In what ways can a social inequalities approach be utilised in the assessment and treatment of women with mental health problems?

“I thought how unpleasant it is to be locked out; and I thought how it is worse, perhaps, to be locked in.”
(Virginia Woolf (1882-1941) – Novelist, Academic, Mental Health Service User, Woman.)

Social inequalities permeate our society. Men and women of many creeds and casts find themselves faced with ‘the little injustices of life’ everyday. However, recent and current research on mental health suggests that inequalities in social experiences and affiliation may have a strong influence on our life experiences and mental health.

In 1999, Cooper et al., conducted research into the social origins of mental health issues and concluded, in part, that women’s mental health is more affected by social environment and fluctuations in ‘social climate’ than men. These findings illustrate the power which social inequalities may have on mental health issues, and also lay grounds for a gender-sensitive assessment of the social inequalities approach. As the title suggests, the purpose of this essay is to explore how a social inequalities approach to mental health can be applied to the treatment and assessment of women with mental health problems. The essay also proposes to look at social disparities between the genders and how they can help us understand facets of life events which may influence women’s mental health issues, as well as how they may impact upon women’s experiences as Mental Health Service Users. For the purposes of this essay, the term ‘mental health problems’ is used broadly, encompassing any and all women who experience mental health issues and/or use mental health services.

The social inequalities approach will be defined, described and applied to gender through looking at Williams’ (2005) model of understanding the social inequalities approach to mental health. We intend to focus on factors such as economic disparities, balancing work-home demands and discriminatory socio-cultural norms. We also aim to highlight the importance of research on the impact of Child Sexual Abuse and Adult Trauma on women’s mental health issues, which is important to discuss in terms of specific formative influences on women’s mental health issues and women’s experiences in Mental Health Services.

Through applying this theoretical understanding of the social inequalities approach and the influence of social inequality and women’s mental health, we hope to describe ways in which it can be utilised in the assessment and treatment of women with mental health problems. The essay will conclude by looking at current developments in policy and practice which are aiming to address the importance of social and gender issues in mental health, and argue the continuing importance of integrating social support with mental health care, with regards to the treatment, rehabilitation and empowerment of women with mental health problems.

Williams (2005) describes 3 key areas through which social inequalities can affect mental health – ‘access to resources that promote mental health’, ‘greater exposure to mental health risks’ and ‘processes that maintain the status quo’ (Williams, 2005). We will attempt to illustrate each of these components of the social inequalities approach with examples.

The resources which promote mental health are resources which we tend to take for granted, such as work, money and social status. However, if we observe statistics closely, we can see that these resources are subject to a major gender disparity. The Equal Opportunities Commission (‘Facts About Women & Men in Great Britain’, 2005) report that roughly half of the UK’s labour force is made up of women. However, statistics indicate that whereas 44% of women who work take on part-time jobs, only 10% of men who are in employment work part-time. The gap between men and women’s hourly earnings for part-time work is remarkable – men have the capacity to earn an average of 40% more than women in part-time employment. The average hourly rate of pay for women working full-time is 18% lower than that of their male counterparts. These differences can explain a disparity in paid income between men and women indicating an inequality, with men earning on average around £559 per month more than women. It is fair to infer from this data that social and economic power and/or status must also face a gender skew.

Research also indicate that women may face challenges and pressure whilst combining paid work with their unpaid family responsibilities. Simon, 2003 describes how working mothers may suffer with stress and feelings of guilt, shame or depression as a result of conflicts between work and home commitments. This research is complimented by that of Lennon and Rosenfield (1992) who offer findings that explain how, although paid employment can be seen a potentially empowering resource (Horwitz, 1982), interactions between home and work conditions play the most influential role in mediating women’s mental well-being. These results are made even more pertinent when observing the division in household labour between men and women which has consistently seen the average woman devote more time, effort and responsibility to household work (including childcare) than men (Mattingly and Bianchi, 2003).

From a feminist perspective, we can argue that much of modern Western society is fundamentally patriarchal in its thought and influence. We suggest that this ‘bias’ in society ‘trickles down’ in the form of many political, social and cultural norms which reinforce day-to-day subtle (and in some cases, not-so-subtle) gender stereotypes and power imbalances. Feminist Naomi Wolf argues in ‘The Beauty Myth’, that "To live in a culture in which women are routinely naked where men aren't is to learn inequality in little ways all day long," (Wolf, 1992). On a broader and more general note, it is also interesting to observe that only 18% of MP’s representing the public at a government level are women.

When observing gender-sensitivity and mental health issues, a major issue to be accepted and understood is the link between Childhood Sexual Abuse (CSA) and adult mental health problems. Harris and Landis (1997) describe the prevalence of CSA histories in women who use mental health services. Research also suggests that users of outpatient mental health services with histories of CSA are likely to experience higher levels of both depressive and psychotic symptoms (Muenzenmaier et al., 1993). Harris and Landis also emphasise the strength with which CSA can affect adult mental health. They go on to describe how current practice tends to lack sensitivity or even acceptance of this theme in women’s (and in many cases men’s) experiences. Gise & Padison (1988) comment upon the danger of this lack of professional understanding of CSA issues in mental health: “a therapist with no understanding of CSA is as likely to be of as much help to clients with experiences of CSA, as a therapist who has no understanding of the Vietnam War would be to a Vietnam Veteran”. Research into the impact of CSA also indicates specific issues which may be pertinent to a social inequalities approach to women’s mental health: Hawton et al. (1997) draw links between ‘deliberate self-harm’ and both CSA and domestic abuse, whereas Harris and Landis (1997) describe disassociative identity order as an explicit study of abuse.

This wealth of theoretical understanding, and the guidelines for social awareness suggest the need for a close understanding of social factors in mental health experiences and an acknowledgement of demeaning experiences and trauma, which are themes which may continue within the care systems which offer ‘treatment’. A key consideration for women’s mental health care is the potential re-victimization and institutional ‘retraumatization’ which can (and often does) occur as a result of experiences in Mental Health Care and Services (Jennings, 1997). Harris and Landis (1997) emphasise the need for attention to women’s security and safety (both real and perceived) within Services, and the importance of support for Care Staff in order to provide a strong and consistent mode of care for Service Users.

Coming from a cultural and therapeutic perspective, Simon’s research (2003) develops an argument which suggests that traditional psychotherapy can be seen to harm as much as it heals, through its strong identification with, and use of, ‘gender expectations’, which, Simon suggests, mirrors dominant gender-biased culture and society. With regards to gender inequalities it is important to consider the use of a feminist therapeutic approach, both tailored for the needs and experiences of women and also provided exclusively by women for women in a safe and mutually inclusive setting. According to Surrey et al., (1991), women are very likely to benefit from interdependence and group affiliation, in a therapeutic context. The power of group work and survivor support is one which tackles openness and acknowledgement of the humanity of mental health service users and also prompts services to develop their locus of care through using Service User’s input and perspectives.Wile (1997) furthermore emphasises the importance of the acknowledgment and ‘witnessing’ of women’s experience with abuse, particularly within the context of offering a successful and empowering therapeutic experience.

However, gender-specific care arrangements have been criticised by some Mental Health practitioners who feel that the ‘segregation’ of women from the ‘mainstream’ of mental health is fundamentally unhealthy and unconstructive. Critics of gender-sensitive Mental Health Care discuss the possibility that specialist mental health care for women could diminish the importance of a thorough understanding of gender issues in primary care (Satel, 1998). This highlights the importance of social and gender issues in every faction and level of healthcare, and offers a criticism which could be used to compliment gender-sensitive care in a way that highlights a need for equality, but an equality which acknowledges the importance of specific service users. Since the late 1990’s, Government policymakers have begun to acknowledge the importance of understanding the impact of inequality and other social issues on the needs assessment and experiences of mental health care service users. Policy has begun to put emphasis on the importance of a social context of care (‘Effective Care Co-ordinatoration for Mental Health Services Modernising the Care Programme Approach’: DoH 1999; ‘Secure Futures for Women: Making a Difference’: DOH 2000, ‘Safety, Privacy & Dignity’: NHS Executive, 2003). However, policy change at a government level appears to be evolving slowly, according to bureaucratic progress. Therefore, it is perhaps more pertinent to look at cases of practical initiatives which are currently working in the UK, within the NHS. The East Sussex, Brighton & Hove Women’s Mental Health Services Development Project was founded with a view to with to tailoring women’s mental healthcare to specific women’s needs, through involving the women who use the services in the development of a holistic model of support (Department of Health, 2005). The Women’s Mental Health Development Project places an emphasis on user input and support from wider social-care networks, such as voluntary help-groups, social services and general healthcare services.

Devon Partnership Trust (NHS) implemented the ‘SAGE Groupwork’ therapeutic project, which was developed with a view to supporting survivors of sexual abuse, and was developed for women, by women (Department of Health, 2005). ‘SAGE Groupwork’ focuses on acknowledging abuse and allowing women to discuss their histories in a safe and supportive environment. The group nature of the therapeutic sessions engenders mutual support amongst women of various stages of crisis recovery, and offers women the chance to share their stories and affiliate with other women who have shared similar traumatic experiences. South Staffordshire Healthcare NHS Trust has also introduced a specifically focused, trained and supported Sexual Abuse Team, which works alongside voluntary ‘survivor’ services and also facilitates training and support for care staff (Department of Health, 2005).

Another example of socially-sensitive care is the ‘Ashcroft’ sheltered housing project in Norfolk, which provides supported sheltered accommodation for women with mental health care needs, whilst focusing on empowering women whilst supporting them in their recovery from crisis. ‘Ashcroft’ not only provides basic ‘traditional’ sheltered accommodation with a high level of social and therapeutic support, but also encourages residents to take gain not just a sense of, but a tangible empowerment and autonomy through opportunities to move into flats within the housing scheme, where individuals can tailor their support in order to fit in with their independence and their specific care needs.

Evidence from current support work places and emphasis on group work, affiliation and the chance for women to reclaim their independence and power over their lives which their mental health problems, institutionalization and personal histories have stolen from them. It appears that an effective response to the inequalities of society is to give a voice to those who suffer under them.

To conclude, the social inequalities approach highlights a need for a gender equality agenda which is aware of, and embraces, the differences between men and women’s experiences and needs as mental healthcare users. It is also relevant to note the implications which social inequalities research has for society and women in general, and to look at revaluing women’s places in society at large. Research into gender-sensitive assessment and treatment indicates a need for a high level of social as well as psychiatric support, in order to promote a healthier therapeutic environment in which to exist and thrive in. Through using the social inequalities model, we have attempted to illustrate the importance of social support and awareness in mental health care, and to offer the development of women’s empowerment and esteem as important tools in order to assist women to find their independence along their journey through Services and out into the greater world beyond.

By Evelyn Irving

Copyright May 2006

Notes

Equal Opportunities Commission. (2005). Facts about Women and Men in Great Britain. Manchester: EOC.
Gise, L. H., & Paddison, P. (1988). ‘Rape, sexual abuse and its victims’ Psychiatric Clinics of North America, 11, 629-648.
Harris, M., & Landis, C. L. (Eds.). (1997). Sexual Abuse in the Lives of Women Diagnosed with Serious Mental Illness. Amsterdam: Harwood Academic Publishers.
Hawton, K., Fagg, J., & Simkin, S. (1997). ‘Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide’. British Journal of Psychiatry, 171: 556-560.
Muenzenmaier, L., Meyer, I., Struening, E., & Ferber, J. (1993). ‘Childhood abuse and neglect among women outpatients with chronic mental illness’. Hospital and Community Psychiatry, 44(7), 666-670.
Ramsey, R., Welch, S., & Youard, E. (2001). ‘Needs of women patients with mental illness’. Advances in Psychiatric Treatment, 7, 85-92.
Satel, S. L. (1998). ‘Are Women’s Health Needs Really “Special”?’. Psychiatric Services, 49:565
Simon, T-L. (2003). ‘The exploration of the working mother's plight through psychoanalytic, feminist and intersubjective approaches.’ Dissertation Abstracts International: Section B: The Sciences and Engineering, 63(11-B), 5571.
Surrey, J., Swett, C., Michaels, A. & Levin, S. (1991). ‘Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric outpatients’. American Journal of Orthopsychiatry, 60(3), 412-417.
Wile, J. ‘Inpatient Treatment of Psychiatric Women Patients’ in M Harris., & C. L. Landis (Eds.). (1997). Sexual Abuse in the Lives of Women Diagnosed with Serious Mental Illness. Amsterdam: Harwood Academic Publishers.
Williams, J. (2005). ‘Womens Mental Health: Taking Inequality into Account’ in J. Tew (Ed.). Social Perspectives in Mental Health. London: Jessica Kingsley Publishers.
Wolf, N. (1992). ‘The Beauty Myth’. London: Anchor.

Links

Department of Health, 2005: East Sussex. Brighton & Hove Women’s Mental Health Services Development Project: www.dh.gov.uk/assetRoot/04/06/20/97/04062097.pdf. As viewed on the 10th of March, 2006.
Department of Health, 2005: Devon Partnership Trust: SAGE Groupwork & South Staffordshire Healthcare NHS Trust: Sexual Abuse Team: www.dh.gov.uk/assetRoot/04/04/20/98/04062098.pdf. As viewed on the 10th of March.