The uncomfortable truth is that many psychiatric wards have a culture of sexual assault

The idea that people, predominantly girls and women, are too mad, too bad and too sad to be believed has been used to silence people since time immemorial

Jay Watts
Wednesday 12 September 2018 12:45 BST
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A staggering 65 sexual incidents were reported per week, a report by the CQC has revealed
A staggering 65 sexual incidents were reported per week, a report by the CQC has revealed (Alamy)

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Sexual assault and harassment is “commonplace” on inpatient psychiatric wards, according to Dr Paul Lelliott, the deputy chief inspector of hospitals and mental health lead at the Care Quality Commission (CQC), following the publication of an important, national report this week. This is not news to psychiatric patients, who have been raising the issue for more than 50 years. Will this report provide the #MeToo wake-up call on sexual violence that mental health services desperately need? Or will the currents of denial, avoidance, victim blaming and silencing that swirl around sexual assault, and which psychiatric discourse specifically enable, block progress as they have time and time again?

The CQC’s report examined incidents in three months in 2017. A total 1,129 sexual incidents were reported – 65 per week – including 29 alleged rapes and 457 incidents of sexual harassment and assault. Two-thirds of the time the person affected was a patient.

Though the figures suggest that most of the incidents were carried out by male patients, few patient groups doubt that this is a gross underrepresentation of incidents carried out by staff members, which are specifically difficult to report given the power asymmetries and gaslighting that make speaking out especially difficult once one is seen as a psychiatric patient.

For the idea that people, predominantly girls and women, are too mad, too bad, too sad to be believed has been used to silence people since time immemorial. Psychiatric diagnoses – especially those that put a question mark on the veracity of one’s testimony for reasons of perceived rationality with psychoses or moral character with borderline personality disorder – give abusers an easy way to intonate or explicitly frame testimony as a sign of illness, hysteria or attention seeking.

Society at large has only begun to move beyond this kind of discourse in recent years because of the new wave of feminism that has shone a light on the devaluing of women and gaslighting that has, historically, been used to protect figures of authority. Mental health services retain a language and set of patriarchal practices that allow people in power to shut down testimony that demonstrably keeps people who have been assaulted and abused locked in a situation, psychically and on our acute wards, where silence feels safer than speaking out.

This does not mean that most staff sexually assault or harass patients. Of course not and the CQC report gives some important examples of wards that have changed the ethos to one that privileges sexual safety. But it does mean that staff routinely ignore or minimise the impact of sexual violence on mental health, both as something that causes people to breakdown in the first place and something that occurs frequently on our wards.

Perhaps the most startling figure in the CQC’s report is that 97 per cent of incidents were classified by organisations as “no harm” or “low harm”. While this shocking figure is partly a function of how “impact” is reported in the NHS, it also demonstrates how trainings that focus on categorising signs of mental illness, divorced from the life contexts that provoke or maintain breakdown, enables staff members to see things like sexual assault awareness training as add-ons rather than core knowledge that must fundamentally alter how psychiatric services are structured.

The need for change becomes even more pressing given the huge percentage of psychiatric patients, especially inpatients, who have been sexually abused in early life. Divorcing these kinds of experiences from mental breakdown serves to reinforce abuser’s frequent messages that there is something fundamentally wrong with survivors, rather than providing a space where sense can be made of how and why someone might come to, as examples, dissociate, hallucinate or experience the self as fragmented as a desperate attempt to maintain psychic agency in the face of sexual violence. Nursing survivors in an environment where sexual assault and harassment is “commonplace”, as happens today, is nothing less than an outrage that actively sends out a message that nothing much can change, re-traumatising survivors and eviscerating hope.

An international movement called Trauma-Informed care threatens to change this. With this approach, establishing psychological and physical safety is privileged above all other tasks on inpatient wards and in community services. Staff are trained to understand the core relationship between sexual violence and breakdown so speech becomes possible and practices such as face-down restraints on young women by a group of male nurses – where one is pinned down and forcibly injected in the bottom – are eliminated. This radical shift in how psychiatric services are organised is crucial given that previous guidance – such as the requirement to ask patients about lifetime experiences of sexual violence – tends to fail to be incorporated into everyday practice unless staff are educated, ideally by survivors, as to why this matters.

While I was pleased to read some of the recommendations for change proffered in the CQC report, there is also nothing new. Single sex wards? Sexual safety awareness training and so on? We have heard it all before. History shows us that the currents of denial, avoidance and silencing around sexual violence are so powerful that change is only possible by altering the misogynistic, patriarchal culture they sit within. This requires nothing less than a radical rethink in how we conceptualise mental distress.

If you have been affected by sexual violence, you can find help via NHS Rape Crisis, which offers specialist support for women and girls; and the The Survivors’ Trust supports people of any gender. If you have been affected by this article, you can contact the following organisations for support:
mind.org.uk
beateatingdisorders.org.uk

nhs.uk/livewell/mentalhealth
mentalhealth.org.uk
samaritans.org

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