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Evolution of secure services ARTICLE for women in Jaydip Sarkar & Mary di Lustro

•• variance in the age of onset of , Jaydip Sarkar is a consultant Summary with men being younger than women; forensic psychiatrist working in Patients detained at high and medium security reveal the secure women’s services and •• disparity in the range and severity of symptoms significant gender differences in the presentation of personality disorder services for men (more severe manifestation of post-traumatic at Arnold Lodge in Leicester, UK. psychopathology, mental disorder and social and stress disorder (PTSD) and bipolar disorder in His interests include neurobiology offending profiles. However, secure mental health women); and and affective neuroscience of services in England, like prisons, generally fail to attachment, personality and its recognise the core importance of the differing •• differences in course and prognosis (better disorders, developmental and adult biopsychosocial development in women and the prognosis of schizophrenia in women), response trauma and psychotherapy, mental impact of life experiences on women’s subsequent to treatment and key risk factors (Seeman 1995). health law and gender equality. biopsychosocial functioning. As a consequence, Mary di Lustro is a consultant As regards personality disorder, women receive forensic psychiatrist in the women’s women are often inadequately provided for in disproportionately more diagnoses of his­t­rionic service at Arnold Lodge medium services dictated by the identified needs, risks secure unit. Her expertise and and dependent personality disorders. Anecdotal and responsiveness of men. The lack of clinically interests are secure services for appropriate facilities for women may account for clinical evidence and DSM-IV-TR (American women, establishment of the the increased frequency with which women are Psychiatric Association 2004) suggest that 75% of women’s enhanced medium secure readmitted to medium security and for their longer patients with personality disorders are women, but service pilot sites, improving gender awareness and enhancing the ability admissions to both high and medium secure care. the rate of borderline personality disorder is the to provide relational security in the New tertiary services are developing as a result same in both genders overall, although with more workforce and the treatment of of the lessons learnt while providing gender-blind severe manifestations in women (Lynam 2007). women with personality disorder. care. However, further development is required to Men have higher rates of most other personality Correspondence Dr Jaydip Sarkar, East Midlands Centre for Forensic ensure that women receive services of the same disorders, with disproportionately high levels quality, range and nature of those received by men. Mental Health, Arnold Lodge, of antisocial and paranoid personality disorder Cordelia Close, Leicester LE5 0LE, DECLARATION OF INTEREST (Lynam 2007). UK. E-mail: jay.sarkar@nottshc. nhs.uk None. Crime and violence There are disparities along gender lines. Women The aim of this article is to highlight core constitute just 6% of the prison population and, differences between the genders, the key factors despite recent increases in the number of violent in terms of needs and the risks associated with crimes committed by women, in 2006 less than 6% various mental disorders. It will trace briefly the were imprisoned for such crimes, compared with evolution of secure services for women and will nearly 95% of men (Home Office 2007). Crime make certain recommendations that could lead to statistics in England and show that men are the provision of responsive, clinically effective and more likely than women to be convicted of a range financially efficient services for women. of violent offences: women are responsible for only 6% of murders, 1.5% of attempted murders, 16% What is different about women? of manslaughters, 7% of woundings and 1.3% of Mental disorder sexual crimes (Home Office 2006). Sexual offences constitute roughly half of all serious violent Gender differences in patients’ manifestation of offences in any one year (Bartlett 2009). psychopathology should be neither surprising Evolutionary salient pressures appear to drive nor controversial. The genders differ in genetics, crime in women. So on one hand, the need to anatomy and hormones determined by evolutionary provide for themselves in a poverty-stricken and pressures. In addition, there are differences in violent environment (Farrington 2004) may fuel psychosocially determined roles – both assigned higher levels of property- and drug-related offences and adopted – within family and sociopolitical in women (Chesney-Lind 1997; Campbell 2001; structures. Psychiatry reflects this. There is: Bartlett 2009). On the other hand, when carrying •• a higher prevalence of substance use disorders in out violent crimes, women are likely to be involved men and mood disorders in women; in ‘low risk’ strategies. There are proportionately

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Hospitals 1999; Sahota 2009). Evidence suggests Box 1 Gender differences in forensic psychiatry that they are also likely to have harmed their

• Mental disorder: women tend to have • Deviant behaviour in women is often own children or intimate others rather than higher prevalence and severity of affective conceived of by society (e.g. the criminal strangers (Jurik 1990; Weizmann-Henelius 2003; and trauma-related disorders and receive justice system, the mental health system) Liem 2008). Many women in secure services have more diagnoses of personality disorders to be based on trauma and inadequacy either no index offence or, if they do, are less likely

• Women commit fewer crimes of all types rather than on antisocial personality to have committed violent and sexual offences and tend to target those with whom they disorder (Coid 2000; Maden 2004). Women are also

are in an attachment relationship (e.g. • Women are more likely to receive the comparatively less likely to have prior convictions partners, children, psychiatric staff) in acts Mental Health Act classification of (Steels 1998) and are less likely to reoffend after of interpersonal violence ‘psychopathic disorder’ (which is not discharge (Maden 2006). However, a 2009 study by • Women tend to receive more mental an ICD-10 category) and to be detained Sahota et al reveals that women committed more health rather than prison disposals when in higher than commensurate levels of violence than men 2 years (38% v . 26%) and 5 years they commit a crime secure care after discharge (49% v . 40%). Within this the rate of arson was much higher in women and increased with the passage of time. The reconviction rate more women represented in simple and aggravated was lower in women (42% v . 50%), although this assaults than in intentional grievous bodily harm is suggested to be an artefact (Sahota 2009). and murder (Kruttschnitt 1993) and weapons Reasons for admission offences (Miller 1986; Steffensmeier 1993). Some of the so-called low-risk strategies appear Many women are admitted to both levels of security to involve targeting intimate others, particularly because of unmanageable self-harm, suicidal acts, their own children or intimate sexual partners aggression towards staff and damage (Weizmann‑Henelius 2003; Liem 2008), or dis­ to property (Bartlett 2001). This stems from the placement of aggression onto inanimate objects difficulties in managing high rates of suicidal through arson, property damage, etc. Women in behaviour and the use of increasingly restrictive prison have higher rates than men of substance and punitive practices to manage self-harm. use, PTSD, personality disorders and childhood Such patients experience the double jeopardy of sexual abuse. They often have basic literacy skills, being retraumatised by their care-givers through are likely to have been unemployed for the 5 years ‘anti‑therapeutic, demeaning and infantilising before imprisonment and to have children at staff attitudes’ (Department of Health 1992), as home (Bartlett 2009). Box 1 summarises gender well as being considered ‘untreatable’ owing to differences found in forensic psychiatry. personality disorders. Men are more likely than women to be detained Features of secure services for women under Part III of the 1983 Act, be subject to restriction orders with a classification of mental Access to services illness, have committed serious violent acts such as A greater proportion of women in high and medium homicide, have a previous forensic history and be security are likely to be detained under Part II admitted because of mental illness or sexually risky of the Mental Health Act 1983 as civil patients behaviours (Women in Secure 1999). because most are likely to have been admitted from National Health Service (NHS) facilities Reasons for admission of non-forensic patients rather than prison (Smith 1991; Milne 1995; into secure forensic services Women in Secure Hospitals 1999). Women are Another set of reasons for admission into higher proportion­ately more likely to receive a hospital than commensurate levels of security may lie in disposal at court (Sahota 2009). The majority of the hidden risks that some of these women pose women detained in high and medium security with to others (and themselves). One explanation for a personality disorder have primary diagnoses of the discordant findings in the study by Sahota borderline or emotionally unstable personality et al (2009) may be because most women in that disorder (Milne 1995; Coid 2000). There are no medium secure hospital were discharged to a significant differences between the genders in high-security hospital. This would suggest that time spent in the community or in institutions risk was increasing when data were collected. The (Steels 1998). trend may have been different if the women had been moving down the security ladder. Also, it Offending history is suggested that as only one in four violent acts The majority of women in secure services results in conviction, there is a ‘hidden’ criminality were convicted of arson (Women in Secure in this group (Sahota 2009). However, this should

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affect both genders, not just women. This may be deplored by independent inquiries (Department of an artefact related to a broader societal bias of Health 1992). viewing deviant behaviour in women as a mental In 1998, results of a major national audit disorder (Prins 1982) rooted in trauma and revealed that 94% of wards were mixed gender, inadequacy, as opposed to antisociality. This may with two‑thirds of women having to sleep in the explain the reluctance of criminal justice agencies same area as men, women having to use the same to prosecute those detained in secure hospitals, bathrooms as men and 3% of women sleeping in especially if aggression is against hospital property areas where the only separation from men was a or staff and the unwillingness of mental health curtain (Warner 1998). The latter would not be professionals to view women’s violence as rooted applicable to women in medium secure services. in deviance rather than trauma. Mixed-gender wards exposed extremely vulnerable women with extensive histories of sexual abuse and Evolution of secure services for women victimisation to some men who had been physically The evolution of secure services for women can be and sexually violent towards women (Bland 1999), considered in three broad phases: are interpersonally exploitative and who may use women for personal gratifications (financial and/or 1 services based on a gender-blind model of care; sexual) (Bartlett 2001). 2 gender-specific services; and These results led the NHS Executive to establish 3 future needs for service development. a national Women’s Project Group in 1999, which culminated in the publication of Secure Futures Services based on a gender-blind model of care for Women: Making a Difference (Department of Historically, men and women had been segregated Health 2000a). The report endorsed the view that within psychiatry. However, from the 1970s, women-centred services should be available both within a context of greater liberalism in Western in hospital and the community. These strands of Europe and North America (Sarkar 2011), there the government’s intentions were woven into a was a trend towards normalisation and mixed national strategy for the provision of mental health wards in all psychiatric hospitals (Warner 1998). services that eventually resulted in the publication This included medium secure units, but not of Women’s Mental Health: Into the Mainstream necessarily high-security hospitals (Bartlett 2001). and Mainstreaming Gender and Women’s Mental Traditional psychiatric frameworks aimed at those Health: Implementation Guidance (Department of with major mental illnesses such as schizophrenia Health 2002, 2003). Safety, privacy and dignity and bipolar disorder are inadequate to capture for women were acknowledged and the government the psychopathology of women with personality established specific targets. These included the disorders. This limits the ability of staff to make removal of 95% of mixed-gender accommodation sense of themes of disempowerment and rejection from NHS trusts by 2002 and the provision of that are often present in women. women-only lounges and living spaces (Department Staff often tend to understand problems of Health 2000b). through the prism of psychotic and affective In 2000, there were 39 medium secure symptoms, labelling those behaviours that do not units, of which almost all were mixed gender, fall within these frameworks of understanding as with only 14 NHS and 79 independent‑sector ‘attention‑seeking’, ‘manipulative’ and ‘problem­ medium secure beds in dedicated women‑only atic’. These behaviours then tend to elicit more services (Bartlett 2001). By 2009, there were 27 restrictive regimes of management (Lart 1999). dedicated women-only medium secure services The resultant behavioural manifest­ations of (9 independent and 18 NHS), providing 543 beds self-harm, staff assaults, false allegations and (261 in the independent sector and 282 in NHS pathological dependency on others reflect the services) (St Andrew’s Healthcare 2009). There maladaptive coping strategies for which the women was at least one women-only service in each health were detained in the first place. A cycle develops region in the country, with six in the North West where elements of gender identity (mother, partner, and only one in the South West. Of the 27 services, daughter, victim, abuser, etc.) are re‑enacted with 19 had a gender-specific care pathway, with either staff through pathological attachment patterns a women-only rehabilitation or pre‑discharge and the women are ultimately retraumatised and ward, or a women-only low secure or step-down revictimised (Welldon 1991). service (Parry-Crooke 2009). All health and social Gender-blind approaches in high security led care partners were invited to offer discrete bespoke to boundary violations and the development of services for women, which reflected the essential inappropriate physical relationships between differences in women’s social and offending profiles, staff and patients, which were categorically mental distress and complex patterns of behaviour,

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enduring mental illness, such as schizophrenia, Box 2 Key drivers for evolution of gender- affective disorder or a combination of symptoms specific services of the two. Any additional comorbidity with

• Lack of privacy, dignity and respect within a personality problems is usually secondary. As a gender‑blind model of care result, most ‘standard’ services tend to manage

• Physical and social abuse of women by male patients their patients primarily with pharmacotherapy and with strategies that utilise intensive care manage­ • Boundary violations and sexual relationships with staff ment for those with acute psychotic disturbances. • Exclusion by services, leading to detention in higher However, the primary diagnoses of those requiring than commensurate levels of secure care with regard to ‘enhanced’ care are severe personality disorders, risk of aggression to others with Axis I disorders (American Psychiatric Association 1994) being largely comorbid as secondary disorders. Although they may receive with their care and treatment needs underpinned poly­pharmacy (Tyrer 2004), most of them require by principles of empowerment, respect and dignity therapeutically enhanced care that is related to (Women In Secure Hospitals 2000). their attachment needs, which is an adaptation of ‘relational security’ (Department of Health 2009). Gender-specific services The development of gender-specific services at lower Importance of relational safety levels of security appears to have been contingent Relational security has been defined as embodying on a drastic contraction of high secure services high patient-to-staff ratios, time spent in (for other key drivers, see Box 2). Responding face‑to‑face contact between staff and patients, to criticisms that many women were detained in achieving the right balance between openness conditions of security greater than commensurate and intrusion, and working towards developing levels of risk, a major review in the three national high levels of trust between the clinical team and high-security units recommended that additional patients (Parry‑Crooke 2009). Clinicians working resources be made available for the dispersal of with women know from experience that women patients who did not require this level of security to tend to live largely in reference to various other alternative settings (Department of Health 2000c). relationships (Box 4). This referential existence Additional funds led to the creation of ‘enhanced’ within a network of relational safety sets them medium secure services to provide ‘for the small apart from men, who tend to have indexical lives number of women, currently in high secure care, in societies that traditionally prioritise individual who have committed severe offences or […] who rights and responsibilities that are regulated by could not be catered for within existing medium laws. A female patient’s disturbed attachments and secure care, but who do not need Category “B” high interpersonal functioning need to be understood secure care’ (Department of Health 2003: p 41). The in the context of the section below and the sense number of women in high security fell from 345 of loss that will result if a care team tries to alter in 1991 to 50 in 2008, with only Rampton High interpersonal functioning without first seeking to Secure Hospital providing care and treatment for establish less dysfunctional attachments. In other this group. Alongside this, three women’s enhanced words, staff must first try to form a meaningful medium secure services (WEMSS) were established relationship with the patient before trying to in 2007, providing 61 beds: 10 at Arnold Lodge in change how she relates to others. It is important for Leicester, 45 at The Orchard in West London and 6 at The Edenfield Centre in Prestwich. Box 3 Characteristics of women requiring an Standard v. ‘enhanced’ services ’enhanced’ medium secure service So what is ‘enhanced’ in these services? The physical security is similar to that within • Significantly higher level of manifested dependency ‘standard’ medium secure services, but WEMSS • Significantly higher degree of complexity of therapeutic offer ‘enhanced’ relational and procedural security needs to women who cannot be managed in conditions • Significantly different nature and degree of risk to lower than medium security. The clinical themselves and/or others, particularly carers and presentation of women admitted to the WEMSS dependent others differs from that of women admitted to standard • Significantly disorganised patterns of attachment and medium secure care (Box 3). affect regulation that relates to the degree of chronicity It is evident that women managed in standard in all of the above areas services have primary diagnoses of severe and

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Evolutionary This provides a gender‑fair Box 4 Factors related to women’s need for theory of personality development and offers attachment relationships perhaps the best understanding of gender-specific

• The sense of self in women occurs in reference to trajectories. It suggests that those personality relationship with others attributes that confer significant benefits in terms

• Higher temperamental levels of negative affect of survival and reproduction upon their bearers are and lower regulative capacities imply a need for transmitted as human-specific, evolved modules relationships, for safety and security of problem-solving relating to these salient life

• Interaction of biological demands on the body with challenges (Cosmides 1992). socially determined meaningful roles lead to critical Women are physically less powerful than men, periods of high risk, e.g. early childhood, menarche, so evolution has conferred on them the protection pregnancy and motherhood, and menopause of higher levels of fear. This is encoded genetically through temperamental differences that prevent women engaging in life-threatening physical any service addressing issues of relational security combat with men (McLean 2009). Girls have a to appreciate that the behaviour of patients that biologically rooted temperamental vulnerability challenges the staff team is functional. It may of negative affectivity – a combination of provide a means of communication, may serve to psychological instability, proneness to anxiety, regulate relationships in the only way available anger and sadness (Rothbart 2006). Lower levels to the patient and may provide the patient’s of regulative capacities compared with boys in only meaningful method of regulating their own managing negative affectivity (Muris 2007) lead emotions. The Department of Health (2009) has to higher rates of internalising symptoms in girls highlighted the importance and utility of relational (Lonigan 2001). security in patient management. These symptoms are related to negative percep­ tions and ruminations, dysphoria and anxiety, and Why do female patients require attachment as a a tendency to internalise negative and destructive treatment approach? impulses. I believe that these may well be the reasons why much of women’s psychopathology is Feminist psychology Traditional theories of psycho­ logical development emphasise the primacy of experienced and manifested through their bodies: separation and independence from others as indi- an ‘embodiment of emotions’. It is their bodies that cators of health and maturity. Feminist psychology act as containers of negative affects and impulses states that such theories deny the positive aspects – the so-called ‘inner space’ (Erikson 1968). Thus, of mutuality and sensitivity to others and the fact women display higher rates of self-harm, eating that the ‘ability to experience, comprehend, and disorders, somatisation disorders, conversion and respond to the inner state of another person is dissociative disorders. These disorders are often a highly complex process relying on a high level chronic, with episodes of acute exacerbations of psychological development and ego strength’ during periods of heightened reactivity to (Kaplan 1984). As a feminist psychiatrist, Miller environmental stressors. (1986: p. 16) provides an eloquent description of Biosocial high-risk periods Two kinds of interaction the differing development of relationships between appear to underlie feminine psychopathology and the genders: the timing of onset. Biological predispositions ‘Male society, by depriving women of the right to its of the nature described above interact with major “bounty” – that is, development according to evolutionarily salient life stressors to produce the male model – overlooks the fact that women’s typical manifestations of psychopathology. Such development is proceeding, but on another basis. salient periods of high stress occur at four distinct One central feature is that women stay with, build life phases: on, and develop in a context of connections with others. Indeed, women’s sense of self becomes 1 during early childhood, abuse can lead to a very much organised around being able to make distortion of attachment that installs a disordered and then maintain affiliations and relationships. Eventually for many women the threat of disruption template governing future relationships; of connections is perceived not just as a loss of a 2 during adolescence, the onset of female fecundity relationship, but as something closer to a loss of self.’ with menarche signals the need for self-care One aim of a theory of personal develop­ment and attachment related to greater gender that emphasises the self-in-relation would be to socialisation and separation, and often the promote a positive view of women’s needs for experience of sexual abuse; high‑quality relationships, rather than seeing this 3 in pregnancy, the need for maternal instinctual as a weakness. tasks postpartum provides high biosocial risks;

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4 at the onset of menopause or an analogous con- acquired coping strategies and the beginning of dition that removes capacity to bear children relapse prevention work. (e.g. hysterectomy, amenorrhoea; Welldon 1991). At the end of the treatment journey, women require ongoing support to maintain the new sets Thus, the woman’s ‘biological clock’, with of skills that they have acquired, together with associated socially meaningful tasks (even if not some preparation for the next stage of their care always desired by the woman) interacts with ‘inner pathway. Staff should have the capacity to assist space’ such that there are different aetiological women in transferring these new skills to different factors leading to the onset and exacerbation of environments and to promote the formulation of psychological disorders during these periods feasible plans for the future. They should be able (McLean 2009). Most disorders with high rates of to provide relapse prevention work that includes prevalence in women in secure care such as eating exposure to potential destabilisers and plans disorders, substance misuse, self-harm, offending, for dealing with periods of increased stress. It sexual perversions and abuse of dependent children is imperative that at this stage staff can manage (Welldon 1991; Pedersen 2004; McLean 2009) the change inherent in discharge, promote the occur during these ‘biosocial high-risk’ periods. establishment of future support networks and Treatment journey for women patients in secure care create a positive transition to the next stage of care for the women. This section suggests a proposed care pathway for women patients in secure care, which incorporates Future needs for service development some of the principles of practice highlighted in this article. During the early stages of treatment the Gender-specific and relational safety needs women will require maintenance of a safe environ­ Gender-specific approaches There have been signi­ ment, containment and ‘therapeutic holding’. They ficant changes since the gender-sensitive agenda may be able, when sufficiently contained and held, was established and promoted at the end of the to engage in limited therapeutic interventions, 20th century. However, much still needs to be such as social problem-solving. During this phase done before women in secure services nationally the staff group should have received training in receive the same service as men in terms of the the management of self-harm and the associated range, quality and nature of services delivered risks, and be aware of the potential impact on within the least restrictive environments. Indeed, them of repeated exposure to trauma through the same could be said about generic mental health witness­ing self-harm. It is also important that services for women in England. These factors must they have the facility to explore issues of malignant underpin any intervention approach that services alienation, power and control in reflective staff adopt. It is evident that neither pharmacotherapy supervision and support. They will also require nor traditional CBT, DBT or psychoanalysis alone training in the specific treatment approaches is sufficient to capture the key determinants of what offered. Subsequently, it may be possible to service users and gender-sensitive providers require. engage the women in more trauma‑informed The challenge is to incorporate innovative, cognitive–behavioural therapy (CBT) work and/or creative ways to make the lives of these women dialectical behaviour therapy (DBT) work (focused meaningful, perhaps by adopting the principles on cognitive skills) and individual body-centred of (Seligman 1990) that approaches (focused on somatosensory experiential drive offender intervention strategies such aspects), with support from the clinical team. In as the ‘good lives’ model and ‘self-regulation’ addition to specific training, staff will require models (Ward 2006). There is a key role that individual and group supervision and reflective occupational therapy services can play, but only practice to ensure that a consistent approach with if these interventions are incorporated within sustainable boundaries is provided. an integrated plan of holistic care that caters to As the women enter a phase of exploration and the woman, as opposed to her diagnostic labels. change, they can complete specific work, such The traditional cognitive therapies offered by as arson treatment programmes and substance many women’s services are provided within misuse and mental health awareness schemes. predominantly behavioural programmes regulated Staff will require training in such approaches and by reinforcement and containment with medication should be able to manage possible relapses while and/or structural security approaches such as such exploratory work is taking place. It may also intensive care and seclusion. be possible to facilitate interpersonal exploration The government’s new vision for mental health and staff should have the requisite skills to provide services – early detection and preventative work, this, together with the maintenance of previously public health psychiatry and mental health

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services, developing resilience and recovery, and capacity for cruelty towards themselves and providing holistic care to service users – is based on dependent others, need for a sense of belonging and principles that are embedded in everyday practice safety in emotionally ‘containing’ relationships. It in gender-sensitive and relationally enhanced is imperative that trainees who intend to work secure service pilots. in a secure setting acquire an understanding of Relational safety The now-defunct National Ser­ relational security, whichever gender they intend vice Frame­works taught us some key lessons. to provide care for in the longer term. Although The strategy was developed to improve services this is a particular focus in services for women, it is generally for adults with mental health problems. likely that in the longer term these principles will It identified key areas and developed specialist be extended across all secure services. services (early intervention in psychosis, assertive However, the establishment of a service focused outreach, home treatment, crisis management, on relational containment and security has etc.), which provided many good practice stand­ significant implications and challenges for staff ards that are now embedded in generic mental at all levels. At the level of recruitment, staff not health services. Gender-specific and relationally only should have the requisite clinical skills, but enhanced services could make a similar contri­ also should have made an active choice to work bu­tion in the development of specialist secure with women. In addition, they should have a good services that can inform practice across all understanding of gender issues and the nature of layers of mental health services in the UK – in the disempowerment that many women will have hospitals and in prisons. Service provision must experienced. Staff should undergo an appraisal be centred on re­lational aspects of care and process that understands their needs, both in terms thus attachment‑based or attachment-informed of individual training and the benefit to the service. approaches are imperative. The critical features As part of this process staff must develop a high that set women’s secure services apart were degree of self-awareness. They have to consider in jointly endorsed by those enabling care for women detail the implications of their own interpersonal and service users themselves in a national audit styles, life experiences and core beliefs in the (Parry‑Crooke 2009; Box 5). context of providing relational security. There must be ample opportunities for reflective practice, Workforce training and development which facilitates frank discussions of interpersonal difficulties in a non‑judgemental way. Such The therapeutic aim of gender-specific and a focus must encompass regular, systematic, relationally ‘enhanced’ services is to develop an individual supervision for all staff, together with understanding of the woman patient’s complex the opportunity for team‑based supervision and psychopathology that is shared with the patients support. There will be high levels of anxiety and is meaningful to them. Ideally, all psychiatric expressed in both the patient and staff group. If trainees should receive training in basic gender staff find it difficult to contain their anxieties, awareness and sensitivity, highlighting the confidential stress counselling should be available differences between the genders that have been and be sensitive to the particular issues raised. identified. This could be incorporated as part It is to be hoped that with greater training and of a general induction process or during specific awareness (Box 6) the anxieties of individuals new rotations. In addition, they need to be well versed to secure services for women will be reduced in line in the particular presenting features of women with with those of staff who are empowered to work in complex needs, e.g. factors underlying self‑harm, such services through the training and supervision described above. If secure services for women are Box 5 Key characteristics of an ideal viewed more positively in the future, trainees will women’s services be more likely to make an active choice to commit to working with women patients as a career. • Relational security: therapeutic relationship with staff

• Trust and positive expectations of self and others Standardised approaches and evaluative research • Empowerment and reduction of social isolation A successful evolution of secure women’s services • Meaningful days and daily staff support will involve the identification and management of • Holistic approach: person-centred core women-centred factors and seek to standardise

• Offering a range of interventions to meet emotional relational security as the predominant mode of needs managing such services. Efforts should be made (Parry-Crooke 2009) to eliminate variation in the quality and nature of treatment provided in the NHS and independent

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MCQs e women prisoners are less likely to have children d the greater focus on relational security does Select the single best option for each question stem in their care. not reflect the differing biopsychosocial development of the genders 1 With regard to gender differences in e women’s enhanced medium secure services mental health: 3 In secure services: developed because of contraction in the high a women are more likely to misuse illicit a women are more likely to be transferred from secure estate. substances prison b schizophrenia has a better prognosis in women b women are more likely to be admitted because c women have a higher incidence of borderline of self-harm or violence towards care-givers 5 With regard to future developments: personality disorder c women are less likely to be detained on civil a meaningful therapeutic relationships are d men have lower rates of antisocial and sections essential in developing relational security paranoid personality disorder d men more commonly have index offences of b treatment approaches should be based on e women have a lower prevalence of mood arson behavioural modification and attachment disorders. e women are more commonly prosecuted for theory institutional violence. c patients’ egregious behaviours are 2 Gender differences in crime: manipulative and do not convey meaning a men are more likely than women to be 4 In secure services: d staff training, supervision and support is convicted of violent offences a gender-sensitive services have been the norm irrelevant in providing higher quality services b women are more likely to commit offences of for many years e transition and change is a low risk period for serious violence b women in enhanced medium secure services women patients. c women prisoners are less likely to have a more commonly have a primary diagnosis of diagnosis of personality disorder mental illness d women are more likely to have been employed c relational security is not a focus for enhanced before imprisonment medium secure services for women

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