Uncharted territory

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Publication Date: 
Mon, 2013-10-07

“Regardless,” says Daley, “the descriptions often reflect and reinforce an idealized femininity about how women should look, including having properly applied make-up, clean clothes that fit well, appropriate colours and styles, and being well groomed.”

Daley looked at charts from different units, and noticed that documentation in some units was more likely to include issues related to sexuality compared to others. For example, charts belonging to women who self-identified as lesbian were all located within the same unit, suggesting that the characteristics of this particular unit was more allowing or encouraging of women's self-disclosures.

This underscored for the researchers that for lesbian/queer women to feel safe disclosing their sexual orientation, the institutions need to provide clear messages of non-judgment and acceptance. Daley suggests that these messages are as relevant for mental health service providers as they are for the people using the system, noting that self-censorship works both ways, and can stand in the way of progress.

Daley, Ross and Costa intended to analyze the sexuality-related content in the charts, but quickly realized that they could not look at sexuality in isolation. Issues of gender, sexuality, race, class were inextricably linked with diagnoses, and needed to be studied together.

“It just kind of exploded, became more complex, and pushed us more to try to theorize this,” she says. “The documentation of women’s experiences doesn’t allow for the social and structural context of their lives,” Daley notes.

It became clear that social determinants of women’s mental health—their living situation, race, class, histories of abuse and experiences of violence—were noted in their charts but not necessarily addressed by mental health care providers. In some cases, issues came up on initial intake, sometimes in the emergency room, and did not come up again in subsequent charting. Daley notes that issues may have come up in conversations between providers and women while they were in-patients, but the thread did not continue in their charts. Daley wonders how women’s experiences might have been different during their in-patient stay and upon their discharge, if these social determinants and experiences related to social structures were included in treatment and discharge plans.

Women, sometimes because of the situations they describe or the way they describe them, can be labeled unreliable historians, says Daley. The way they talk about their experiences can be seen as symptoms for the purposes of diagnosis, rather than circumstances that may be contributing to their troubles and need to be explored.

To include women’s voices, Daley suggests that mental health service providers must sometimes challenge their training and their understanding of what is “true.” Sometimes a story that a woman weaves may not make sense from the perspective of the biomedical model that seeks to categorize statements as absolute truths or untruths.

“Our framework for understanding what people are saying needs to shift to understand women’s personal stories,” says Daley. “Social determinants inform how people experience stress and how they are experienced by mental health service providers. It’s a vicious cycle.”

Daley notes the chart of a black woman, which documented her living environment as racially violent, where a housemate was verbally attacking her using racial slurs and making her living situation unbearable. The issue was documented in the assessment conducted in the emergency department; “It gets lost  [not documented] in the in-patient chart documentation,” says Daley. “The social and structural context is removed in understanding her distress.” Presumably, upon discharge, she would be returning to the same home. How much did the racial violence she experience influence her mental health? If this had been explored in during her treatment, could a housing change have been made that would have better supported this woman’s mental health?

“Having said that, I don’t know for sure if a mental health service provider ever explored this experience of racism with the woman. Maybe they did and it’s not documented. How is that decided to be not significant in terms of documenting content?” Daley wonders.

A challenge of the project, Daley explains, is figuring out how to take this awareness and move it to an institutional level to talk with mental health care providers about change.

“We want to see providers engage in a critical reflective process about the ways that dominant gender norms and values affect biases and practices,” she says. “And how do we take it to women with lived experience of the psychiatric system to talk about their experiences and their rights so they can participate in the process?”

Daley notes that “this small charting project really raises issues both around in-patient context and when people are discharged too. If there’s attention to social and structural issues in the in-patient context, it calls for a stronger connection between institution and community.” It also and focuses on mental health service providers and their working conditions.

“It’s a hard place to be,” she says. “Distress, trauma, people coming into work with their own stuff; it’s not an easy context to get it right. We want to acknowledge that workers themselves are often overworked, lack resources, and may lack training.”