Uncharted territory

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Publication Date: 
Mon, 2013-10-07

Exploring how women’s experiences are documented in psychiatric settings

By Jane Shulman

It started as a small charting project with the goal of looking at the ways that lesbian and bisexual women’s sexual orientation is documented in their psychiatric in-patient charts. The idea was to study the ways that psychiatric practices reinforce social norms around gender and sexual orientation, and how these practices affect women’s experiences during interactions with the psychiatric system.

The project quickly became an entry point to a discussion about the way women’s backgrounds—including their intersecting experiences of gender, race, class and violence—are “taken up” by mental health service providers. In other words, how these aspects of women’s identities affect health service providers’ understanding of women’s distress, and how they affect health care responses or interventions in psychiatric settings.

See also Jane Shulman's review of Committed to the Sane Asylum by S. Schellenberg & R. Barnes

The inspiration for the project grew partly out of lead researcher Dr. Andrea Daley’s dissertation about the lived experiences of lesbian and queer women in the psychiatric system. She was interested in the ways women negotiated issues related to their sexuality and sexual identity. She began to wonder how mental health service providers (MHSPs) understood the relevance of sexual minority women’s experiences, as evidenced in their psychiatric charts.

“I started to think about the disjuncture between practice and documentation,” says Daley, an associate professor in the School of Social Work at York University. “I was interested in how women, gender and sexuality get constructed in the process of documentation, and what documentation reflects in terms of norms, institutional structures and power.” That led to thinking about the language that mental health service providers use in their documentation and the ways that they document, and helping social work students think about the implications for the people they will be writing about.

As a social work educator, Daley wanted to help students think about the impact of documentation and the powerful role that charting has in steering conversations among professionals. The idea was not to focus on individual practices, but to look at what informs documentation practices on institutional and systemic levels.  

Co-investigators Dr. Lori Ross, senior scientist with the Health Systems & Health Equity Research Group at Toronto’s Centre for Addiction and Mental Health (CAMH) and Lucy Costa, an outreach worker at the associated Empowerment Council, offered important institutional and experiential perspectives that complemented Daley’s research and clinical background. The study was funded through York University’s SSHRC Small Grants Program.

“We are interested in how language is located within a history of heteropatriarchal knowledge of medicine and psychiatry—in a culture, and then within an organization and its policies and guidelines,” Daley says. “The intention isn’t necessarily to uncover inadequate individual practices, but to think more broadly about organizational structures and what gets attended to during a woman’s admission and discharge as reflected within chart documentation.” 

She notes that individual charting practices are probably shaped by a combination of history, contemporary organizational polices, program models of care, professional practice standards and guidelines within the institution of psychiatry.

Daley explains that, in broad terms, they were asking, “how are psychiatric institutions implicated in the organizing of gender relations, and how can we use this to build with the ‘Mad Movement’ that is seeking to challenge psychiatry’s regulatory powers?”

The Mad (short for madness) Movement is a growing collaboration by people who have experience with the psychiatric system. The idea is to provide information and support and engage in advocacy and empowerment among peers. Mad groups stage events and share resources. The Mad Students Society has chapters on university campuses, and Mad Pride is held annually in Toronto with events around International Mad Pride Day on July 14.

Daley looked at 45 women’s in-patient charts from a Toronto hospital to choose 25 that the team would study. She alone had access to the charts in the interests of protecting confidentiality.

She looked at charts from different units, and noticed both similarities and differences in documentation content. 

“In a naïve way, I thought I could read charts looking at what was considered to be sexuality context, not even LGBT specifically. But getting into charts, seeing all of the dynamics present around race, class, gender,“ Daley says. “It was kind of shocking. It felt at times like I was reading charts from the 1950s. There are still references to women’s physical appearance and how they should look—make-up, the colour of pants and sweater a woman is wearing and how her hair is combed.”

She notes that the inclusion of women’s physical appearances is probably part of professional practice to describe patients for other providers as well as for institutional requirements related to locating and identifying patients that may go missing from in-patient units.