Sexual behaviours on acute inpatient psychiatric units

Sexual assault in the inpatient psychiatric setting

Sexual assault in the inpatient psychiatric setting is a significant problem with serious, lasting consequences. It is important for psychiatric providers to appreciate the nature and magnitude of this problem to be able to provide an appropriate response when faced with these challenging scenarios, as well as to advocate for the implementation of preventive measures. This article provides a review of the existing literature regarding sexual behavior in the inpatient psychiatric unit, describing the epidemiology of sexual assaults in these settings, and exploring the characteristics of both victims and perpetrators, with a particular focus on factors of relevance to the inpatient psychiatric patient population. Inappropriate sexual behavior in inpatient psychiatric settings is common, however the varying definition of such throughout the literature serves as a challenge to clearly identifying the frequency of specific behaviors. The existing literature does not identify a way to reliably predict which patients are most likely to engage in sexually inappropriate behaviors on an inpatient psychiatric unit. The medical, ethical, and legal challenges that such cases present are defined, followed by a review of current management and prevention strategies, and suggested future directions for research.

Gender and intersecting vulnerabilities on the mental health unit: Rethinking the dilemma

BACKGROUND

Gender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them.

METHODS

This paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design.

RESULTS

Key themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit.

CONCLUSIONS

While findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who "understand," and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities.

Addressing Sexual Violence in Psychiatric Facilities

Preventing sexual violence in psychiatric facilities has been a longstanding challenge that has received only limited attention from researchers and regulators. Numerous factors at the patient-, staff-, facility- and health care system-level contribute to sexual assaults within these facilities and difficulties in obtaining justice for victims. In the wake of the #MeToo movement, significant strides have been made in addressing sexual violence within society. Extending these efforts to the isolated worlds of psychiatric facilities is a logical next step; the time has come for psychiatry to better address this chronically overlooked patient and workplace safety issue.

Sexual violence and mental health services: a call to action

People who experience sexual violence are highly likely to experience psychological and/or mental health (MH) problems as a result. People who use MH services often have a history of sexual assault and are also likely to be revictimised as an adult. Yet despite there being a very clear association, MH services are not yet performing routine enquiry, and even if they do, are not confident about how to record and manage disclosures. There is some emerging evidence that people with MH problems are exposed to sexual violence in inpatient MH settings, perpetrated by both other patients or members of staff. In this editorial, we explore the evidence to support a wider focus on sexual violence as a part of routine care, as well as some recommendations about how staff can more effectively discuss sexual issues including that of sexual victimisation.

The capacity to consent to sex in mental health inpatient units

OBJECTIVE

Discussions of capacity to consent in mental health care usually revolve around capacity to consent to treatment. This paper instead explores the issue of capacity to consent to sexual activity in a mental health inpatient setting as a way of exploring capacity from a different perspective. This is not a purely theoretical exercise, with both consensual sexual activity and sexual assault commonplace in mental health inpatient units, current policy and practice approaches are clearly not working and require re-examination.

METHODS

Four key frameworks are explored: human rights law, mental health law, the criminal law and the law of tort governing the duty of care. These frameworks are explored by highlighting relevant case law and statutes and considering their potential application in practice. This is undertaken using the state of Victoria, Australia, as a case study.

RESULTS

The four frameworks are shown to be consistent with each other but inconsistent with contemporary policy. All four legal frameworks explored require clinicians to take a case-by-case assessment to ensure that a person's right to make their own decisions is preserved 'unless the contrary is demonstrably justified' or where it is 'legally demanded'. While Victorian inpatient units attempt to enforce a blanket ban on consensual sexual activity in inpatient settings, this ban may be without legal basis and may be in breach of both human rights and mental health law.

CONCLUSION

In policing the lawful bodily interactions of their patients and pushing sexual activity out of sight, clinicians may be breaching their duty of care to provide sexual health support and risk creating an environment in which the therapeutic relationship will be sacrificed to the enforcement of institutional policy. Clinicians and policymakers must understand the relevant legal frameworks to ensure that they are acting ethically and lawfully.

'Hiding in plain sight': Exploring the complexity of sexual safety within an acute mental health setting

It is increasingly being recognized that individuals who access acute mental health services are at risk of sexual assault. Assaults may be perpetrated by other patients but also by staff working in mental health environments, although this latter group remain largely under-researched. Following a reported professional sexual assault and review of an acute inpatient mental health setting in the UK, the overall aim of this study was to explore the mechanisms and structures that were put into place following the investigation and in so doing examine the wider questions of sexual safety in acute mental health settings. A qualitative approach was utilized and involved interviews with clinical staff (n = 8). Thematic analysis was used to analyse the data resulting in four main themes: 'Feeling betrayed': The relational context of the ward environment'; 'Doing what we were meant to be doing': Quality of leadership'; 'Covering yourself': Safeguarding practice; 'The subtleties of abuse': Complexities of safeguarding '. The findings of the study highlight the need for clear organizational structures of support, a clearer understanding of 'sexual safety', and education and training which explicitly addresses recognition and complexity of sexual violence.

Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2013-2017

Since the 1960s, empirical research has worked toward a better understanding of the characteristics of assaultive psychiatric patients. International research through 2012 indicated that male and female patients with schizophrenia and other diagnoses presented the greatest risk for assault. This present review of studies that presented raw assault sought to assess the latest research findings on assaultive patients for the most recent 5 year period, 2013-2017. It was hypothesized that male patients with schizophrenia would present the greatest risk. The findings indicated a sharp increase in the total number of reported assault incidents over the proceeding decade. These assaults were committed largely by male patients with a diagnosis of schizophrenia. Explanations for these findings and an updated methodological inquiry are presented.

Aggression on inpatient units: Clinical characteristics and consequences

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient-staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression-rule breaking, aggression-medication, and aggression-containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression-containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.