Minds – Perceptions of
Safety in a Rehabilitation
for Serious Persistent Mental Illness
Mary V. Seeman
Centre for Addiction and Mental Health
Citation: Waddell A.E., Ross
L.E., Ladd, L., Seeman, M. (2006) Safe Minds – Perceptions of Safety in
Clinic for Serious Persistent Mental Illness. International Journal
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
This paper has been
presented at the 55th Annual Meeting of the Canadian
Association, Vancouver BC, 2005.
study was supported by a grant from the Donner Foundation of Canada. The
authors gratefully acknowledge the participation of patients and staff
Schizophrenia and Continuing Care division of the Centre for Addiction and
whether women with severe, persistent mental illness feel safe when
rehabilitation programs. Method: After discussion with stakeholders, a
questionnaire was designed and administered to women attending a large,
mixed-gender urban outpatient psychosocial rehabilitation clinic.
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
sexual advances during previous treatment (N=19) were more likely to
report feeling currently unsafe. Conclusions: Women who report having
approached by co-patients or staff in a sexual manner during prior
continue to experience psychiatric rehabilitation program sites as
places. While not wanting women-only clinics, many women ask for
Key Words: Women; Safety;
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
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.
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.
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.
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%).
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.
Descriptive statistics were calculated for each questionnaire item to
determine frequency of endorsement.
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)
Sexual Harassed %
Two-Tailed Significance (p)
The outpatient washrooms are safe
The stairs are adequately lit
The waiting room is a safe place for children
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
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.”
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.
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.
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
Tarantello C, Jones M, et al. Violence and aggression in psychiatric
units. Psychiatr Serv. 1998;49:1452-57.
TardiffK, Koenigsberg HW.
Assaultive behavior among psychiatric outpatients. Am J Psychiatry.
Naudts K, Hodgins S. Neurobiological correlates of
violent behavior among persons with schizophrenia. Schizophr Bull.
2006; 32:562 - 72.
Frueh BC, Knapp RG, Cusack KJ, Grubaugh AL, Sauvageot JA,
Cousins VC, Yim E, Robins CS, Monnier J, Hiers TG.Patients' reports of traumatic or harmful experiences within
psychiatric setting. Psychiatr Serv. 2005;56:1123-33.
5.Robins CS, Sauvageot JA, Cusack KJ.
Suffoletta-Maierle S, Frueh BC. Consumers' perceptions of negative
and "sanctuary harm" in psychiatric settings. Psychiatr Serv.
6.Gillig PM, Markert R, Barron J, Coleman F.
A comparison of staff and patient perceptions of the causes and cures
physical aggression on a psychiatric unit. Psychiatr Q. 1998;69:45-60.
7.Ilkiw-Lavalle O, Grenyer BF. Differences between
patient and staff perceptions of aggression in mental health units.
8.Duxbury J. An evaluation of staff and
patient views of and strategies employed to manage inpatient aggression
violence on one mental health unit: a pluralistic design. J Psychiatr
Health Nurs. 2002;9:325-37.
9.Duxbury J, Whittington R. Causes and
management of patient aggression and violence: staff and patient
J Adv Nurs. 2005;50:469-78.
10.Quirk A, Lelliott P, Seale C. Service
users' strategies for managing risk in the volatile environment of an
psychiatric ward. Soc Sci Med. 2004;59:2573-83.
11.Ford E, Rosenberg M, Holsten M, Boudreaux
T. Managing sexual behavior on adult acute care inpatient psychiatric
Psychiatr Serv. 2003;54:346-50.
12.Spiessl H, Frick U, von Kovatsits U, Klein
HE.[Segregated or mixed sex treatment
in the psychiatric clinic--what do patients prefer?] Psychiatr Prax.
13.Cleary M, Warren R. An exploratory
investigation into women's experiences in a mixed sex psychiatric
unit. Aust N Z J Ment Health Nurs. 1998;-40.
14.Mezey G, Hassell Y, Bartlett A. Safety of
women in mixed-sex and single-sex medium secure units: staff and
perceptions. Br J Psychiatry. 2005;187:579-82.
15.Krakowski M, Czobor P. Gender
differences in violent behaviors: relationship to clinical symptoms and
psychosocial factors. Am J Psychiatry. 2004;161:459-65.
16.Classen CC, Palesh OG,
Aggarwal R. Sexual revictimization: A review of the empirical
Trauma Violence Abuse. 2005;6:103-29.