social events and the relative numbers of women and men to ensure
that, as a rule, women are not always in the minority. Women-only activities should be the norm,
with the capacity for mixed-sex activities as part of a recovery/ rehabilitative process. Decisions about
the appropriateness of mixed activities should be made on an individual basis. They should be dictated
by a woman’s capacity to make safe, informed decisions about their welfare and risk assessment as to
which men patients would be safe and appropriate for inclusion in mixed-sex activity.
In-patient beds will need to be supported by multi-disciplinary/multi-agency community teams. These
teams should provide consultation and liaison services and ensure links with the criminal justice system,
prisons, courts and probation (see service specification).
The policies and procedures, staff training and support for units will need to acknowledge the multiple
needs of many of the women patients such as their high levels of self-harm, eating disorders, substance
misuse, abuse and specific offending profiles e.g. fire setting.
Service planning should include the needs of women within the prison service given their high levels of
psychiatric morbidity.
Services for women with very challenging behaviours
Whilst it is clear that there are few women who require category B security there are a group of women
with very challenging behaviours who are currently in high secure care. These women require levels of
relational and procedural security that not usually provided at lower levels of security. To provide for
these women outside category B high secure care new types of services will need to be developed. It is
likely that this will require commissioners to work together as the number of women is small. In some
areas, work to identify and plan for this group has started.
Services for women with learning disabilities
As the number of women will be small, collaborative work between commissioners and providers is also
needed to ensure that women with learning disabilities, who need secure/forensic care, have access to
dedicated facilities/care packages at appropriate levels of security.
Evaluation
Published research on women in secure care tends to be descriptive. A recent review of the literature
suggests a lack of systematic information on current service models and therapeutic interventions.189
All new services should be evaluated.
Service development next steps
• Following the establishment of two providers of category B high secure women’s services,
namely Broadmoor and Rampton, consideration will be given to the future appropriate siting
of the reducing high secure women patient population. This should include careful monitoring
of admissions to ensure their appropriateness;
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• Ongoing work between secure providers and commissioners, the criminal justice system and
the Home Office to further develop integrated, women-only secure services to provide for the
needs of all women who do not need category B security, including those with very challenging
behaviour, those with learning disabilities and those within the prison system;
• Ongoing work between commissioners and the high secure hospitals to plan for the very small
group of women who may need category B high secure care in the future.
Positive practice examples
The Longhirst Unit, Northgate Hospital in Northumberland provides in-patient care for women
with learning disability and mental illness/personality disorder. Many of the women have
committed serious fire setting and/or violent offences. The unit has low physical security and
high levels of relational security, with a staff:patient ratio of at least 1:2. The service comprises
two nine-bed areas and a four-bed rehabilitation bungalow. Therapeutic groupwork includes
‘surviving abuse’; anger management and addressing fire setting. Staff work jointly with women
on a individual, needs led basis in addressing their self-harming behaviours. Staff supervision and
training are a high priority and the Unit maintains a high level of staff retention.
Contact Jean Callender, telephone 01670 394000
The Gaskell Unit, at Newton Lodge in Wakefield, is a medium secure, ten bed self-contained
women-only unit. It has its own multi-disciplinary team, including four clinical nurse specialists in
substance misuse, anger management, self-harm and surviving trauma/abuse. The staff:patient
ratio is at least 1:2, with a high proportion of qualified staff. They provide a needs led service
with women actively involved in the philosophy and operation of the unit e.g. through regular
community meetings and a independently facilitated women user group. A wide range of activities
take place on the unit that are open to women patients in other parts of the service.
Contact Sue Threadgold, telephone 01924 328651
St. Andrews Hospital, a national charity based in Northampton, is developing a discrete pathway
of care for women patients with safety and security needs within a mixed hospital environment.
Current components are: 14 bed secure admission unit for the assessment and treatment of
women presenting with complex and severe emotional, psychiatric and behavioural difficulties;
15 bed secure unit for women with a diagnosis of borderline personality disorder who engage, for
a minimum of one year, in dialectical behavioural therapy; six bed ‘step down’ facility for women
in need for continuing care and rehabilitation. It is also anticipated that one of the hostels in the
hospital grounds will be designated women-only.
Contact Fiona Mason/David Nevason-Andrews (DBT), telephone 01604 616000
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Outline service specification for integrated, dedicated secure care services for women
This specification should be considered in conjunction with the sections describing the development
of gender sensitive services (see sections 5 to 11).
Client group
Women with complex mental health care needs. Women in this group often have: more than one mental
disorder including mental illness, substance misuse, learning disabilities, eating or personality disorders,
particularly borderline personality disorder; have a history of severe prolonged abuse and significant
experience of separation and loss, including that of their children; experience intense feelings of
powerlessness and vulnerability with difficulties in forming trusting relationships; present with self-harm,
offending behaviours, pervasive anger, depression, mood instability, dissociation and/or anxiety; are
managed in conditions of physical security greater than their needs, having been transferred from
conditions of lower security.
Structures
Secure in-patient services
A range of provision will be needed to create an integrated, dedicated system of secure care for women.
This system will need to provide:
• short assessment and longer-term placements;
• a range of settings that can cater for the range of needs, including intensive care, challenging behaviour,
remand assessment, rehabilitation, personality disorder and learning disabilities;
• services for the small number of women, currently in high secure care, who have committed severe
offences or who have very challenging behaviours who could not be catered for within existing medium
secure care, but who do not need Category B high secure care;
• multi-disciplinary, multi-agency teams to support in-patient services;
Physical design
• wherever possible environmental security should be provided by the built environment rather than
perimeter fences and specifically address maintaining an environment that reduces as far as possible the
capacity for self-harm (see Internal security, page 65);
• ward lay out should be such that zonal observation is a realistic alternative to high levels of one to one,
or more, nursing;
• crisis suite/s i.e. bedroom, day and bathroom area/s that are separate, or can be separated off, should be
considered as an alternative to a seclusion room;
• child/family visiting areas should be provided;
• women-only secure outside space should be available;
• wards should have no more than 12 beds;
• quiet/low stimulus area/s should be provided.
Other related in-patient/residential services will be needed. This includes non-secure general in-patient
assessment and treatment services that will accept women with challenging/offending or self-harming
behaviours and high support community residential placements.
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Primary health care
In-patient services should have dedicated primary care input including, well-woman sessions, dentistry and
general practice. Health promotion services should be provided.
Forensic community teams
These should be multi-disciplinary and include input from the following disciplines: psychiatry,
psychology, psychotherapy, social work, occupational therapy and nursing. Sessional input from other
services/disciplines, such as substance misuse and eating disorders may be required. It may be appropriate
to arrange secondments from learning disabilities/rehabilitation/probation services, to increase the range of
experience, the likelihood of recruitment and the capacity for interagency liaison.
Functions to be provided by the service
Consultation and liaison
Support to:
• criminal justice system: probation service (including bail and probation hostels), courts and prisons;
• local adult and child and adolescent mental health and learning disabilities services, giving advice on
how women may be managed without admission to secure beds;
• private sector/out-of-area placements.
Assessment and care planning
• assessment should inform a formal care planning process under CPA;
• should be multi-disciplinary, holistic and comprehensive including issues of abuse, self-harm, substance
misuse, sexuality and gender sensitive assessment of risk;
• will need to take place in a variety of settings including the community, family and residential homes,
and distant secure placements including prisons, high secure hospitals and the independent sector;
• the link with local court/police diversion and liaison services should be explicitly agreed.
Treatment and continuing care
Teams should provide the following:
• Community follow-up of those discharged from secure care, those who do not require secure
placement, but whose behaviours are too unusual/severe to be contained by local general mental health
teams and those with established forensic/offending problems and mental illness/personality disorder;
• A range of out-patient and in-patient interventions including: a range of psychological therapies
including family, systemic, cognitive/behavioural approaches in group and individual sessions;
interventions to deal with substance misuse, anger management/impulse control, self-harm, eating
disorders, offending behaviours (including fire-setting) and experience of sexual/physical abuse; ECT;
medication;
• Daytime activity programmes including: education (including basic numeracy/literacy) and
occupational programmes, development of coping, social and parenting skills, complementary therapies,
social/leisure opportunities. Links with community based organisations should be made.
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Policies and procedures
Policies and procedures should address access to mixed-sex activities, if and when, clinically appropriate and
observation policies sensitive to women’s need for privacy and least restrictive care, such as zonal
observation and additional support plans.
Policies and procedures for dealing with self-harm will also need to be agreed, including agreements with
local emergency care providers.
Workforce
Development of:
• a dedicated, appropriately skilled staff group with capacity for cross-cover and development of specialist
skills;
• a stable staff group which will help consistency in practice and the development of therapeutic
relationships;
• an appropriate gender mix of staff (existing women-only services often use a minimum of 70% female
nursing staff with access to women staff at all times).
Training
The service will need to be able to provide training to other organisations and professionals as well as
appropriate training for its own staff group.
Staff support
This should be an integral to the organisation of services and include supervision and space for reflective
practice.
Management
Multi-disciplinary/multi-agency management teams to help create gender sensitive organisational culture,
policies and practice.
Research
Sufficient funding should be available to ensure that the service is established with a culture of research
and audit. Formal links to an academic base should be made.
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Women’s Mental Health: Into the Mainstream
Consultation Questions
• Are there other issues that should be considered to ensure that acute in-patient facilities are safe
for, and responsive to the needs of, women service users?
• Is there a need to further develop women only crisis houses?
• Are there specific issues with respect to the development of secure/forensic care for women that
should also be incorporated into a service specification?
Key Messages
• Acute in-patient services should provide a self-contained, women-only unit to ensure choice is
available for acute admissions.
• In secure settings, single-sex units should be the norm.
• Following the establishment of two providers of Category B high secure women’s services,
namely Broadmoor and Rampton, consideration will be given to the future appropriate siting
of the reducing high secure women patient population.
• Providers and commissioners should work together to ensure that all women who do not need
Category B high secure care have access to more appropriate accommodation in dedicated,
women-only secure services or other facility as their needs require.
• Women’s secure/forensic services should be developed as part of a system of care providing for
a range of security and treatment needs.
• Women’s secure/forensic services should be developed alongside other facilities to provide an
effective pathway of care, such as access to high support community placements, and with
formal links with the criminal justice system and generic mental health services.
• Development of new women’s secure care services should provide for the needs of a range of
women, including those with personality disorder, highly challenging behaviours and learning
disabilities.
73
Child sexual abuse, domestic violence and sexual violence are common amongst women, often hidden
and generally poorly provided for in all settings. Organisations need to:
• Address the lack of staff awareness, understanding and training;
• Provide specific support/treatment interventions;
• Recognise the need for staff support, particularly for those who may be survivors of abuse
themselves.
To generate local expertise and ensure that the impact of violence and abuse is addressed as a core
mental health issue, a lead person should be identified in every NHS Trust to:
• facilitate appropriate interagency working;
• ensure access to appropriate staff training;
• monitor assessment and care planning processes to ensure that abuse is sensitively addressed;
• develop the provision of specific support/appropriate treatment interventions;
• develop staff support processes;
• help the organisation address issues that may lead to retraumatisation of survivors (see footnote
page 30 for definition).
12.1.1 Child sexual abuse
Service development
The importance of including sexual abuse in assessment and care planning has already been highlighted.
These processes need be developed alongside training to increase awareness and skills in the sensitive
exploration of abuse issues, developing appropriate interventions, ensuring staff support is provided and
generating interagency working that addresses sexual abuse.
12.1 Services for women with experience of violence and abuse
Section 12
Services for specific groups of women
12.1.2 Domestic violence
Multi-agency working
The importance of multi-agency work in addressing the needs of this group of women has been
identified in Department of Health guidance.190 This guidance provides a valuable resource for health
care professionals, including those in mental health services. Managers and health professionals in
primary and secondary mental health services need to be jointly involved in establishing and
implementing domestic violence policies and protocols to reflect local need.
A number of forums exist in which the needs of this group of women should be addressed:
• Health Improvement Programmes;
• Health Action Zones;
• Sure Start programmes;
Positive practice examples
Within the Devon Partnership Trust, based in Exeter, a multi-disciplinary team of women mental
health workers offers group work for women with mental health difficulties who have suffered
child sexual abuse, based on a psychological empowerment model of trauma recovery. Each group is
evaluated through qualitative feedback and pre- and post-group measures of trauma, depression
and self worth. There are consistently positive outcomes. At a review following each group, access
to other services (eg safe, supported housing, health information, psychological and creative
therapies) is arranged if necessary.
“Responsibility is replaced on the perpetrators of abuse and on the social context that perpetuates
inequalities of power. Within the presence and support of other survivors, women are enabled to
speak what has previously been unspeakable.”
Contact Gilli Watson, telephone 01392 403170, email giwatson@plymouth.ac.uk
In 1993, South Staffordshire Healthcare NHS Trust appointed a Sexual Abuse Team to highlight
child sexual abuse as a core mental health issue and work in partnership with a voluntary service,
Emerge (for survivors of sexual abuse). The team, based at St. Georges Hospital in Stafford,
provides advice, support, training and supervision for mental health professionals working
with adult survivors of child sexual abuse and direct therapeutic input. The Team also facilitates
a Sexual Abuse Forum and runs support groups for adult survivors and partners/friends of
survivors jointly with Emerge.
Contact Chris Holley, telephone 01785 257888 Ext. 5715, email chris.holley@ssh-tr.nhs.uk
A multi-agency and multi-professional group in Sheffield, in consultation with staff working
in adult mental health services and survivors, compiled a handbook – Breaking the Silence –
covering important issues in understanding child sexual abuse and its consequences and good
practice guidelines for clients and staff. The Handbook stresses however that there is no adequate
substitute for the thorough, ongoing training and supervision of staff working with survivors
in mental health services.
Available from: Pavilion Publishing Customer Services, telephone 01273 623222
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• Crime and Disorder Partnerships;
• Domestic Violence Forums (where generally to date heath care professionals have only played
a small part);191
• Mental health promotion programmes;
• Area Child Protection Committees.
“Ultimately, changes in community responses to domestic violence, to woman abuse, will be
measured not by the number of multi-agency forums that are established, nor by the number
of public pronouncements by government and statutory bodies as to the seriousness of the
issue, but by the quality and sensitivity of services that are (or are not) available to women and
children who are at risk from violence from men who they know or with whom they live.”
Nicola Harwin, Director Women’s Aid Federation of England
Service development
To ensure that mental health services are actively engaged with service development for domestic
violence, local implementation teams should liaise with local domestic violence forums and ensure that
protocols are established for making links between refuges and other organisations providing crisis or
temporary accommodation and appropriate mental health services support.
Positive practice examples
Apna Haq, working within the Asian community in Rotherham, South Yorkshire, supports families
in crisis and provides support for women and children facing domestic violence. They provide
community awareness raising and training events, training for professionals, individual support
for women and group work for young people.
Contact Zlakha Ahmed, telephone 01709 552121
Refuge is developing a cost-effective blueprint model to address the psychological impact of
domestic violence, funded by the Department of Health, with three objectives: to establish
a straightforward, comprehensive assessment measure, to identify the most appropriate
and effective support strategies to enable women to regain control over their lives and to
disseminate assessment methods and intervention techniques to practitioners working with
women experiencing, or escaping from, domestic violence.
Contact Roxanne Agnew Davies, telephone 0207 395 7700, email info@refuge.org.uk
Gateshead primary care mental health team are developing links with the Safer Families Project,
that works with women (and their children) who have experienced domestic violence and male
perpetrators, with the aim of future joint work e.g. community mental health team referrals. There
has also been sharing of good practice in developing service evaluation tools. The Domestic
Violence Forum also has an active practitioners network.
Contact Caris Vardy telephone 0191 443 7061 email, Caris.Vardy@exchange.gatesh-tr.northy.nhs.uk
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Self-harm is defined by the National Institute for Clinical Excellence as:
“Intentional self-poisoning or self injury, irrespective of the apparent purpose of the act.” 192
The term covers a wide range of behaviours including cutting, overdose, burning with cigarettes or
caustic agents, self-strangulation and inserting/ingesting sharp or other harmful objects. Much of the
available research evidence relates to self-poisoning, which is more likely to present acutely to services,
particularly accident and emergency services.
The prevalence of self-harm is difficult to ascertain. Studies are likely to produce under-estimates; many
individuals hide their self-harm and/or it may not be severe enough to need attention from health
services. It is estimated that 4–5/1000 per annum of the population self-harm. This results in at least
140,000 hospital referrals and 85,000 hospital admissions per year in England and Wales.193,194
Generally, studies suggest rates 2–3 times higher in women than in men, although the gap in sex
specific rates may be closing.195,196
12.2.1 Repeated self-harm
The majority of people who self-harm repeatedly are women, some of whom meet the criteria for
borderline personality disorder. Many of these women have histories of multiple deprivation and
violence and abuse as a child or adult.197,198 Self-harm is particularly common in women in prison and
in secure mental health services.
Self-harm, particularly acts such as cutting or burning, may be a means of releasing negative feelings,
coping with psychological distress, increasing a sense of reality or of self-punishment.
12.2 Services for women who self-harm
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• Women experience violence and abuse more commonly than often thought.
• It can play a contributing factor in the development of mental ill health. Histories of violence
and abuse are common amongst women in touch with mental health services.
• Violence and abuse are often not asked about/detected by mental health or other practitioners.
• Interventions/services are poorly developed to help support women with experience of violence
and abuse.
• A lead person should be identified in every NHS trust to ensure that the impact of violence and
abuse is addressed as a core mental health issue.
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“It is widely accepted that self injury is an expression of distress, a way of coping with
emotional pain and that injuring can release, relieve or express acute feelings of self-hatred,
anger or anxiety. People who self-harm frequently report feeling relief immediately after
injuring. The relief may be short-lived, particularly if the source of distress is not being
addressed. The injuring itself may bring a range of difficult feelings including shame, stigma,
isolation.” 199
The reasons women give for self-harm are very individual:
“I’m sad about all my scars but they are also really important. I can look at them and
know I’m not mad and I’m not making it all up.”
“It’s like there’s a child inside me screaming most of the time. I see her as bad.”
“Hurting myself stops the screaming, then I can cry, see the child’s wounds,
feel compassion and look after her.”
“When I’ve seen the blood run I’ve felt relieved and purged, the stress recedes and I’ve felt as
though I am back in control of my mind. Once more I have defeated those emotions and
painful memories.”
“Cutting was my only release from the unbearable chaos inside me.”
12.2.2 Self-harm and suicide
The distinction between self-harm with and without suicidal intent and the overlap between the groups
is a complex area. Many women who self-harm make a clear distinction:
“There is no hazy line. If I’m suicidal, I want to die. I have lost all hope. When I’m
self-harming, I want to relieve the emotional pain and keep on living. Suicide
is a permanent exit. Self-harm helps me get through the moment.”
For health and other practitioners, making this distinction in individual cases may be difficult and
generate considerable anxiety. However, this should form an integral part of the assessment process (see
Section 12.2.4 on Service development).
A clear association between self-harm and completed suicide (usually by self-poisoning, sometimes
cutting and less common self-ligation) has been shown in research studies. About half of those who
commit suicide have a history of self-harm and 20–25% of all suicides attend a general hospital after
a non-fatal act of self-harm in the 12 months before they die.200 At least 1% of patients presenting to
general hospitals after an episode of self-harm kill themselves within the year, 3–5% kill themselves
within 5–10 years. A history of multiple episodes of self-harm is a particular risk factor for completed
suicide.201 It is however often difficult to predict exactly who this will be or when it will occur, hence the
potential difficulties in risk assessment and management (see Section 12.2.4 on Service development).
12.2.3 Effectiveness of interventions
Systematic review of randomised controlled trials, using further episodes of self-harm as the outcome
measure, suggests:202
• problem solving therapy produces lower rates of repetition of self-harm during follow-up
periods, although effect sizes are small;
• dialectical behaviour therapy (DBT) in cases of borderline personality disorder can reduce selfharm
(see borderline personality disorder section);
• no apparent benefit from anti-depressants (unless depression is also present);
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• assertive outreach can help to keep patients in treatment.
Limitations of the studies include: most were of self-poisoning, used subjects recruited from general
hospital samples and many were too small to have the power to detect significant differences.
Considerable uncertainty therefore remains. A randomised controlled trial of interpersonal therapy after
deliberate self-poisoning has also shown positive outcomes.203 Further research looking at outcomes for
individuals who self-harm regularly is needed.
12.2.4 Service development
Local services need policies and training to assess and manage women who self-harm. Local accident
and emergency departments may have a policy on assessment and management that includes the local
mental health service, but many mental health settings do not.
Policies, training and staff support should:
• recognise the importance of the woman’s view of the event;
• understand that staff may behave in a punitive or dismissive way, which may exacerbate
patients’ negative feelings about themselves or the care provided for them;
• understand that staff may find dealing with repeated or serious episodes of self-harm
frightening and/or rejecting;
• understand that some women describe constant observation to prevent self-harm as intrusive
and inappropriate, alternative approaches to maintaining a safe environment should be
explored e.g. zonal observation, additional support plans and crisis suites;
• address the development of therapeutic interventions to help to provide alternative mechanisms
of coping.
Overall, the aim of training and policy development should be to develop a balance between:
• understanding that some women use self-harm as a coping mechanism or survival strategy;
• an active concern for the individual’s safety; and
• therapeutic approaches that help women to address underlying causes and move towards other,
more positive, means of coping and expressing themselves.
The National Institute for Clinical Excellence (NICE) is preparing a guideline on the “short term
physical and psychological management and secondary prevention of self-harm in primary and secondary
care” regardless of whether the behaviour is accompanied by a mental illness. It will apply to all people
over the age of eight. (Publication date 2004)
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Positive practice examples
The National Self-Harm Network is a survivor-led organisation that campaigns for the rights and
understanding of people who self-harm. They undertake training workshops for staff, work with
services to establish good practice models, organise user-led national conferences and have recently
published two resources for those living with self-harm: ‘Cutting the Risk’ and the ‘Hurt Yourself
Less Workbook’.
Contact National Self-harm Networks, P.O. Box 16190, London NW1 3WW
The Mental Health Care Group, based in Denbighshire, provides residential community based
services, including women-only provision, within the independent sector. They have developed a
detailed policy and procedural manual on working with self-injury, informed by service user
experience. It covers all aspects of working with residents who self-injure from principles,
procedures, risk response through to staff support, training and competencies.
Contact Sue Hope-Borland, telephone 01824 790600, email suehope-borland@mental-health-care.co.uk
Positive practice examples
The Crisis Recovery Unit is a unique national specialist service, primarily working with women, who
persistently harm themselves, providing an in-patient facility at the Royal Bethlehem Hospital in Kent
and an out-patient unit at the Maudesley Hospital, South London. In-patient service users typically
have received a borderline personality diagnosis, have other difficulties such as substance misuse and
eating disorders and survived abusive experiences, particularly sexual abuse. The service offers a six
month care package, including one-to-one therapy and group based work to maximise residents
personal responsibility and their long term safety.
‘It is mixed, but rarely has men there. The service there was amazing compared to what I had
experienced before. I was respected – there was lots of time to talk and explore things both
in groups and in one-to-ones … It was very structured, groups were held at set times … there
were counselling sessions that were planned in advance and ‘safety planning’ times as many
times as you wanted’
Contact Jane Bunclarke, telephone 0208 776 4102
Bristol Crisis Service for Women is a charity set up in 1986 to respond to the needs of women
in emotional distress with a particular focus on self-injury. They provide a national confidential
helpline (around 50% of calls relate to self-injury), support self-help groups and publish self-help
booklets, undertake user focused research/evaluation, organise conferences, provide training for
staff and have produced good practice guidelines for working with people who self-injure.
Contact Hilary Lindsay, telephone 0117 925 1119, email bcsw@womens-crisis-service.freeserve.co.uk
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Personality disorder has been defined as an enduring pattern of inner experience and behaviour that
deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has onset
in adolescence, is stable over time, and leads to distress or impairment 204
At least eight different personality disorders are described, depending on which classification system is
used. Although these disorders are clearly described there remains considerable controversy over their
construct and use, particularly as a significant proportion of individuals will fit the criteria of more than
one category of personality disorder. This, in conjunction with concerns about treatability, has led to
poor and patchy provision of services. This is despite the fact that personality disorder is common, both
as a diagnosis in isolation, but also in conjunction with other mental disorders and interventions do
exist that produce good outcomes (at least in some people).
There is a significant gender difference in reported prevalence of personality disorder, both in overall
prevalence, but also in specific disorders: men are more likely to be diagnosed with anti-social
personality disorder and women are more likely to be diagnosed as having a borderline personality
disorder (BPD).205,206,207
A strategy for the development of NHS personality disorder services will be published in 2002.
This section only addresses borderline personality disorder.
12.3.1 Borderline personality disorder
“the essential features of borderline personality disorder are a pervasive pattern of instability of
interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early
adulthood and is present in a variety of contexts.” 208
The diagnosis of borderline personality disorder, in common with other personality disorders,
is for many a stigmatising label that leads to victim blaming and accusations of attention
seeking/manipulative behaviour. This, in conjunction, with general fears about treatability have
led to poor service provision and marginalisation in service planning.
12.3 Services for women with personality disorder
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• Self-harm is relatively common and covers a range of behaviours including self-poisoning and
cutting. It is particularly common amongst women in prison and women in secure mental
health services.
• There is an overlap between acts of self-harm and attempted suicide, making the distinction can
be challenging for practitioners.
• Local services need policies to assess and manage women who self-harm.
• Practitioners need training and support to provide appropriate assessment and interventions.
• However, evidence of the effectiveness of interventions is currently limited.
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“Having that diagnosis resulted in my getting treated exactly the way I was treated home.
The minute I got that diagnosis people stopped treating me as though what I was doing had
a reason. All that psychiatric treatment was just as destructive as what happened before.”
“Denying the reality of my experience – that was the most harmful. Not being able to trust
anyone was the most serious effect … I know I acted in ways that were despicable. But I
wasn’t crazy. Some people go around acting like that because they feel hopeless. Finally, I
found a few people along the way who have been able to feel okay about me even though
I had severe problems. Good therapists were those who really validated my experience.” 209
Borderline personality disorder commonly occurs with other conditions, particularly substance misuse,
major depression, anti-social personality disorder, self-harm and episodes of psychosis.210,211 Studies
suggest that between 26–71% of individuals with borderline personality disorder have histories of child
sexual abuse.212 As significant histories of abuse are common in other diagnostic groups, some have
suggested that it is the presence of severe, repetitive abuse, involving multiple traumas that is important
in the development of borderline personality disorder.
In recent years there has been increasing work on links between complex post traumatic stress disorder
(PTSD) and borderline personality disorder. Many clinicians now see borderline personality disorder as
a variant of complex PTSD.213 There is increasing evidence to suggest that these two disorders can be at
least partly understood through failure to develop secure attachments during childhood.214 Neurophysiological
studies suggest that in PTSD brain function may be affected giving a physiological, as well
psychological, component to the disorder.215,216 This is further supported by ideas of self-medication
through re-traumatisation (see footnote page 30 for definition). Individuals may achieve this through
repetition-compulsion in abusive relationships, self-harm or binge eating: activities that may alter the
production of endogenous, or natural, opiates i.e. provide self-medication. These understandings have
led to the development of therapeutic models based on concepts of trauma and recovery.217
The co-existence of borderline personality disorder with other disorders has been associated with poor
outcomes.218 Other variables associated with poor outcomes include histories of parental cruelty, child
neglect and sexual abuse.219,220
12.3.2 Effective service interventions
Specific interventions that have been evaluated include the following.
• Psychodynamic psychotherapy
One randomised study has shown that psychoanalytically-orientated psychotherapy and partial
hospitalisation can produce significant improvement in acts of self-harm, the number and
duration of in-patient admissions, the use of psychotropic medication, and self-report measures
of mental health over standard psychiatric care.221 Improvement was maintained at 18-month
follow-up.222
• Cognitive therapies
Cognitive behavioural therapy has been shown to be effective in small trials, including a small
randomised trial.223 Small, non-randomised trial suggest that cognitive analytic approaches may
also be of help in some patients.224
Dialectic behaviour therapy, a special adaptation of cognitive therapy, has been shown in small
randomised trials to reduce episodes of self-harm, at least at six month follow-up. It is less clear
whether it is effective in treating other aspects of borderline personality disorder.225
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* ‘Typical’ refers to traditional anti-psychotic drugs (eg chlorpromizine, haloperidol) and ‘atypical’ (or novel) anti-psychotic drugs are
those that have come on to the market relatively more recently (eg clozapine, olanzapine).
• Therapeutic community treatment
A recent meta-analysis concluded that therapeutic communities could provide effective
treatment for personality disorder. However, there are a number of models and approaches
and work is required to gain an understanding of which approaches are most effective with
particular client groups. A recent study suggested the importance of specialist follow-up for
those with borderline personality disorder.226 There was significantly greater improvement on
global assessment of mental health and in social adjustment at twelve months, after a short
in-patient admission and outreach, than with no specialist aftercare.
• Drug treatment
Although drugs are widely used in the treatment of personality disorder, particularly antipsychotic
drugs, there is considerable confusion about their value.227 There is some evidence
that both typical and atypical* antipsychotics may be of help to some patients with borderline
personality disorder.228,229,230 Tricyclic antidepressants and selective serotonin reuptake inhibitors
are also suggested to be of help.231
The mood stabilisers lithium, carbamazepine and sodium valproate have all been used to treat
borderline personality disorder, although current evidence for their effectiveness is limited.232
12.3.3 Service development
Although there is much to learn about which individuals may benefit from which type of intervention,
there is evidence to suggest that effective interventions do exist. Key issues in service development
will be to ensure adequate and accurate assessment, consistency and adequate in-patient support.
Restricting the people involved in care to those whose roles and tasks are clear reduces the chances
of creating inconsistency
Models of care include one-person taking all treatment and care responsibility, an experienced
practitioner or a specialist team approach. There is currently no research evidence to recommend one
over the other.
At a local service level both community mental health teams and primary care staff need training,
supervision and support to assess and manage this group of women. Specialist psychological therapy
services could provide training and outreach to help support other practitioners, as well as providing
secondary treatment services. A range of psychological therapies will be required.
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Positive practice examples
The Cassel in Richmond, Surrey provides three inter-linked residential services for single adults,
adolescents and parents (with their children) with severe borderline personality disorders and
profound difficulties in their relationships with others. The patient group is predominantly women.
Group and individual psychoanalytic psychotherapy and psychosocial nursing approaches are
provided within a therapeutic community ethos. Typically patients return home at weekends and
are encouraged to build links within their community. The outreach teams undertake direct work
with patients, prior to and after their Cassel stay, in liaison with local services for whom they
provide support and training.
Contact Kevin Healy, telephone 0208 237 2922, email K.healy.Cassel@btinternet.coms
The Pele Tower is an innovative supported housing project for people, primarily women, with
a diagnosis of borderline personality disorder. Initiated by Newcastle’s Regional Department
of Psychotherapy, the project addresses the difficulties of accessing suitable accommodation
for clients with this diagnosis. Pele offers a high level of support to residents within a
psychodynamic ethos, including in-house group work and community meetings and works
closely with referring agencies in providing a seamless service between therapy and
community support.
Contact Julia Mundy, telephone 0191 565 8111, email peletower@btconnect.com
The Traumatic Stress Service, Maudesley Hospital in London is an out-patient service run by a
multi-disciplinary team specialising in the treatment of individuals who suffer from both simple and
complex post traumatic stress disorder, many of whom are women with a history of childhood
trauma and who have received a diagnosis of borderline personality disorder. After a thorough
assessment, based on an attachment model of development and a systemic understanding of their
social context, patients are offered an individualised treatment package involving one or more
therapeutic approaches. The Service’s work is reviewed and audited quarterly and based on the
latest research developments on attachment, PTSD and dissociation.
Contact Felicity de Zueleta, telephone 0207 919 2969, email f.dezulueta@iop.kcl.ac.uk
Halliwick Psychotherapy Unit at St. Ann’s Hospital, Haringey, London provides an evidence-based,
integrated psychotherapeutic approach to working with people with a diagnosis of
personality disorder.
Approximately 60% of patients are women, primarily with a borderline personality disorder.
A package of group and individual treatment is offered (within a day hospital over five days
or on an out-patient basis three sessions per week). Assertive outreach is provided as an integral
part of the engagement process. Patients also have access to a self-booking psychiatric clinic
to discuss medication Beacon status
Contact the Unit on telephone 0208 442 6528, email halliwick.therapy@beh-mht.nhs.uk
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Research suggests that substance misuse among patients with mental disorder should be considered
as usual rather than exceptional. Service provision for this group is however poorly developed. The
Department of Health Dual Diagnosis Good Practice Guide 233 emphasises the need for mainstream
mental health services to provide appropriate interventions.
Local services should ensure that the general and specific needs of women with dual diagnosis are met.
For women this means ensuring that alcohol/substance misuse is asked about in assessments, as it may
remain hidden, providing for the abuse of prescription medication, monitoring the prescription of
benzodiazepines, providing for child-care needs and addressing violence and abuse. It is likely that
ongoing training and skills development for mainstream staff will be required, alongside support,
supervision from specialist workers or teams.
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• A dual diagnosis of mental illness and substance misuse is common.
• There may be added stigma attached to women substance misusers, especially alcohol.
• Women may hide their substance misuse and not access services.
• General mental health service practitioners will need training and support to provide for this
group. Local specialist practitioners/teams could help provide this.
12.4 Services for women with dual diagnosis with substance misuse
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• Services for personality disorder are patchily provided across the country.
• Effective interventions do exist, for at least a proportion of people with personality disorder,
particularly women with borderline personality disorder.
• Specialist psychotherapeutic services can help to provide effective interventions and advice and
training to general mental health services/other sectors to help to provide services for this group.
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The occurrence of mental ill health at or around childbirth is common. The months surrounding
the birth of a baby carry the greatest life time risk of developing mental illness for women.234 The
adjustments necessary at birth affect a woman’s physiological, social and psychological world, and no
matter how positive the emotional response to a baby’s birth, it is a highly stressful time. The impact
of perinatal mental ill health can be widespread. The effect on child development is of particular
importance. If mother-infant attachment is upset, social, cognitive and intellectual development may
all suffer. This is thought to be particularly true for boys.235
Any type of disorder may occur postnatally and about twenty are described.236 The most common is
postnatal depression and the most serious puerperal psychosis. Psychiatric illness is implicated in about
10% of maternal deaths.237
“It wasn’t a life, it was an existence.”
“I was so afraid … so scared … I couldn’t relax.”
“They are mine … I should look after them …
they’re not going to be babies for long.”
“It kills me, I can’t move, I feel like screaming.”
12.5.1 Baby blues and postnatal depression
It is important to distinguish between the relatively normal occurrence of the ‘baby blues’ and postnatal
depression. Baby blues usually occur shortly after childbirth, tend to be self-limiting, short-lived and
mild in nature, although potentially very distressing to the mother and her family. Estimates of
prevalence range from 26–85%, depending on how the condition is assessed.238 Postnatal depression on
the other hand usually begins in the first 12 weeks after birth, although it can emerge anytime in the
first year. Quoted prevalence rates vary between 10 and 15%, 3 to 5% meet the criteria for moderate to
severe depression.239 There is debate as to high much depression is present in the antenatal period.
12.5.2 Puerperal psychosis
This is a serious disorder in which depression or mania occurs in the first six weeks after birth; onset
is often in the first week postpartum. There is pronounced disturbance of mood, which can be either
consistently low or high or fluctuate unpredictably between the two extremes. Irritation, delusions and
hallucinations may also be present. About 2 per 1000 women delivered are admitted to hospital with
the condition.240 (A further 2 per 1000 deliveries are admitted with non-psychotic conditions). There
is risk of recurrence of puerperal psychosis. Women who have non-puerperal relapses, have a greater
risk of a second puerperal episode. Psychotic relapses may also occur postpartum in women who have
existing psychotic illness, such as schizophrenia. Estimates suggest 2 per 1000 of women delivered will
be suffering from severe, chronic or enduring mental illness.241
12.5.3 Specific groups
Women from black or minority ethnic groups
Race and culture may have a significant impact on perinatal mental health. It may “predispose,
precipitate or perpetuate” mental illness and thus cultural differences should be acknowledged.242 This
may be because of a variety of factors such as tensions in the extended family or cultural attitudes to
the desirability of male offspring.243 Family support may not always exist and problems can be further
exacerbated by isolation, particularly in rural areas, language and communication difficulties,
experiences of racism and indifference from NHS and other statutory services
12.5 Services for women with perinatal mental ill health
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Teenage mothers
Young women may present during pregnancy and post delivery with a range of mental health problems.
Many Health Action Zones and Sure Start initiatives include projects to promote mental health in
teenage mothers.
Women with substance misuse
Substance misuse can complicate both pregnancy and childbirth. This has been highlighted in the
Confidential Inquiry into Maternal Deaths.244
Women with learning disabilities
Women with mild to moderate learning disability may face special problems in their adjustment to
motherhood and meeting the needs of their developing child. Primary care, maternity services and
specialist mental health services undertake joint assessment and management where appropriate.
Bereavement
Women, who suffer bereavement either through a miscarriage, still birth, perinatal death or in some
cases post-abortion can develop mental ill health, usually depression.
12.5.4 Effectiveness of interventions
Baby Blues
Baby blues are usually self-limiting and respond to simple reassurance from general practitioners;
practice nurses, health visitors, midwives or family and friends. Adequate preparation for childbirth and
child-rearing may help in preventing and/or alleviating distress.
Postnatal depression
Prevention: There is some evidence to suggest that parenting and antenatal support may be effective in
preventing the development of postnatal depression in vulnerable mothers
Screening: Health visitors in Britain are in a good position to detect psychological problems and illness
in newly delivered mothers. Detection can be improved significantly through the use of screening
questionnaires. The most widely used is the Edinburgh Postnatal Depression Scale. This is well
validated within caucasian populations in English, but not within black and minority ethnic groups.
Psychological interventions: Such as ‘listening visits’ and interpersonal and cognitive behavioural therapy
have been shown to be effective.245 Postnatal therapeutic groups run by health visitors and mental
health nurses have also proved to be effective.
Antidepressants: May be required in more severe cases.
Positive practice example
A collaborative programme between Sheffield Primary Care Trust, Sure Start and the University
of Sheffield has developed a culturally sensitive interview instrument. This is to screen Punjabi
speaking women to identify psychological distress after childbirth and enable appropriate support
and care to be provided.
Contact Abi Sobowale telephone 0114 237 5476/Raiza Bhatti-Ali telephone 01274 228855
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Puerperal psychosis
For the most seriously ill mothers who are suffering puerperal psychosis, they generally respond well to
anti-depressants, supported by psychological treatments sometimes for both the mother and the family.
Antipsychotic medication, mood stabilisers and sometimes electro-convulsive treatment may be needed.
12.5.5 Service development
The Mental Health National Service Framework requires health authorities to develop protocols for the
management of postnatal depression. These protocols should span early identification of postnatal illness
and its management in primary care through to more specialist treatment in secondary care.
It is likely that having a mental health practitioner in each specialist mental health service with an
interest in perinatal mental health will lead to the improvement of local service provision, both at
primary and specialist level. They could help to develop a community-based multi-disciplinary/ multiagency
perinatal mental health service, working in partnership with local communities to build capacity
for early identification, support and treatment. This could be underpinned by a care pathway approach
for all pregnant women from the booking-in phase, covering mental health promotion, early
intervention for vulnerable mothers and follow-up. Care plans for mothers in contact with specialist
mental health services should specifically address needs related to their pregnancy.
Nationally, the provision of specialist perinatal mental health services is patchy and unco-ordinated.
There are at least 10 specialist mother and baby units.246 It is however more usual for acute in-patient
services to offer in-patient care. Generally, the mother and baby (sometimes mother without baby) share
facilities and an environment with other patients with differing needs and demands. Local appropriate,
dedicated, in-patient provision needs to be commissioned across a number of primary care trusts.
Local education and training programmes need to develop local knowledge and skills in assessment and
intervention.
Positive practice examples
The Mother and Baby Service at the Queen Elizabeth Psychiatric Hospital comprises a nine bed inpatient
unit, day hospital/day service and a community nursing function dealing with 600 referrals
pa. The Service is for mothers suffering from a range of mental health problems during pregnancy
and in the first year post-partum e.g. difficulties in adjusting psychologically to motherhood, mild
depression/anxiety and puerperal psychosis. They also support women with pre-existing serious
mental illness who give birth. They liaise with local obstetric and primary care services and provide
an education programme for health visitors in identifying vulnerable women.
Contact Dr Gill Wainscott, telephone 0121 678 2000/2195
The Charles Street Parent and Baby Unit in Stoke, Staffordshire provides preconceptual counselling
for women at risk of perinatal mental health problems and antenatal and postnatal assessment,
treatment and support for women (and their families) for up to twelve months after the birth of a
child. Service delivery encompasses an open referral system, daycare (with creche), out-patients,
outreach and obstetric liaison. The multi-disciplinary team provides training for allied practitioners
e.g. health visitors, midwives. An active ‘Mum’s Group’ of previous service users is involved in
service management and offers buddy support for new users. Active liaison with local maternity
services and Sure Start projects increases the profile of services for young parents and their children
including vulnerable families from minority ethnic, asylum seeker and refugee communities.
Contact Janice Gerrard, telephone 01782 425090, email JaniceE.Gerrard@buckmail.nsch-tr.wmids.nhs.uk
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Women’s Mental Health: Into the Mainstream
Eating disorders are far more prevalent in girls and women, and include bulimia nervosa, anorexia
nervosa and binge eating disorder. Obesity alone is not included in psychiatric diagnostic systems.
At any one point in time up to 10% of girls and women may have an eating disorder. Eating disorders
can be mild, self-limiting and amenable to self-help, but for some the illness can be severely debilitating
and have a significant mortality rate. Anorexia has the highest mortality rate of any single psychiatric
illness, if deaths from medical complications, starvation and suicide are combined
Most cases of anorexia and bulimia are in women with a typical age of onset during teenage.
Approximately 1–3% of women, or over 5% if partial syndromes are included, are affected by
bulimia.247,248,249 Anorexia affects about 0.1–1% of young women (about 4000 new cases every
year).250,251 They are both more prevalent in occupations where slimness is valued e.g. dancers and models.
Other psychiatric disorders are often associated with eating disorders. In bulimia 36–70% of women
have a lifetime risk of major depression, anxiety is similarly common.252 Approximately 30% of those
with bulimia have a history of post-traumatic stress disorder.253 Similar proportions have a history of
anorexia. Depression is found in approximately 50% of women with anorexia. Co-morbidity is more
common in clinical than in community samples, with personality disorder, substance misuse and selfharm
commonly found.254
12.6.1 Effectiveness of interventions
Key findings are:
• Compliance with any treatment may be low, with high drop-out rates, particularly for
medication and some in-patient regimes;
• Some of the most severely affected may be excluded from treatment trials;
• As with other mental ill health, detection in primary care is low, many cases of bulimia in
particular are not detected;
12.6 Services for women with eating disorders
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• The development of mental ill health in the period of time after a baby is born is significant
(10–15% of women develop postnatal depression) and can have a negative effect on the child,
as well as the mother.
• Perinatal mental illness is a significant, and potentially preventable, cause of maternal mortality.
• Vulnerable mothers can be identified at antenatal stage; early intervention may be effective.
• Local specialist perinatal mental health services need to be developed. Formal agreements
between maternity, primary care (including health visitors) and specialist mental health services
are needed to ensure that a range of provision, training and support is available.
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Women’s Mental Health: Into the Mainstream
• For bulimia cognitive behavioural therapy is best evaluated and most widely used.255 A usual
course consists of between sixteen to twenty sessions. At completion 40–60% of patients are
symptom free.256 Self-help, with some therapist support, has been found to be equally
effective.257 Interpersonal therapy has been shown to be as effective as cognitive behavioural
therapy. Anti-depressants seem to have a variable response rate;258
• There are few randomised control trials to assess effectiveness of anorexia treatments.
The age of the patient and the severity of disorder will determine the treatment that is most
appropriate. Brief focused out-patient psychotherapy can be effective and prevent relapse for
those less severely affected.259 The involvement of the family in therapy is recommended in
those with young onset. In-patient care is necessary for those with severe weight loss. Day-care
also shows promising results. A small randomised trial of intensive in-patient treatment versus
day-care with cognitive behavioural therapy showed fewer relapses, more stable weight
and fewer admissions in the day-care group.260 Specialist care seems more effective than
non-specialist;
• Early intervention is recommended.
Evidence of service user perspectives on services and on cost effectiveness is lacking.
12.6.2 Service development
Large areas of the country have no access to NHS dedicated services.261,262 This is reflected in significant
private sector provision.
Different models of service provision have been recommended such as a comprehensive specialist service
co-ordinated centrally with service elements based in a range of district localities. Others argue that not
all services should be comprehensive, given the range of services needed, and that specialisation is
required for a few patients. Therefore specialist treatment centres are recommended. There is as yet no
research to guide decisions on the most appropriate model.
Given this, there needs to be at least:
• improved detection in primary care and access to simple psychological therapies, including
self-help approaches for less severe cases;
• access to specialist dedicated eating disorder services for more severe cases. These should be able
to provide assessment, consultation, liaison and treatment services.
Services for people with eating disorders have been defined as specialist mental health services. This
means that primary care trusts will be expected to act collaboratively to ensure that the right level and
quality of service is available to their populations. Strategic health authorities also have a role in
ensuring that this happens.
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Women’s Mental Health: Into the Mainstream
The prison mental health strategy, Changing the Outlook, and the NHS Plan make clear the
commitment to improving mental health care for offenders. The Government’s Strategy for Women
Offenders 263 highlights the specific needs of women with mental ill health. Service planning and delivery
needs to specifically address this group given the considerable morbidity experienced by women in
touch with the criminal justice system (see section 1.3 on the wider government agenda and section
2.3.7 on women offenders).
12.7 Services for women offenders with mental ill health
Consultation Question
• What do practitioners/services require to help them develop appropriate responses for this group
of women?
Key Messages
• Eating disorders affect a significant proportion of young women. Severe anorexia is associated
with a significant mortality rate.
• Most cases of eating disorders will be seen in primary care and will not require specialist mental
health service interventions.
• Appropriate assessment and interventions in primary care are required.
• Consultation/liaison services are also required to ensure adequate advice, training and support
for primary care and specialist intervention for the most severe cases.
Positive practice examples
The Eating Disorders Unit, South London & Maudsley NHS Trust, offers a service across the
spectrum of severity of eating disorders for patients of all ages, providing seamless care from child
to adulthood. The Unit serves a population of two million in South London plus national referrals.
Care packages range from self-help, more complex psychological therapies through to day and
in-patient care for the most severely ill. Aftercare is provided in close collaboration with a
Richmond Fellowship hostel. Carers are actively encouraged to participate in treatment. The
team is committed to an evidence-based stepped care approach to treatment and the quality of
care is assessed with a comprehensive outcome monitoring system. The Unit’s research portfolio
aims to increase knowledge of causation and to develop better treatments for sufferers.
Contact Dr Ulrike Schmidt, telephone 0207 919 3180, email ulrike.schmidt@slam-tr.nhs.uk
The Eating Disorders Association is a national charity providing information, help and support for
anyone over eight years of age affected by anorexia nervosa, bulimia or related eating disorders.
This includes people with personal experience of eating disorders, carers, families, friends and
professionals. Their services include telephone helplines, a UK wide network of self-help and
support groups, a website with help and information, a comprehensive range of information
including leaflets for young people and lists of treatments available around the country.
Contact Eating Disorders Association, telephone 01603 619090, email info@dauk.com
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Women’s Mental Health: Into the Mainstream
12.7.1 Service development
Changing the Outlook requires all prisons to examine critically the services they provide and develop
action plans to ensure that they meet the identified needs of their particular population.
Currently three women’s prisons are involved in the NHS funded project to develop mental health
inreach services in prisons. A further three women’s prisons will join the project during the course of
2002/03. As with the development of secure care for women, mental health inreach will need to
develop assessment and interventions that address abuse, dual diagnosis with substance misuse, selfharm
and personality disorder. It is likely that this will require training, support and supervision of
prison health care staff, as well as the provision of specialist mental health service interventions.
Local service planning should include the prison population as part of its community. This requires an
understanding of the local prison population (should the primary care trust/strategic health authority
include one), the need for primary and generic specialist mental health provision and also the need for
specialist secure/forensic provision for both local women and those in more distant prisons who require
transfer to the NHS. A crucial issue for both mental health services and criminal justice agencies is to
examine ways of improving women’s community based mental health care and access to it by women
in the criminal justice system.
Availability of and confidence in community alternatives need to be improved if the female prison
population is to be reduced. The female prison population has been increasing dramatically over recent
years, at a far greater rate than the male population, and almost twice as many women prisoners suffer
from mental ill health than male prisoners (see section 2.3.7 on women offenders).
Perhaps the most compelling justification for a distinct response to women’s offending, including the
provision of women-specific services and interventions, is the fact that women’s offending carries a
higher individual and social cost than men’s offending. For example, the separation of children from
their mothers whilst they are serving a prison sentence has a detrimental knock-on effect in terms of
transmitted disadvantage and social exclusion. It is all the more importanty, therefore, when dealing
with women offenders to ensure that custody is only used as a last resort for the most serious offences
and where it is necessary for the protection of the public.
Many of the factors that affect women’s mental health, e.g. poor housing, lone parenthood, experience
of abuse, social exclusion, are often the same factors that impact on their risk of offending, It is often
the way these factors combine that has the greatest impact on whether a woman is likely to offend.
The Department of Health and the Home Office are therefore working together to consider how the
Women’s Mental Health Strategy and the Women’s Offending Reduction Programme (see section 1.3 on the
wider government agenda) could link up to tackle these factors. The aim is to promote a co-ordinated
approach so that women with a range of problems and needs can feel assured that the departments and
agencies responsible for providing help and support respond to their needs as a whole, rather than in
isolation. Relevant agencies and organisations will be invited to contribute ideas on how the two
initiatives could best be linked.
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Women’s Mental Health: Into the Mainstream
Consultation Question
• What examples are there of existing joint initiatives for women offenders between mental health
services and criminal justice agencies, and how successful are they?
• What more is needed to provide adequate community provision specifically for women
offenders with mental ill health?
• What could be done to improve links between mental health services and criminal justice
agencies to ensure that women’s mental health care needs are identified and addressed as early
as possible?
Key Messages
• Local service planning and delivery should specifically address the mental health care needs
of women offenders.
• Availability and confidence in community alternatives must be improved if the female prison
population is to be reduced.
• Women’s offending carries a higher individual and social cost than men’s offending.
• Many of the factors that affect women’s mental health are often the same factors that impact on
their risk of offending.
Positive practice examples
Adelaide House is a women-only bail hostel in Liverpool providing a safe environment for
20 women, over age 17, who are either awaiting their court appearance, on licence following
release or serving an alternative sentence to custody. The all female staff team provide 24-hour
cover. In fulfilling it’s aims of protecting the public and reducing offending, the hostel facilitates
the women’s access to all relevant services in meeting their diverse needs. These include physical
healthcare, housing, maintaining contact with their children, addressing drug misuse, counselling
(a high percentage of residents have experienced violence and abuse), education, training and
employment opportunities.
Contact Cathy Earlam, telephone 0151 263 1290
Revolving Doors Agency’s assertive outreach team based in Islington works with people who have
had contact with the criminal justice system, are vulnerable to mental ill health and have multiple
needs. In addition to the police, courts and solicitors, they take referrals from the community
mental health team based in HMP Holloway. The service aims to provide long-term continuity
from first contact at the police station, through remand and sentencing to resettlement in the
community. They act as a link between client and relevant services with respect to physical
healthcare, drug misuse, specialist mental health needs, benefits and accommodation.
Contact Amy Moore, telephone 0207 5278200
93
The overall aim of the Strategy is to produce a framework for the delivery of comprehensive, high
quality, mental health services that meet the needs of individual women. Within this overall aim the
Strategy will seek to:
• acknowledge and address the links between the social and economic context of women’s lives,
their mental health and support/treatment needs;
• address specific issues related to gender, race, age, disability and sexual orientation;
• ensure women’s safety, privacy and dignity;
• engage with women users on a partnership basis;
• tackle the impact of organisational culture on the delivery of high quality services.
Membership and Terms of Reference of Advisory Groups for the Women’s Mental Strategy
Two advisory groups are working in parallel as follows:
1. Overarching Advisory Group
Terms of Reference
• To provide guidance and direction to the Government’s mainstream mental health agenda to
ensure that both policy and practice are gender sensitive and meet the specific needs of women;
• To describe a service framework/service model for women’s mental health services with
particular reference to the Government’s commitment to developing women-only community
day services;
• To undertake specific projects to address the aim and objectives of the Strategy as agreed with
Project Managers.
Kathryn Abel Senior Lecturer, Women’s Mental Health, University of Manchester
Cheryl Adams Professional Officer, Community Practitioners and Health Visitors Association
(CPHVA)
Kathy Billington Secretariat, Mental Health Services Branch, DH
Cathy Borowy Deputy Branch Head, Mental Health Services Branch, DH
Jenny Bywaters Deputy Branch Head, Mental Health Services Branch, DH
Anne Cremona Consultant Psychiatrist, Royal College of Psychiatrists
Janet Davies Chair, Mental Health Services Branch, DH
David Fordham Mental Health Strategy Manager, East Sussex, Brighton and Hove Health
Authority
Helen Hally Director of Nursing, Haringey Primary Care Trust; Professor of Nursing Policy,
Middlesex University
Appendix 1
Terms of reference and membership
of advisory groups
Dora Kohen Consultant Psychiatrist, Royal College of Psychiatrists, Prof. of Women and
Mental Health to the Lancashire Postgraduate School of Medicine and Health
Cath Laverty Central Manchester Joint Commissioning Consortium
Ruth Lesirge Director, Mental Health Foundation
Liz Mayne Mental Health Services Branch, DH
Carolyn Merry Mental Health Lead, Trent Social Care Region
Abina Parshad-Griffin Disability Rights Commissioner; User/Chair of Mental Health Action Group
Sally Prescott Mental Health Lead, Northern and Yorkshire NHS Region
Sian Rees Mental Health Services Branch, DH
Kay Sheldon Mindlink National Advisory Panel (member)
Fenella Trevillion Association of Directors of Social Services, Greenwich Health Authority
Margaret Unwin Threshold, Brighton
Jennie Williams Senior Lecturer in Mental Health, Tizzard Centre, University of Kent
Melba Wilson Policy Director, MIND
2. Advisory Group focusing on issues relating to secure services and services for women with
a history of abuse and/or self-harm
Defined Client Group
Women who have complex needs, including offending behaviours and learning disabilities. Women in
this group often: have more than one mental disorder including mental illness, substance misuse, eating
or personality disorders, particularly borderline personality disorder; have a history of severe prolonged
abuse and significant experience of separation and loss, including that of their children; experience
intense feelings of powerlessness and vulnerability with difficulties in forming trusting relationships;
present with self-harm, pervasive anger, depression, mood instability, dissociation and/or anxiety; are
managed in conditions of physical security greater than their needs due to a lack of appropriate services.
Terms of Reference
To provide advice relating to the development of high quality mental health care for the defined client
group. This should include consideration of the following issues:
• Health promotion;
• The effectiveness of interventions, particularly for self-harm and dealing with histories of
abuse;
• Models of care and practice;
• Training and staff support;
• Organisational development;
• Research and development.
Anne Aiyegbusi Nurse Consultant, Women’s Directorate, Broadmoor Hospital
Diana Baderin Director, National Probation Service
Cathy Borowy Deputy Branch Head, Mental Health Services Branch, DH
Andrea Campbell Director of Community Care, Sefton Health Authority
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Women’s Mental Health: Into the Mainstream
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Women’s Mental Health: Into the Mainstream
Sue Clarke Clinical Psychologist, Head of Intensive Psychological Therapies Service,
Dorset Healthcare Trust
Anne Crump National Self-harm Network; Service User
Sarah Davenport Lead Consultant Psychiatrist, Women’s Services, Ashworth Hospital
Felicity de Zulueta Consultant Psychotherapist, Traumatic Stress Service, Maudesley Hospital
Liz Dewsbury Director, WISH (Women in Secure Hospitals)
Sheila Foley Chair, Prison Healthcare Task Force, DH
Tony Maden Professor in Forensic Psychiatry, West London Mental Health Trust
Liz Mayne Mental Health Services Branch, DH
Jennifer Morris Mental Health Unit, Home Office
Debbie Murdock Manager, Women’s Services, Rampton Hospital
Sian Rees Mental Health Services Branch, DH
Cynthia Robinson Co-Founder, Ashcroft Project, Norfolk
Sara Scott Manager, Gender Training Initiative
Penny Stafford Mental health service user
Sue Threadgold Clinical Lead, Women’s Services, Gaskell Unit, Wakefield
Anita Wadhawan Secretariat, Mental Health Services Branch, DH
Christine Whalley Assistant Chief Executive, Calderstones NHS Trust
We would also wish to acknowledge input from a wide range of other contributors
– too many to name individually here.
96
Appendix 2
Women’ Mental Health:
Into the Mainstream
Strategic Development of Mental Health Care for Women
Consultation questionnaire
This consultation process follows the Cabinet Office Guidelines on written public consultations
www.cabinet-office.gov.uk/servicefirst/2000/consult/code/consultationcode.htm
Comments from:____________________________________________________________________
(your name)
Organisation: ______________________________________________________________________
(if applicable)
Address:___________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Perspective_________________________________________________________________________
(e.g. CPN, Carer, GP, service user etc. – as many as are applicable)
Any comments received will be treated in confidence
1. Overall
Does this consultation document cover areas that you
expected/would have wished to have seen covered? Yes No
If not what are the gaps or concerns that have not been addressed?
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Women’s Mental Health: Into the Mainstream
2. Service specifications
Please provide comments on the service specification for the:
• women-only community day service;
• women’s secure services;
Are the specifications sufficiently:
• clear to enable services to develop them?
• challenging to make progress, but realistic enough to be achievable in timescales set out?
3. Implementation
What are the key priority areas for implementation and how should improvements be measured?
4. Other comments
Any other comments or views on the specific issues highlighted throughout the document?
Please return by 31st December 2002
To: Kathy Billington, Policy Manager, Department of Health, Mental Health Services,
Room 311, Wellington House, 133–155 Waterloo Road, London SE1 8UG.
e-mail: Kathy.billington@doh.gsi.gov.uk
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Women’s Mental Health: Into the Mainstream
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