Women and Mental Health

Identify practical and effective strategies for achieving positive change in health for communities facing disadvantage / exclusion.

I realised that women in the mental health services are a community facing exclusion and disadvantage for many reasons. People with a history of mental illness are discriminated against in many ways, e.g. in the job market, and can face violence and exclusion within their communities. Women in this situation also have more specific issues to contend with. Throughout this project I will explain what these issues are, and seek to find ways to achieve positive change for them.

I began this project by writing a questionnaire (which you can find at the end) and distributing it on the Internet. I was pleased to receive 14 responses. I will summarise here the results of the questionnaire.

All of the women who filled in the questionnaire had been diagnosed as having mental health difficulties, and had received some kind of treatment from mental health services. The diagnoses ranged from depression (the most common) to manic depression or bipolar disorder, schizophrenia, schizoaffective disorder, borderline personality disorder, anxiety and obsessive compulsive disorder. Many of the respondents had several of these diagnoses, and the length of time they had suffered from these ranged from 8 to 32 years.

The types of support the women received were varied: counsellors, community mental health services, user-controlled organisations, psychiatrists, drop-in centres and support from friends. Unfortunately the majority of the women questioned said that there was no specific resources for women, with the exception of the provision of women counsellors and one person spoke of a women-only group, but this was a "closed" group so was not easily accessible. Two of the respondents said they had requested female counsellors or doctors but had been refused. All of the women questioned said they, or people they knew, would want women-only provision within their mental health treatment.

The reasons given for this were: "safety, and the service would ideally be run by other users of mental health services"; "sexual abuse"; "feel vulnerable in mixed groups"; "I'm a lesbian and feel more comfortable with women"; "I've been abused by men and am uncomfortable with men in power over me" and even "our brains are more complex"!!

I asked the respondents whether they felt that women had different needs in mental health services than men, i.e. if the issues were different for women. Everyone thought that yes, women's needs are different and here are some of the reasons stated:

• Health issues (one respondent was a survivor of breast cancer)
• Childhood physical or sexual abuse
• Lesbian - finds it alarming to have to mix with men when most vulnerable and is frustrated and oppressed by heterosexist assumptions by patients and staff
• Powerlessness
• Domestic violence
• Safety from violence
• Childcare issues
• Eating disorders affect more women than men
• PMS
• Sexual harassment and abuse while accessing mental health services
• Depression affects more women than men (NB 1 in 4 women and 1 in 10 men develop depression during their lifetime)
• Women completely lose out in our patriarchal society and are survivors of trauma by men

All but one of the respondents had been admitted to a psychiatric hospital for inpatient treatment and these admissions were described as: "the worst experience of my life"; "on the good side: single rooms, facilities good, got away from it all. On the bad side: I never met my keyworker, never had a care plan, was ignored in hospital and the quality of the groups were poor - they were unsafe and male dominated and the activities were demeaning and oppressive"; "it worked for a short period"; "disempowering and frightening"; "intimidating, loud and aggressive men"; "I was lucky because the therapy focussed on cognitive behavioural therapy rather than drugs"; "horrible, felt imprisoned. It was a respite from home life but was oppressive, isolating, intimidating and scary"; "non-helpful, traumatising, disempowering".

So despite the mixed responses here, there is an overwhelming feeling of how disempowering and oppressive hospitalisation was for many women. Later in the project I will discuss how it could be possible to empower women in mental health services.

All but one of the women questioned were in mixed-sex wards when they were admitted, and there was a mixed response to whether they would prefer mixed to single-sex wards. The women who could see the benefits of a mixed ward felt that this was because this was "the world we must re-enter", and that they enjoyed the company of men. However, those who wanted single-sex wards and facilities stated that this was for safety reasons. One woman spoke of how she was in a single room but was not allowed to lock the door and woke up on a number of occasions to find a man in her room. Others stated that they found disturbed men sometimes aggressive or sexually inappropriate, that they don't want to share toilets with members of the opposite sex, that their recovery was quicker in a single sex ward with all women and women staff, and another woman spoke of men using pornography in the smoking room on the ward, and men in the women's corridor. Another woman spoke of having been sexually harassed while on a ward by patients AND staff, and another woman stated that on a single-sex ward there were not the same worries about sexual harassment or assault or people who were angry and aggressive.

I asked the women how they would feel more empowered in mental health services, and how they feel it would be best to empower other women using services. All of the women were keen to suggest things. There are common themes within their responses, and all the points raised are really valid.

Examples of comments are:


• "No more forced treatment. Things like massage, meditation and yoga offered"
• "Choice, respect, dignity, privacy, a positive vision of possibilities. Seeing the positive parts of me not just the dysfunctional ones"
• "More education about illnesses, more well-trained psychologists"
• "Give choices and options. Talk these through when well"
• "Knowledge and options and choice are the most important empowering issues in mental health for women"
• "Single-sex wards, female key worker, women's meetings on the ward and at other mental health settings. Access to a female advocate"
• "The right to see a female doctor or counsellor. Respect of personal space. Respect for circumstances. Single-sex wards so vulnerable women can feel safe"
• "Explain the way the medications work"
• "Address the REAL needs of women and provide most sensitive support while giving choice of mixed or single-sex services"
• "By creating a world of peace and justice and provide women-centred, non-pathologising assistance to those in severe emotional crisis, and educate them that what is classed as 'symptoms' was actually a useful way of coping at one point, e.g. dissociating, self-injury".

Obviously, then, many women have a clear idea of how we can be empowered and treated better within the Mental Health Services. In the rest of my project I will look in more detail at certain issues which arose from the questionnaires, and try to come to some more conclusions about empowering women.

Sexual abuse is an issue for everyone in a society where by the age of 16, one in three girls will have been sexually abused, and by the age of 18, one in seven boys will have been sexually abused. Although childhood sexual abuse affects both females and males, the proportions show that it affects many more girls than boys.

This has a clear link in with women in the mental health services because studies show that women with histories of abuse in childhood have higher levels of psychotic and depressive symptoms than women without, and between 50 - 75% of women with severe mental health problems have a history of childhood sexual abuse, and between 49 - 51% of female users of mental health services were sexually abused as children.

Many women who have suffered childhood sexual abuse will display symptoms such as self-harm, eating disorders, depression, dissociation, compulsive behaviour, phobias, suicide attempts, anxiety and sexual difficulties. Often mental health professionals treat these at face value, and only the SYMPTOMS are treated, rather than looking deeper and seeing what the cause of the problems are. This then reinforces the culture of silence and shame experienced by many survivors, and will not help them in the long-term.

However, despite clear evidence of the damaging nature of sexual abuse, many women report that their abuse has been seen by mental health professionals as incidental to their mental illness, rather than admitting that it was clearly contributory. Women's attempts to discuss their past experiences are often silenced and this silence needs to be broken.

When women attempt to talk about the abuse they suffered, many find that their memories are ignored or are put down to psychosis or hallucinations. This contributes to the disempowering of so many women (up to 75%) within psychiatric services, when if only the staff would listen the women would feel heard, empowered and strengthened.

Many of the experiences of childhood sexual abuse are paralleled by the feelings of women in the psychiatric system, as can be seen by the responses to my questionnaire - feelings of powerlessness, intimidation, fear, and the reality of having boundaries violated and things spiral out of our control (e.g. forced admission to hospital, forced psychiatric drugs).

Many people with mental health problems spend at least some time as an inpatient on a psychiatric ward. A recent study by Mind, the mental health charity, entitled Environmentally Friendly, produced some disturbing results about the conditions on these wards, finding them "un-therapeutic" and "depressing".

In their press release, statements such as "people would recover quicker and go home sooner if conditions were improved and dignity restrained" and "If you weren't suicidal on arrival - the unit could make you so" lead to some distressing conclusions about the state of the psychiatric ward system.

More than half of the people surveyed (56%) said that the ward was an un-therapeutic environment, which was more than double those who said it was therapeutic (25%). Just under half (45%) said the ward conditions had a negative effect on their mental health, 57% of patients said they didn't have enough contact with staff with the majority (82%) saying they had 15 minutes or less with staff each day. This is clearly not conducive to a helpful, therapeutic environment. People who have been admitted to a psychiatric ward are often there in severe emotional crisis or distress, and support from staff is essential to help them begin to recover.

30% of patients said illegal drugs were being used on the wards and 66% of these said that drugs were easily available to patients.

Within the responses to my questionnaire it was acknowledged that often when a respondent apparently went into hospital by choice, this was not a clear, free choice as they were being threatened with a Section which would have been applied had they not agreed to go in voluntarily.

Throughout the UK there are campaigns for single-sex wards to be available to all patients admitted to a psychiatric ward. The majority of people admitted to an acute ward are admitted to a mixed-sex ward. On admission during a mental health crisis, "it is unlikely that at any point in their life anyone could feel more vulnerable and would be more in need of high quality and sensitive care" (The Sainsbury Centre, 1998).

In 1998 a BBC Newsnight report found that 49% of women had suffered some form of sexual abuse while in psychiatric care, 16% of women said they had been touched inappropriately, 6% said they had been coerced into sexual activities and one woman said that she had been raped on a psychiatric ward. A study in the US in the late 1980s revealed that 71% of women who used psychiatric services had been threatened with physical violence, 53% had been physically assaulted, 38% had been sexually assaulted and of these, 27% had been sexually assaulted by STAFF. Incidentally, a study in the US showed that 15% of male therapists admitted to sexual contact with clients, and given the inherent power relationships between service user and service provider, this is necessarily an abusive relationship.

Another study showed that of 53 women patients, 56% had been pestered, including being touched on the legs, breasts and bottom, and being constantly asked to have sex, while 12% of the women had been asked to have sex for favours, including cigarettes, money or alcohol. This prostitution of women who are at their most vulnerable is completely unacceptable and is not at all conducive to the necessary therapeutic environment.

A study by the Sainsbury Centre for Mental Health found that only 73% of mixed-sex wards had some procedures and practices in place that addressed the safety needs of women, which is clearly not enough to solve the problem as 57% of staff reported that women patients were sexually harassed.

These figures all go to show that mixed-sex ward environments are not safe places for women, and considering that the women on these wards are at their most vulnerable and probably in a mental health crisis, the situation clearly does need to change.

It is argued that mixed-sex wards are beneficial because they represent real life, however there is no clinical evidence that this has any therapeutic gain. And psychiatric services should ideally represent a "safe" space, rather than necessarily mirroring "outside" life.

The Campaign for Women Only Psychiatric Wards (CWOPW) defines a single-sex ward as "No male patients anywhere on the ward, with no mixed areas at all, 24 hours a day, 7 days a week" however this is not the same as the governmental definition - in fact the government still does not even have a definition of a single-sex ward, so that a mixed ward with separate washing facilities and female bedrooms at one end of the corridor can be described as a single-sex ward.

There is a clear inequality between those who use and those who provide mental health services. This means that when users of mental health services report abuse, very often these complaints are disregarded or handled ineffectively. Provision of advocates and safe opportunities for service users to report abuse would improve this situation, as would a fair system for reporting abuse - as long as the service users know that this system exists and how to use it, otherwise it is worthless.

Lesbians, like any other group of people, can and do suffer from mental health difficulties. These are compounded, or even caused, by living in a society which is hostile to lesbians. The Mental health system can be incredibly homophobic - presumptions of heterosexuality are rife, and although in 1991 the World Health Organisation stopped homosexuality being classified as a mental illness, many mental health professionals still treat it as such.

Homophobic abuse often starts at school, and a recent survey found that 61% of gays and lesbians under 18 had been harassed and 48% violently attached, because of their sexuality.

A disproportionate number of young lesbian women have self-harmed, compared to heterosexual young women, and 41% of young lesbians had attempted suicide.

Clearly, living in a homophobic society is detrimental to the health of lesbians and gay men. It is important to acknowledge that it is not BEING a lesbian which is bad for your mental health, but rather it is society's negative attitude to it. Lesbian and gay young people are more vulnerable to substance abuse, depression, failure at school, and homelessness - for instance 1 in 4 of the young adults living on the streets in the US identify themselves as lesbian, gay or bisexual.

Being a woman in a society where women are raped, violently attacked and sexually assaulted and abused is equally going to be damaging to women's mental health - which could go some way to explain the disproportionate number of women suffering from depression.

Many women have difficulty accessing mental health services and support because of childcare needs. A study showed that 40% of women who use mental health services have or have had children. A study in West Lambeth found that 58% of women using outpatient services were mothers, and many of those mothers have had their children forcibly removed.

Mothers are as susceptible to mental health problems as anyone else, and are at risk of post-natal depression. It is vital that support and help is available to them without them fearing that they will lose their children by asking for help.

People on low incomes are under extra stress than those with more money, and can experience isolation, uncertainty, stigma, and poor access to good resources. It is known that depression is common among those on low incomes and those who are unemployed. Women in this country earn 70p for every £1 earned by a man, and many women live on the poverty line.

Through my research for this project, and the responses to my questionnaire, I have identified several strategies for achieving positive change for women in the mental health system. Here I will explain some of these strategies and how and why they could be successful.

Equal Opportunities Policy:

If mental health service providers had a clear equal opportunities policy which was made clear to all service users, this would send out a clear signal on issues such as sexual harassment of female service users. It would also mean that anyone who did sexually harass a female service user would have no excuses, and so the case could be dealt with properly.

People with a history of mental illness are discriminated against in the job market because of the stigma attached to mental illness. Projects where people are helped to access employment or training can also provide information for potential employers to educate them about mental health histories, and could go some way to combatting the discrimination.

Many women who answered my questionnaire expressed a wish for more programmes specific to women - as well as single-sex wards, they wished for women's groups, women-only spaces in community mental health care settings, automatic availability of female doctors, key workers and counsellors on request. Many women in the mental health services have difficulty trusting men, and this should be sensitively respected by providing them with the best possible appropriate care, in this case with female workers.

It is important that childcare facilities are provided in mental health settings so that women can fully access the care they need. Also changing the hours that services were available could make it much easier for women to access appropriate care.

The services which women access are currently very separate - e.g. women's refuges, independent counselling services, mental health services and advice centres. If these could be more closely linked and integrated this would be better for all the women involved, as liaison could take place, and women with severe mental health difficulties could find it easier to access other services they need.

This would make services more sensitive and appropriate to all women, but particularly those from minority ethnic communities, and lesbians.

This is the reality which many, many women live with and it is important that mental health services acknowledge this and provide sensitive and appropriate care. The trauma and abuse suffered must be seen as an important causal factor in many women's mental illness, rather than as incidental to it.

It is important that women are able to participate in our own care plans, to have input into what treatment we receive (e.g. to choose to take prescribed drugs rather than to be told there are no alternatives, to choose to be admitted into hospital rather than forced).

by Philippa Willitts

Picture of my lego clone!

Name :
Philippa Willitts (Pippa)

Email :
purple_pippa@yahoo.com