Citation:
Waddell A.E., Ross L.E., Ladd, L., Seeman, M. (2006) Safe Minds – Perceptions of Safety in a Rehabilitation
Clinic for Serious Persistent Mental Illness.   International Journal of Psychosocial Rehabilitation. 11 (1), 4-10

Corresponding Author and Address for Reprints:
Mary V. Seeman, MD
Centre for Addiction and Mental Health
250 College St.
Toronto, Ontario
M5T 1R8  Canada

Acknowledgments:
This study was supported by a grant from the Donner Foundation of Canada.
The authors gratefully acknowledge the participation of patients and staff of
the Schizophrenia and Continuing Care division of the Centre for Addiction
and Mental Health.

Abstract
Objective: To determine whether women with severe, persistent mental illness feel safe when attending rehabilitation programs. Method: After discussion with stakeholders, a written questionnaire was designed and administered to women attending a large, mixed-gender urban outpatient psychosocial rehabilitation clinic. Responses were analyzed using descriptive statistics. Results: Sixty-eight women participated in the study.  While the majority (N=42) reported feeling safe in their current program, those reporting sexual advances during previous treatment (N=19) were more likely to also report feeling currently unsafe. Conclusions: Women who report having been approached by co-patients or staff in a sexual manner during prior treatment continue to experience psychiatric rehabilitation program sites as unsafe places. While not wanting women-only clinics, many women ask for women-only programming.

Introduction
Though much safer than they once were, psychiatric inpatient wards continue to be settings where harmful experiences occur (1). This is perhaps inevitable since the acuity level on inpatient units is high and since severe mental illness is associated with aggression (2,3). The situation is not limited to inpatient settings. Frueh et al. (4) recently reported that, among 142 adults attending a day hospital program, 31% had experienced physical assault, 8% had been sexually assaulted, and 63% had witnessed traumatic events over the course of treatment. This group found an association between patients’ exposure to sexual assault prior to the beginning of psychiatric treatment and a subsequent experience of sexual assault by a psychiatric staff member. The Frueh research group classified such experiences as ‘sanctuary harm’ and conducted qualitative interviews with 27 patients to learn more about such incidents. Of the 27, 18 had the bad experience on an inpatient ward. One prominent theme that emerged from the interviews was the danger inherent in a psychiatric hospital setting: the fear of physical violence and the perceived arbitrary nature of the rules imposed on patients. A second important theme centered around patient-staff interactions, frequently seen as unjust, disrespectful, and impersonal (5).

Patients and staff are known to view safety issues from somewhat different perspectives (6). Staff tends to attribute aggressive events to illness factors whereas patients hold interpersonal and environmental factors to be equally responsible (7,8, 9). Quirk et al. present the patient perspectives from two studies: (a) ethnographic research on three UK acute psychiatric wards, undertaken between 2000 and 2002, and (b) a content analysis of qualitative data from a 1999/2000 survey of psychiatric wards in England.  They find that patients, as staff, attribute physical assault risk to the acuity level of co-patients illness but they feel that the risk is enhanced by poor staffing levels and negligence in surveillance (10). Staff is probably better at preventing physical aggression than they are at protecting vulnerable patients from unwanted sexual approaches from other patients (11). That is because of the ambiguity that surrounds interpersonal behavior and the wish on the part of staff to not intrude and not appear seem overly authoritarian. According to Quirk et al., this leaves patients to fend for themselves, something not all are able to do well (10).

One solution is services segregated by sex where women would be protected but, despite the fact that women are usually the targets of violence in psychiatric settings, when asked, most women express a preference for mixed sex wards over single sex wards (12, 13). This may well be because single sex wards do not guarantee safety from assault and exploitation (14). While differences do exist between male and female aggression, both sexes, when acutely ill, are aggressive to similar degrees (15).

Inpatient settings are particularly dangerous because patients tend to be severely ill and not able freely to leave. They stay in such settings overnight when supervision may not be adequate and the perception of danger increases. Outpatient settings are less frightening places. Fearful patients can bring companions to outpatient appointments and can leave more easily, if frightened. Nevertheless waiting rooms, hallways, elevators, stairwells, smoking areas, bathrooms in outpatient settings can still be perceived as potentially dangerous. Patients often come to the same location for many years so that animosities and fears can grow, both among patients and between patients and staff. Although patients are relatively stable in such settings, acute relapses do occur and smoldering delusional thinking can sometimes erupt. Because several women patients expressed fears when attending their outpatient rehabilitation appointments we decided to systematically question them about their perceived safety and whether or not they would prefer to receive services segregated by sex.

Methods
Ethics Review
Informed consent was obtained in writing from each participant individually after one of us (LL) explained the purpose of the study verbally and read out loud a summary of the protocol. The study was reviewed and approved by the institutional review board of the Centre for Addiction and Mental Health, University of Toronto.

Instrument Design
Published questionnaires were not applicable to outpatient settings so, after lengthy discussion with a variety of stakeholders, we designed a survey instrument. It takes the form of a written questionnaire and includes a mix of closed-ended, open-ended and 5-point Likert scaled questions.  There are ten sections in the questionnaire: background information, facilities, services, staff, other patients and clients, access to clinic, experience in other outpatient mental health clinics and inpatient experiences, children at the clinic. A copy of the questionnaire is available upon request.

Subjects
All female clients with severe and persistent mental illness attending an outpatient psychosocial rehabilitation service (the Archway Clinic) affiliated with the schizophrenia and chronic care division of the Centre for Addiction and Mental Health (CAMH) were eligible to participate.  Recruitment was via flyers posted at the clinic site and word of mouth advertisement via case managers. Out of 76 regularly attending women at the Archway Clinic, 68 consented to participate. These women were primarily middle-aged (28% aged 35-44 and 29% aged 45-54) and were long-term clients of CAMH, with 38% reporting that they had been using the service for more than 5 years. Only 10 subjects had begun attending within the preceding year. Participants reported a range of visit frequency ranging from one per month (28%) to one per weekday (4.4%).

Survey Administration
One survey administrator (LL) was present as all subjects individually completed the survey. She provided clarification of questions and, in cases where women reported difficulty writing, she transcribed their responses verbatim.  All participants were paid a $10 (Canadian) honorarium for their participation.

Data Analysis
Descriptive statistics were calculated for each questionnaire item to determine frequency of endorsement.

Results
Perceptions of Safety
Most participants (61.8%) perceived themselves to be safe while attending the rehabilitation program. Nevertheless, 60% reported having been “hassled” to some degree during appointments (e.g. being asked for cigarettes or money by co-patients, being offered illegal drugs). Nineteen participants reported that another patient or a staff member had approached them in a sexual manner at some time in the total course of their psychiatric care. This latter group was significantly less likely than the remainder to endorse satisfaction or perception of safety with various aspects of the rehabilitation program. All the questions reflected this pattern as, for example, Table I.

Table 1. Percent Endorsement of Survey Items in Women Who Reported Previous Sexual Harassment (N=19) vs. Women Who Did Not (49) 

Spontaneously offered comments also reflected this pattern. Examples of positive comments:
“Every time I have entered Archway I have experienced a pleasant environment.” “All staff are friendly and helpful and emotionally well.” “On the whole, the attitude and service at Archway is great.” “A good place.” “There is an effort being made for the needs of the people that come here.” “The two workers I have at Archway are very caring and helpful.”

Examples of negative comments:
“I as a female do not feel comfortable in Archway. Loud, swearing patients make me nervous.”

“Interior of Archway is safe but the area surrounding feels a bit unsafe.” “Nurses should listen to patients. Psychiatrists should show compassion.” “The nurses and doctors could be nicer. Sometimes they do and say the wrong things.” “Staff could be more considerate.” “More staff should interact with clients.” “More staff should be available to sit and talk.” “I would like it to be more comfortable at Archway.”

The women as a group did not endorse the need for a women-only clinic. Twenty women (23.9%) said yes; 25 (26.9%) said no. The rest were neutral. However, the majority of respondents (47, 72.3%) agreed that they would like to have women-only groups offered within the mixed-sex program. Some examples were: cooking and nutrition classes, art groups for women, shopping group (“go shopping as a group of ladies and not only with the case worker”), guidance group on pregnancy and children, therapy for women who deal with past abuse. “I would like more services focused towards disabled women.”
 
Discussion
In agreement with previous psychiatric literature (12, 13), the majority of women surveyed felt safe in the mixed-gender rehabilitation program and rejected the idea of a woman-only service. However, women who reported sexually inappropriate advances during their treatment history were less likely to report feeling safe and were less likely to express satisfaction with the service. This parallels the results of Frueh et al. (4).

This study has implications for service provision; it suggests that there are sub-groups of women who attract unwanted sexual attention from co-patients and sometimes from staff. This is consistent with data indicating that two-thirds of women who experience sexual victimization will be revictimized at some point in their lives (16). The experience of perceived sexual harassment while accessing mental health services is associated with feelings of discomfort and threat when attending treatment programs, and may become a significant barrier to accessing care. The expression of discomfort may be considered “delusional” and be ignored by treatment providers. This is, in our view, a serious clinical error. Whatever the explanation for such perceptions, they need to be addressed to ensure that patients continue to access the service and benefit as much as possible from the treatment provided.

Limitations
There are several limitations to this study. The survey instrument was, out of necessity, developed specifically for the survey and awaits psychometric testing. Generalizability of these findings is also limited by the fact that highly dissatisfied or highly fearful patients could choose not to attend the program. In other words, the degree of general dissatisfaction with services provided is probably underestimated in this study. Finally, the study was conducted in one psychiatric setting, and replication at other sites is warranted.

Utility
These findings have already produced an immediate and lasting effect at the participating site.  The results were disseminated at local meetings for front line health care providers, as well as for patients.  These meetings led to a modification of the clinic space in order to provide a “for women only” waiting area. The findings have also generated discussion at the institutional level and led to a modification in the reporting protocol for patient charges of sexual harassment. Immediate changes such as these empower patients because they demonstrate that client fears, wishes, and needs are taken seriously and that the staff and the institution are responsive to patient preferences.

References