11 September 2017

From healing to horror

Clinical Mental Health Patients Psychiatry

When Sandy Jeffs walked into Larundel Psychiatric Hospital she was sick. She was suffering the delusions of schizophrenia and losing touch with reality.

But what should have been a place of healing instead became one of sexual harassment and persecution.

One time, Jeffs was stalked by another patient, a man while in a hospital ward. She was unable to escape from the locked ward, but the nurses didn’t believe her when she reported it, instead blaming it on a delusion. Another time, also while in hospital, a naked, sexually aroused male in-patient suddenly appeared in her bedroom. She was physically unharmed but the incident left her “horrified and scared”.

Now a poet and a member of the Women’s Mental Health Network Victoria, Jeffs wrote about her experiences during the 15 years in and out of the “big madhouse”.

She wrote of the struggle that she and other women had, trying to cope with the “uninvited attention of abusive male inmates”.

In writing A Story of Madness, Jeffs hopes to bring attention to the threats women continue to face in psychiatric wards and to motivate the change needed to protect them.

For psychiatrist Professor Jayashri Kulkarni, women are at too-high a risk as long as men and women are housed alongside each other in psychiatric units.

As many as one in two women reported having been sexually assaulted as an inpatient in a psychiatric ward, and 85% said they felt unsafe during their stay, according to a 2013 survey by the Victorian Mental Illness Awareness Council. And experts say this figure appears to have remained consistent over the last decade.

Sexual assault is devastating. So the fact that up to 90% of women admitted to psychiatric inpatient facilities have a history either childhood sexual abuse, family violence or intimate-partner abuse, means the potential for this trauma to be significantly compounded is huge.

Many are hospitalised involuntarily, but for those who aren’t, first- or second-hand experiences of assault can be the kind of traumatic event that puts them off seeking future help.

History

Women and men were not always housed together, explains Professor Kulkarni, a director of a large psychiatric research group the Monash Alfred Psychiatry Research Centre and expert in women and psychosis.

Back in the early 20th century, when psychiatric inpatient-stays tended to be of months or years, Australian women and men were segregated into different wards.

This changed in the 1960s, when hospitals began housing men and women in the same ward in an attempt to create an environment that more closely resembled the outside world.

Then a major shift occurred in the 1990s with the deinstitutionalisation of psychiatric care which was transitioned to community psychiatry. The idea was that anyone who could be managed outside of hospital was – which meant that people had to be very, very unwell to get into an inpatient psychiatric unit. As a result, the acuity of inpatient units increased.

“You’ve got very sick people in the inpatient unit, and often that means you’ve got a great deal of disinhibited behaviour, because people are so unwell,” Professor Kulkarni says.

To add to that, mental-health experts have seen increasing issues with drugs of abuse such as ice and other amphetamines, which creates an even more volatile situation within inpatient units.

And then there is the growing bed pressure, which forces hospital staff to aim for a rapid turnover of patients.

“In that environment, it has been noticed is that assaults on female patients has increased,” Professor Kulkarni says.

Surveys of psychiatric inpatients reveal a number of uncomfortable situations where women feel vulnerable and the support and protection from staff is inadequate, according to the Women’s Mental Health Network Victoria, who refer to themselves as the “Network”.

“Women all agreed that verbal intimidation by male patients was routine, and that the staff response is often ‘If you’re frightened, we’ll put you in [the High Dependency Unit]’,” they say in their 2007 booklet, Nowhere to be Safe.

Inappropriate sexual activity is also complicated on the wards, with one woman recalling patients having sexual relations but that “the women involved were too unwell to make informed decisions”.

For example, one woman described seeing an acutely unwell woman being told by other patients that her husband “was never coming to visit again” and pressuring her to have sex with another patient. Then those same patients told her husband that she had slept with one of the patients on his next visit, creating significant distress for both parties.

Then there’s the outright assault, where women report being heavily sedated and not able to fend off attackers, and not being believed when they reported assaults.

Unisex bathrooms, high-dependency units with even less autonomy and control, heavily sedating drugs and dehumanisation by staff are all issues that have been reported as contributing to this unsafe environment.

Undertaken by The Network, a 2006 survey  found that out of 42 mental-health, two out of three said harassment and abuse occurred in the wards, with one in three saying it happened frequently.

Ten years ago, the UK acknowledged recognised they had similar problems, with their National Audit of Violence: revealing almost one in three patients experienced violence in their current ward, and almost half witnessed it. This prompted stricter policies in enforcing same gender wards.

But Australia hasn’t followed suit.

If this level of violence and intimidation happened on the medical or surgical unit of a general hospital there would be a hue and cry, Professor Kulkarni says.

Part of the reason it has been given so little attention, she suggests, is likely to be the stigma around mental illness and the difficulty gathering good data on this sensitive topic.

Professor Kulkarni acknowledges the current figures may be partly explained by an increasing willingness for patients to come forward and for staff to record and take action on complaints.

On the other hand, rape and sexual assault is notoriously underreported, leading some experts to believe recorded figures are just the tip of the iceberg.

As for the issue of gender-segregated units, some argue the overall effect would be limited as it would do nothing to prevent women-on-women assaults or staff-on- patient assaults.

“It doesn’t solve everything – of course not – but it’d be a major shift in readdressing the problem,” Professor Kulkarni says. “Because most assaults are male-on-female and most of the sexual assaults are definitely male-on-female.”

As many as 50% of women report being sexually assaulted while a psychiatric ward inpatient

Robyn Minty, spokesperson for the Network, says the sexual assaults and violence has long been recognised as a problem for women in psychiatric inpatient units, and that the continued risks were “deplorable”.

“One person is too high, because we’re talking about hospital, and in hospital you should be safe,” the public-health consultant and nurse of 40 years says.

Minty also defended against criticisms that the figures into sexual assaults were drawn from small sample sizes, saying the research has shown consistently high reported figures over the last decade.

However, she stepped back from the Network’s previous advocacy for single-gender wards, suggesting other solutions might be less costly. Some estimates put a price tag of around $8 million on the cost of redesigning a ward into a single-sex unit, and there are 57 hospitals in NSW with mental-health wards, around two dozen in Victoria and dozens more across the rest of the country.

On the other hand, separate corridors, lounges and more staffing may be a more reasonable solution, Minty says. For example, hospitals that introduced locks and swipe cards for patient corridors appear to have fewer complaints.

And now the results from a newly completed survey undertaken by the Network show that 56% of women would actually prefer to stay in mixed-gender wards, and only 44% would prefer same-sex wards, she says.

The Victorian health department says the development of new acute and sub-acute mental-health facilities in the state will include swipe-card access for bedrooms, and options for areas such as bedrooms and lounges to be designated as women-only. It has also earmarked $6 million for capital improvements in the mental-health facilities across the state.

Other states have echoed the commitment to safety in their facilities, but note the difficulties of creating gender-specific accommodation.

“The reality is the high demand on facilities and variable numbers of male and female patients makes this difficult to achieve on a practical basis,” a NSW Health spokesperson says, a sentiment shared by many other state health departments.

Western Australia has two mother-baby inpatient mental-health units that are gender-specific, and the state’s chief psychiatrist Dr Nathan Gibson says he supports the development of female-only wards as one response, but not the only one.

“Sexual safety will be improved by an increasingly more rigorous approach to risk assessment and management of sexual vulnerability, and the formal adoption of a zero-tolerance approach to sexual harassment and abuse,” he says.

A Queensland Health spokesperson says the state employs a number of different mechanisms to protect patients including: private rooms and ensuites with locks, visual observations,  gender-specific recreation areas and nurse line-of-sight to specific beds.

But when faced with potential alternatives such as these, Professor Kulkarni is sceptical.

“You know I think we’ve tried it all,” she says, pointing to a 2010 initiative where she and her colleagues were able to get a women-only wing in some hospital wards “after haranguing, hassling and lobbying”.

“We thought, ‘this is great’, because it’s not that hard, you just build a bit of a wall, and have a door that’s locked, and have seven or eight beds that are for women only.”

But what they found was it hadn’t been maintained in many units.

“The door has been propped open, the actual area gets eroded because the bed pressure climbs and so people go ‘oh well there’s a couple of beds there, we’ll just get men in those beds’,” Professor Kulkarni says.  Installing locks on bedroom doors becomes useless if staff practice is to leave them open at night for periodic checks, she says, and relying on more security guards creates privacy concerns for patients and a possible shift in the therapeutic milieu of the ward.

Security guards would also need to be there and watching around the clock, so some have suggested more surveillance via CCTV.

But again, the design of many units is so bad that there are lots of little nooks and crannies where CCTV cannot reach, she says.

“Then you have to be careful about privacy as well, and paranoid patients get very unwell about that.”

So each of these different possible solutions has some major downsides, and as Professor Kulkarni’s past experience has shown, training programs about gender sensitivity and reporting aren’t all that effective.

“Some people put a lot of effort into the reporting of assaults, but it’s like closing the door after horse has bolted. I think it’s really time for something quite dramatic and major to happen,” she says.

In 2011, Dr Bianca Fileborn co-authored a paper about women’s experiences of sexual assault in institutions for the Australian Centre for the Study of Sexual Assault, in which they also advocated for gender-segregated areas.

Now a lecturer of social sciences at the University of NSW, Dr Fileborn said that part of the problem is both the way we treat sexual assault allegations in society and the way we treat mental illness.

There is a long history of stigma and stereotyping of women, Dr Fileborn says: “They’re mad, bad or completely delusional, that they’re prone to lying about sexual assault”.

Women with mental-health issues are considered to be more likely to lie or be confused about their experiences. They are seen as not being credible witnesses or narrators of their own lives and experiences, she says.

And to make matters even more challenging, there may be additional barriers such as cognitive impairment, fear of disbelief, ridicule, blame or persecution.

“When you’re in an institutional setting, you’re in an incredibly vulnerable position,” she says.

“You do lose a lot of control over your daily routine and activities, what you’re doing with your time, where you are and what you can wear. There’s a huge amount of trust and power that’s placed into the staff members that are providing care to these women.”

What makes this harassment and violence against women in psychiatric facilities so galling is that it arises from a huge breach of power and trust, both for the individual women, but also for the community at large, Dr Fileborn says.

“We should feel that we’re able to trust these institutional settings to do the right thing and to take care of people who are in a vulnerable position or who are unwell,” she says.

Professor Kulkarni is awaiting the report on psychiatric inpatient units by the Victorian mental-health complaints commissioner, expected by the end of the year, to see if recommendations will support a more UK-style move.

She is hoping so, because attacks of this kind on women who are in a place to get well and to heal, are a negligence of the duty of care.

Jane Ussher, professor of Women’s Health Psychology at the University of Western Sydney, agrees, saying it feeds into a long history of poor and distressing treatment of psychiatric patients in hospitals.

Professor Ussher advocates for single-sex wards to protect women from sexual assault, and argues there will be benefits for male inpatients as well.

Mixed-gender wards also put vulnerable men in a problematic situation. Male patients are there because they are unwell. In a distressed and disturbed state they may commit an action that hurts others, and have to face the consequences.

The fact that the UK has returned to single-sex wards, and Australia hasn’t, raises “major questions”, she says.

“Women in psychiatric hospitals are a very vulnerable population, and they are a population who have often experienced sexual abuse in the past.

“This may be a factor why they are distressed and why they are experiencing behaviours or emotions that are deemed to be psychiatric problems. So to put such women in such a vulnerable situation, where they may be abused by another patient, is outrageous frankly.”

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