GENDER SENSITIVE REHABILITATION SERVICES FOR WOMEN A workshop

Transcription

1 GENDER SENSITIVE REHABILITATION SERVICES FOR WOMEN A workshop Theresa Tatton Consultant Psychiatrist Women s Medium Secure Service Fromeside Bristol Shawn Mitchell Consultant Psychiatrist Women s Service St Andrew s Healthcare Northampton

2 WHY? Gender differences

3 GENDER What are the differences? Sex biological make-up vs Gender social construct

4 MENTAL ILLNESSES & DISORDERS Gender Differences General Classification systems Women Overall rate of mental health problems equal Based on male presentations Men Schizophrenia rates and symptom Equal prevalence Increased rates of late onset (over 45) Less evidence of negative symptoms More likely to have affective symptoms More positive symptoms persecutory hallucinations Younger age of onset

5 MENTAL ILLNESSES & DISORDERS Gender Differences Schizophrenia - outcomes Schizophrenia - treatment Women Less socially impaired More likely to live independently More likely to be married of co-habiting More likely to have children Better treatment response, although if treatment resistant do worse than men More likely to develop tardive dyskinesia Need lower doses of neuroleptics Men

6 MENTAL ILLNESSES & DISORDERS Gender Differences Depression Women Unipolar depression twice as common in women May be more persistent than in men Heritability higher More psychomotor retardation More significant impairment in family and marital adjustment More likely to suffer from a variety of physical illnesses Men No gender differences in risk in societies where social roles have a protective factor for women and men are not able to mask depression with alcohol or adopting violent behaviour No differences in duration or severity of episodes

7 MENTAL ILLNESSES & DISORDERS Gender Differences Bipolar Disorder Bipolar Disorder/Depression - treatment Women Equal incidence More likely to have rapid cycling More episodes of depression Longer index episodes of major depression Lower rates of spontaneous remission More likely to respond to lower doses of SSRIs Men No difference in age of onset Similar outcomes after CBT

8 MENTAL ILLNESSES & DISORDERS Gender Differences Women Men Suicide Higher rates of attempted suicide Higher rates of completed suicide Self harm Alcohol dependence Higher rate than men Up to 49% of women who self harm have been sexually abused Higher rates in divorced and separated women. Drink heavily at a later age Develop alcohol related problems and dependency at an earlier age. Develop alcohol problems after or during depression Lifetime prevalence rate twice as high in men than women. More likely to become depressed following substance misuse

9 MENTAL ILLNESSES & DISORDERS Gender Differences Substance misuse Co-morbidity with alcohol and substance misuse Women More likely to begin using and continue using due to influences of family members or male intimates Quicker course to dependency Interpreted as a means to self medicate More likely to abuse or become dependent on prescribed medication Those with co-morbidity of schizophrenia less likely to receive treatment for substance misuse Men More related to availability More likely to abuse illicit substances More likely to have a substance related psychosis

10 MENTAL ILLNESSES & DISORDERS Gender Differences Anxiety Disorders Somatisation Antisocial Personality Disorder Emotionally unstable personality disorder Co-morbidity Women A third more likely in women Twenty times more common in women Three times more common in women More likely to have three or more comorbid disorders, associated with increased disability Two thirds more likely to have mixed anxiety and depressive disorders Men Diagnosis three times more likely

11 MENTAL ILLNESSES & DISORDERS Gender Differences Pathways into services Expression of mental distress Women Primary care Community services Maternity services More likely to present psychologically Depression Anxiety/phobias/OCD Self Harm Eating disorders Perinatal MH problems Men A&E Criminal Justice System Drug & alcohol services More likely to use inpatient services More likely to be referred to a psychiatrist Suicide Drug & alcohol problems Anti social behaviour Anger attacks Go missing/rough sleepers

12 MENTAL ILLNESSES & DISORDERS Gender Differences Women Men Medication Treatment needs and responses Prescribed psychotropic medication more frequently Physical & relational security Tackling underlying issues Expertise at responding to a history of sexual abuse Holistic approach Flexible access-carer duties Women-only facilities Role of voluntary sector Focus on wellbeing/physical health not mental health eg. Exercise, nutrition Pro-active outreach via generic community services Work friendly GP hours Early intervention/aot Men-only therapy groups

13 SOCIAL FACTORS Gender Differences Life experiences Women Sexual/physical abuse Domestic violence Caring and domestic responsibilities Single parent Live alone in old age Men Do not express emotion Fighting/bullying Expectations of strength/protective of others Parenting 63% had at least one child 33% primary caretaking responsibility for at least one child 48% of young women with severe emotional disturbance became mothers within 5 years of leaving school 26% had at least one child 5% primary caretaking responsibility for at least one child(test 1990)

14 SOCIAL FACTORS Gender Differences Socio-economic realities Women Poverty/pay Part time or unemployment Less education achievements Low value, status and power Competing, multiple, unsupported roles Men Greater risk of being distant from children Stress in workplace Burden of responsibility Unemployment Retirement

15 BIOLOGICAL FACTORS Hormones Menstrual cycle may affect drug distribution and metabolism may experience premenstrual exacerbation of schizophrenia or bipolar affective disorder Oral contraception interact with psychotropic medication Menopause following menopause physiologically more like men Pregnancy changes in drug kinetics and dynamics teratogenicity

16 ABUSE Experiences of service users 50% of women in mental health systems and prisons are survivors of violence and abuse Women in mixed sex psychiatric environments are vulnerable to threats, harassment and abuse by male patients (Barlow & Wolfson 1987, Dept of Health & Home Office 1992)

17 ABUSE Consequences Domestic violence associated with: depression PTSD anxiety insomnia alcohol and drug abuse suicide attempts exacerbation of psychotic symptoms Childhood abuse associated with: substance and alcohol abuse eating disorders cutting and other forms of self harm Women have reported inpatient settings as punitive rather than treatment focused - sense of powerlessness marked - reinforcing and perpetuating their role as victim.

18 INPATIENT FACILITIES Secure settings Women in secure settings are: more likely to be a risk to themselves need more support and less security more likely to have an index offence of arson more likely to be admitted for: damage to property suicidal or self harming behaviour aggression towards staff in psychiatric hospital of lesser security

19 NATIONAL LEGISLATION & GOOD PRACTICE GUIDELINES For all health care: Department of Health The Provision of Single Sex Accommodation: to have at least good physical separation of sleeping accommodation for men and women whilst in hospital, including safe facilities for patients who are mentally ill The Delivering Same Sex Accommodation Programme

20 NATIONAL LEGISLATION & GOOD PRACTICE GUIDELINES Mental Health Act Commission Women Detained in Hospital In hospital women should be able to: Lock doors Have the choice of a female key worker Be in contact with other women Have the opportunity to take part in woman only therapy groups and social activities Engage safely in a full range of activities, even when their number may be small Have access to a female doctor for medical care Have access to a female member of staff at all times

21 NATIONAL LEGISLATION & GOOD PRACTICE GUIDELINES Into the Mainstream (DoH 2002): to outline a direction to help achieve a mainstream approach to gender in mental health service organisation and delivery. covers services for adults of working age, in line with the Mental Health National Service Framework. Many of the principles, however, are relevant to all age groups and to men as well as women. Secure Futures for Women: Making a Difference

22 INPATIENT FACILITIES Inpatient settings For women -increased risk of intimidation and sexual assault (Russell 1997) Reduction in incidence of male violence (Huges 1992) Difficult to offer treatment interventions addressing past abuse in an environment where woman are a minority Men are vulnerable too: from allegations by women women can look to males protecting them from other male and female service users if an altercation were to occur, the chances are that the male would be seen as the likely perpetrator

23 INPATIENT FACILITIES Inpatient settings Women in secure hospitals identified: A wider range of women only activities to be made available More effective user participation systems, which are less male dominated To be able to choose single sex settings where they feel less vulnerable

24 HOW? Rehabilitation needs of women

25 REHABILITATION NEEDS: Disability Traditional models of psychiatric rehabilitation focused on chronic schizophrenia and resultant negative symptoms. Women more likely to have complex needs and multiple diagnoses Women have better living skills, due to: Socialisation Later onset of mental health problems (Schizophrenia) Women in secure settings are less likely to have schizophrenia, and those who do are less likely to have as severe negative symptoms as men Attitude - Women are more motivated to work

26 REHABILITATION NEEDS: Assessment Abuse can be emotional, physical, sexual past or present need to ask direct questions Risk assessment schedules most developed on a male population there results for women service users need to treated with caution Assess for affective disturbance Consider assessing self esteem, impulsivity

27 REHABILITATION NEEDS: Treatment Interventions less diagnosis focused and more focused on symptoms Multiple diagnoses which NICE guidelines? Medication lower doses of neuroleptics mood stabilsers Effective treatment of affective disturbance in schizophrenia Emotional unstable personality disorder consider clozapine

28 REHABILITATION NEEDS: Psychological interventions Emotional regulation skills to be able to manage mood instability to be able to have skills to tolerate levels of distress Relationships skills assertiveness training interpersonal skills Self esteem enhancing interventions Interventions to address past traumas and abuse

29 REHABILITATION NEEDS: Psychological interventions Substance use related skills need to assess as service user may be reluctant of disclose special attention to abuse of prescribed medications due to factors relating to abuse may need interventions to address trauma and relationship issues for women who are mothers, may need skills training and support for identifying and dealing with substance abuse in their children Stress management skills including sleep hygiene Interventions addressing sexuality sexual expression

30 REHABILITATION NEEDS: Psychological interventions Education Vocation

31 REHABILITATION NEEDS: Interventions Self care skills often regaining them money management Other care skills women are more likely to have to care for others, need to develop skills such as: nutrition and menu planning, meeting the hygiene needs of children and other adults ensuring the safety of the home environment Physical healthcare communicating with health professionals being able to identify and deal with common health problems accessing routine healthcare Self help groups and peer support

32 REHABILITATION NEEDS: Sexuality Medication side effects: menstrual dysfunction infertility teratogenisis Vulnerability Contraception Sexual needs particularly in abused women

33 REHABILITATION NEEDS: Parenting Increased risk of birth complications Increased risks of relapse during postnatal period Parenting skills Joint working with Childcare Services Legal support for child custody issues Residential services for mothers and children Children as carers

34 REHABILITATION NEEDS: Services In rehabilitation services - smaller numbers than men separate gender areas Separate gender services Non hospital based services women only crisis houses

35 REHABILITATION NEEDS Staff skills listening skills non judgmental unconditional - not about no rules and boundaries but respect, not being dismissive of difficult to engage [nuisance] people and providing time for the individual access to regular, systematic supervision and opportunities for reflective practice individual supervision and training of staff [particularly where services are being redesigned and there is consequent organisational change]

36 REHABILITATION NEEDS Staff skills understanding and managing people with complex problems who are difficult to engage, not seeing them as a nuisance, not using labels to exclude managing people who reject the people who are trying to help them and who constantly test the boundaries holistic approach to the whole person, their social and psychological needs avoiding assumptions and confusion about labels [for example using Borderline Personality Disorder, Personality Disorder and Severe Personality Disorder synonymously] understanding the short and long term impact of abuse on women (Secure Futures for Women: Making a Difference)

37 REFERENCES: Women and Psychiatric Treatment Editors: Henderson, Smith, Smith and Stevens Publisher: Routledge Gender Disparities in Mental Health Department of Mental Health and Substance Dependence World Health Organisation Psychosocial Rehabilitation Service Needs of Women Mowbray, Nicholson and Bellamy Psychiatric Rehabilitation Journal, Fall 2003, Volume 27, Number 2