Submission to:
Adult Acute Mental Health Inpatient Unit
ACT Health Directorate
Email: DCECorporate@act.gov.au

Submission on Adult Acute Mental Health Inpatient Unit: Model of Care
(Consultation draft stage 3)

from
the Women’s Centre for Health Matters Inc.
and
the ACT Women and Mental Health Working Group

November 2011

The Women’s Centre for Health Matters acknowledges the Ngunnawal people as the traditional owners and continuing custodians of the lands of the ACT and we pay our respects to the Elders, families and ancestors.

We acknowledge that the effects of forced removal of Indigenous Australian children from their families as well as past racist policies and actions continue today.

Submission on Adult Acute Mental Health Inpatient Unit: Model of Care (Consultation draft stage 3)
Women’s Centre for Health Matters Inc.
November 2011

This document was prepared by WCHM staff member:
Laura Pound: Mental Health Project Officer

Enquiries on this submission may be directed to:
Marcia Williams: Executive Director
ed@wchm.org.au 

PO Box 385, Mawson, ACT, 2607
Phone (02) 6290 2166
Facsimile (02) 6286 4742
admin@whcm.org.au 
www.wchm.org.au 

Introduction
About the Women’s Centre for Health Matters
The Women's Centre for Health Matters Inc. (WCHM) is a community-based organisation that works in the ACT and surrounding region to improve women's health and wellbeing. WCHM focuses on groups of women who experience disadvantage and uses social research, community development, advocacy and health promotion to empower these women to achieve the highest possible standard of health and wellbeing.

WCHM believes that health is determined not only by biological factors, but by a broad range of social, environmental and economic factors known as the ‘social determinants of health’. We acknowledge that the environment and life circumstances that each woman experiences have a direct impact on her health, and in many cases, women’s poor health is rooted in social disadvantage. For these reasons, WCHM is committed to taking a ‘whole of life’ and social approach to women's health, that is also firmly situated within a human rights framework.

About the Women and Mental Health Working Group
WCHM provides project and secretariat support to the ACT Women and Mental Health Working Group (WMHWG), whose membership comprises of local service providers, Government representatives, other community organisations and peak bodies, and women living with mental health issues. The ACT WMHWG was established in 2007 to provide a regular forum in which members could work together on matters impacting on women in order to provide improved outcomes for them, and to develop and maintain a full range of women friendly services.

Response to the Consultation draft stage 3 Adult Acute Mental Health Inpatient Unit: Model of Care
WCHM and WMHWG welcome the opportunity to participate in the Adult Acute Mental Health Inpatient Unit Model of Care (AAMHIU MOC) consultation process.  WCHM is an organisation that works with women who may experience, or are experiencing disadvantage, and works to ensure that these women’s views and experiences are heard. We are therefore keen to ensure that the model of care is inclusive of the needs of our community’s women, particularly those women who are most vulnerable. For that reason we have limited our comments in this submission to those aspects of the draft AAMHIU MOC in which we have the most knowledge and expertise, based on our research and consultations about the specific needs of ACT women living with mental health issues.

Gender sensitive service delivery
About gender sensitive practice
Women’s mental health is best understood by considering not only the biological and physiological contexts of a woman’s life, but also the social, cultural, economic and personal contexts. Evidence suggests that practitioners who implement this approach, those who are ‘gender-sensitive’, achieve better health outcomes for women. In contrast, ‘gender neutral’ or ‘gender blind’ approaches neglect the unique needs of women with mental health problems, perpetuating mental health inequalities between men and women.

Research has found that the prevalence of psychiatric disorders is greater in women than in men . Further, there are differences in the biological, psychological and social factors which cause the illness; impact on the course and expression of the illness; and impact on age of onset, symptoms and comorbidity with other illnesses. There is also a strong inverse relationship between social status, and physical and mental health outcomes. This greatly affects women, as women’s status remains lower than men’s in almost every society.

Gender sensitive health services are more than just ‘women only’ services: they are characterised by availability, accessibility, affordability and appropriateness (see Appendix A for specific principles of gender sensitive mental health service delivery). 

Gender sensitive practice in the AAMHIU
WCHM and WMHWG welcomes the gender sensitive provisions reflected in the draft AAMHIU MOC that will enable the unit and its staff greater ability to provide a gender sensitive mental health service. These provisions include:
•	The gender needs of consumers respected as a ‘principal of care’
•	An acknowledgement that women are vulnerable consumers and at risk of violence in the mental health inpatient environment
•	The provision of women only wings, rooms with ensuite bathrooms and lounge area
•	Locked rooms with swipe card access for consumers, and systems to ensure the safety of consumers in regards to staff overriding room locks
•	The mother and baby unit for women with severe post natal depression, including collaboration with midwives
•	A family friendly and child play area
However, WCHM and WMHWG wish to recommend some changes to the draft AAMHIU MOC. Firstly, the document states that “The issues in relation to a number of women’s perceptions of not feeling safe or secure in inpatient units have been addressed through...”  (own italics). The language should be changed here, to reflect the reality that women are at risk of sexual assault and violence in mental health inpatient units. While it is positive to recognise that a perception of being unsafe is equally important to actually being unsafe, stating that women only ‘perceive’ that they are unsafe ignores evidence that women experience more sexual or other violence in comparison to men. Therefore, the sentence should read, “The issues in relation to the fear and reality of women not being safe or secure in inpatient units have been addressed through...”

Secondly, a way of monitoring people’s behaviour in the mental health unit (including patients, staff and visitors) is to provide them with a Code of Conduct that details what is appropriate and inappropriate behaviour, language and relations while in the unit. The Code of Conduct should also detail the possible consequences of non-compliance. Distributing a Code of Conduct ensures that people inside the AAMHIU abide by gender sensitive practice guidelines.

Finally, all AAMHIU staff should complete training that aims to increase their understanding and awareness of issues and sensitivities relating to gender. The draft AAMHIU MOC outlines a number of training opportunities that will be available to staff, including consumer centred ethos training and a number of modules to ‘mitigate operational risks’. These courses should include some orientation to gender sensitive practice, both for new and existing staff members, especially so that staff understand the different contexts and life experiences that may exist for the different genders.

Recommendations
1. Change the language used in the draft AAMHIU MOC to reflect the fear and reality of violence and insecurity for women in mental health units.
2. Provide a Code of Conduct to all patients, staff and visitors of the AAMHIU to reinforce appropriate behavior and gender sensitive practice guidelines.
3. AAMHIU staff should complete gender sensitive training.

Service delivery: Recovery and discharge processes
WCHM welcomes initiatives in the draft AAMHIU MOC that have a focus on the mental health recovery perspective. These initiatives include:
•	Training that embraces a recovery orientation
•	Language and principles based on consumer centeredness and a recovery orientation
•	Discharge practices that include working with community services and resources
•	Respect for consumer’s rights to socialise and undertake therapeutic programs including educational and leisure activities

However, despite these initiatives, the MOC does not reflect the level of integration between AAMHIU and the community that is necessary to facilitate discharge and recovery processes. As inpatients, women’s community, recovery and psycho-social supports must remain engaged throughout the treatment and discharge processes in order to insure the best long term outcomes.

Discharge planning should also take into account women’s lower status. In almost every society women’s status remains lower than men’s. This is reflected in the high incidence of violence against women; women’s lower socio-economic status; an under-representation of women in positions of power; and an over-representation of women in part-time and casual work, amongst other things. These influences of low social status and the social determinants of health, for example caring responsibilities, must be considered at all stages of engagement in order to meet women’s needs in a holistic manner.

In addition, staff should be trained to use non-judgmental language when working with women consumers, so as not to further discriminate or stigmatise. Examples of non-judgmental language in the mental health sector include:

Attention seeking	They are trying to build relationships and find it hard to be alone with their thoughts and feelings.	
Paranoid	They experience the world as very threatening and can feel very unsafe.	
Secretive	They protect their privacy.	
Suspicious	They are not at the point of trusting us yet.	
Untreatable	We are finding it difficult to treat her.	

Recommendations
4. AAMHIU MOC to reflect further integration of community supports into the inpatient experience, including discharge planning, in order to aid in recovery processes.
5. Service delivery and discharge planning to take into account gendered experiences and the social determinants of health.
6. Training for AAMHIU staff about non-judgmental language when working with mental health consumers.

Peer support
WCHM and WMHWG welcomes the AAMHIU MOC inclusion of ‘consumer consultants’ whose role it is to assist consumers with their concerns and address issues in regards to their participation. However, there should be an increased focus on these consumers playing a peer support role. Research conducted by WCHM in 2011 shows that peer support is a gender sensitive way to assist in mental health recovery, with benefits including:
•	Increased mental health and wellbeing, including increased knowledge of symptoms and supports available, more periods of wellness and self management, and increased support when experiencing an episode
•	Increased social connectedness and sense of belonging
•	Increased confidence, benefiting community participation through volunteering and work
•	Health promotion, through encouraging information sharing and knowledge about mental health and wellbeing

Recommendations
7. Consumer consultants in AAMHIU to fulfill a broader and more therapeutic peer support function due to the benefits of peer support and the ability of this model to be gender sensitive.

The AAMHIU MOC in practice
WCHM and WMHWG understands that the AAMHIU MOC document is ‘top level’ and that details about its implementation will be contained in policies and standard operating procedures (SOPs). Community members and organisations should continue to be involved in processes reviewing these policies and SOPs, and should receive feedback on how the MOC is being implemented ‘on the ground’. This is to ensure that the MOC is a living document that is understood and ‘enforced’ by AAMHIU staff, processes and allocated resources, resulting in real change for women consumers in the AAMHIU.

Recommendations
8. Community members and agencies to be further involved in the implementation of the MOC to ensure changes occur on the ground at AAMHIU. 

Conclusion
This submission to the draft Adult Acute Mental Health Inpatient Unit at the Canberra Hospital: Model of Care aimed to highlight issues from the perspective of women in the ACT, particularly women living with mental health issues. We look forward to participating further in the consultation process, and in the implementation of the MOC for the AAMHIU.

References

Barnes, M, A Davis, S Guru, L Lewis & H. Rogers, Women-only and women-sensitive mental health services: A summary report, University of Birmingham, United Kingdom, 2002.

Dohrenwend, BP, ‘Socio-economic status and psychiatric disorders’, Social Psychiatry and Psychiatric Epidemiology, vol. 25, 1990.

Judd, F, S Armstrong &  J Kulkarni, ‘Gender-sensitive mental health care’, Australasian Psychiatry, vol. 17, no. 2, 2009.

Stewart, DE, ‘Social determinants of women’s mental health’, Journal of Psychosomatic Research, September 2007.

Mental Health, Justice Health & Alcohol & Drug Services, Adult Acute Mental Health Inpatient Unit, Canberra Hospital, operational Model of Care, version 1.0., 19 October 2011.

Pound L, K Judd & J Gough, Peer support for women living with mental health issues: The views of ACT women, Women’s Centre for Health Matters, September 2011.

Appendices

Appendix A: Characteristics of gender sensitive mental health service delivery

•	A holistic approach to mental health, where women are treated as whole individuals rather than as their illness or diagnosis – using a social model rather than medical model.
•	Offer women choices about the type of support they receive, and who provides it to them (i.e. the choice between a male or female doctor). This is of particular importance for some CALD women, Aboriginal and Torres Strait Islander (TSI) women, women who have suffered trauma, and/or women who may feel uncomfortable disclosing personal information to a male practitioner.
•	Provide women with opportunities to be actively involved in their own care and treatment, including service planning and delivery (i.e. advanced directives).
•	Offer women choice in treatment options, which may include medication, talking therapy and/or other community-based services like peer support.
•	Have staff that treat women with respect, give them time to talk and listen to what they have to say, including the provision of long consultations and more preventative health measures and counselling where needed.
•	Have staff and practitioners with qualifications in women’s health and/or are trained to understand the impact of gender on mental health and well-being.
•	Are culturally sensitive.
•	Understand that all health issues and life events may affect men and women differently across their lifespan and use a life course approach in service planning and delivery.
•	Take into account the ‘social determinants of health’, that is, they acknowledge the way that women’s personal circumstances and socio-economic status affects their mental health. For example, a woman’s child and/or other caring responsibilities, her relationships, housing status, income, age, sexuality, ethnicity, religion and cultural and linguistic background, all have the potential to negatively impact upon a her mental health and wellbeing.
•	Employ a holistic, individual approach to service delivery that recognises that women often have a multitude of concurrent challenges, which often lead to a cycle of difficulties.
•	Pathways of care are easy to navigate, information is provided in preferred formats, and for those women who experience difficulty in understanding and/or navigating the health system, assistance is provided.
•	‘Women only’ spaces within their buildings.
•	Provide family-friendly and more specifically child-friendly environments, and services are inclusive of family.  
•	Keep women’s personal information confidential at all times.
•	Have a stable and secure funding base, which allows them to offer consistency and longevity in the support they provide.