Select Committee on Health Minutes of Evidence

Memorandum by WISH



WISH is the only national charity with a 10 year track record of—working and on behalf of women patients detailed primarily in high security hospitals, medium secure units and prison psychiatric units—working to the following key objectives:

Working in the current psychiatric system:


    —  Supporting and empowering women patients as they move through the secure system and eventually return to the community;

    —  Working constructively with staff and managers to improve the quality and appropriateness of the care and treatment delivered to women patients.

Influencing the reform of secure psychiatric provision for women patients


    —  Working formally at national level through the NHS Executive, Department of Health, Home Office, politicians, purchasers, existing & potential new providers; initiating relevant research with a practical application (see Appendix I)[3], speaking regularly at national/regional conferences.



Women require a dedicated secure mental health service that provides:

(1)  Gender sensitive care and treatment to meet women's different needs which takes full account of the gender differences in the social and offending profiles (where this applies) of women and men patients. (1)

Social Profile

  There are close links between women's early experiences of childhood trauma and familial abuse, their experiences of institutionalised care and adult mental distress; they're more likely than men to have experienced early contact with/admission to psychiatric services; to have never experienced employment; to have been solely dependent on social security benefits; experienced sole parenthood.

Offending Profile

  This reflects the different way women and men deal with chaotic histories and their different socialisation processes. Women are more likely to internalise their anger and pain eg serious self-mutilation, eating disorders. Where there is a serious violent offence, it is usually an isolated offence committed in a clear family or social context and therefore they pose no grave danger to the general public. Men are more likely to externalise their pain and anger in persistent and random violent and sexual offences against strangers, mainly women.

  Arson is the most common index offences for women and research (2) indicates that there is rarely any intention to endanger life or property and that clear antecedents include high rates of deprivation and abuse, deficits in anger management, depression, poor communication skills, low self-esteem.

  As women patients only comprise 10-15 per cent of the medium secure and 16 per cent of the high secure population, they are seriously marginalised and force-fit into a system delivering care and treatment primarily to meet the needs of an overriding male forensic mental health population.

  In the first Literature Review of Women and Secure Psychiatric Services (3), it is highlighted that women are in a minority, follow the same treatment programmes as men and services are referred to as "Type A in which appear to be an afterthought . . . and Type B which appear to gender blind".

  "We acknowledge that the high security hospitals and secure mental health services in general, currently tend, primarily due to the greater numbers of men requiring the services, to be male orientated and not well suited to the needs of women patients"

    —  Extract of letter from Mr John Hutton MP, Minister for Mental Health, to Claire Ward MP

  Women patients perceive their care and treatment in secure psychiatric settings as being overwhelmingly punitive and controlling evidenced by the first systematic patient consultation exercise undertaken in 1999 (4), commissioned by WISH, to inform strategic planning. Fifty six women undertook confidential interviews of one to one and a half hours duration.

Women require a dedicated secure mental health service that provides:

  2.  A safe environment in high secure care. Although women patients are detained in separate living accommodation, many of the off-ward activities take place with men patients. Bearing in mind that the vast majority of women are survivors of severe and systematic sexual abuse by men and a significant number of men patients have committed serious violent and sexual offences against women, this context can in no way be described as a conducive therapeutic setting for women patients.

  In medium secure care, the vast majority of medium secure units are totally mixed where there is invariably only a handful of women patients and, in a few, where women find themselves as the sole woman patient in the unit.

  We have a catalogue of instances of intimidation, bullying, sexual harrassment, assault and rape of women by men patients.

  The above provision can in no way ensure a safe environment for women patients. There are now a small number of women-only medium secure units but, regrettably, the private sector is leading in the provision of these.

Women require a dedicated secure mental health service that provides:

  3.  Secure settings at the appropriate level of physical security. As far back as 1995 when the Special Hospitals Service Authority was superseded by the High Security Psychiatric Services Commissioning Board, it was conservatively estimated that 78 per cent of women in high security only required medium physical security and 69 per cent in medium secure care only required low physical security (5).

  For the devolution of commissioning responsibility for high security to the eight regions as from 1 April 2000, Broadmoor assessed that only 14 of their 79 women patients (18 per cent) required physical high security.

  Women patients are largely spiralled up the secure system as they are deemed "too difficult to manage" in terms of damage to property and risk to other patients or staff, rather than an explicit danger to the general public.

  It is important to note that, on 1996-97 figures for high security (6), 26.2 per cent of women were detained on civil orders compared to 8.9 per cent of men and 48.6 per cent of women were detained on Restricted Orders compared to 72.7 per cent of men.

  We contend that women are labelled in this way and remain detained for inordinate lengths of time in secure settings as suitable services are not available to meet their different needs from the adolescent stage onwards—in terms of their social and offending profiles (where this applies); their mental distress and complex patterns of behaviour, their care and treatment needs.

  In addition, in high secure care, their average length of stay is longer than men patients: eg in 1996-97, 15.8 per cent of women discharged had been detained for less than two years and 35.3 per cent of men left within two years of their admission. In addition, a larger proportion of women are detained from a young eg in 1996-97, 41.1 per cent of women patients were admitted before the age of 24 years compared with 29.1 per cent of male patients and just under 10 per cent of women patients were admitted as teenagers (6).

  I will finish this section of our submission with the following quote:

    "Their security has been shattered at an early age by the intrusive acts of powerful others including physical, emotional and, most notably, sexual abuse (often in the context of generational abuse). The subsequent devastating sequelae include a very poor or non-existent sense of self, shattered trust, non-existent or poorly defined boundaries between self and others underlying a tendency, under stress, to regress to psychotic-like states, consequent very low self-esteem, and the experience, at times, of overwhelming guilt, anger, hopelessness and despair leading to all forms of self-abuse including para-suicidal behaviour. There is a common existential experience shared by women of not being heard and rarely believed, chronically frightened and overwhelmingly powerless except in outbursts of rage against property, self or others" Moira Potier, Head of Psychology, Ashworth Hospital.

    —  Extract of evidence to the Committee of Inquiry into complaints at Ashworth Hospital, August 1992.

The way forward in providing appropriate mental health services to women

  Although we work primarily on behalf of women patients in secure psychiatric settings, the principles essential to meeting their needs are applicable to women right across the mental health sector.

  For this reason, we actively welcomed the process implemented by the High Security Psychiatric Services Commissioning team, led by Dame Rennie Fritchie, in formulating a national Women's Mental Strategy that was presented to the Minister for Mental Health early February 2000, and our organisation was fully involved in this process.

  The process considered the following:

    —  preventative and early interventions that needed to be installed from the child and adolescent stage;

    —  the needs of women detained in the existing secure psychiatric system;

    —  rehabilitation pathways;

    —  community support/resources.

  The process adopted also took into account the gender and social inequalities that impact on women's mental health from poverty, lack of education, little or no employment, homelessness through to single parenthood, domestic violence and sexual abuse.

  We gave our full support, at draft stage, to the strategy submitted to the Minister for Mental Health which highlighted the following essential principals:

    —  an holistic, woman centred approach;

    —  greater emphasis on relational security than physical high security;

    —  full acknowledgement of gender differences;

    —  interagency electric model of service;

    —  empowerment, listening to women, validating their experiences;

    —  creating of a "women's community".

  WISH has published its own recommended "Philosophy of Care" for dedicated women's secure mental health services which, again, is applicable across the mental health sector.

  Our major concern at this stage is that the Women's Strategy is apparently not to be made public as all essential principals are felt to be enshrined in the National Service Framework—which is a clear reversal of intention. A National Women's strategy document is essential to ensure that its implementation is driven in a planned and co-ordinated way throughout the National Health Service by commissioners and providers working in close collaboration.

  We are also concerned regarding the impact on women patients assigned a Personality Disorder, primarily a Borderline Personality Disorder, of proposed Government legislation to address the needs of dangerous and severely personality disordered men. A much greater proportion of women in the secure psychiatric system than men are diagnosed in this way, very few are a grave danger to the public who, as a result of severe and prolonged early trauma, have undergone significant, abnormal personality changes.


1.Stafford P, Defining Gender Issues . . . Redefining Women's Services, WISH, February 1999.
2.Stewart L A, Profile of Female Firesetters, British Journal of Psychiatry, 1993.
3.Lart R, Payne W, Beaumont B, MacDonald G, Mistry T, Women and Secure Psychiatric Services: A Literature Review, School for Policy Studies, Bristol University, 1998.
4.Parry-Crooke G, Good Girls: Surviving the Secure System, University of North London, February 2000.
5.Special Hospitals Service Authority, Service Strategies for Secure Care, SHSA, December 1995.
6.WISH Annual Report, The Hidden Injustice, WISH, February 2000.

March 2000

3   Not printed. Back

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