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.

“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.”

The research team has been pleasantly surprised by the response to their findings. “People are really, really interested and want to engage,” says Daley. Their academic articles have been incorporated in three university courses so far, and the team has met with one organization to come up with ways to move the research into concrete outcomes within institutions. “It’s a pleasure to have people engage with something that’s produced through research. It speaks to working with the community.” She notes that collaborating with the Empowerment Council built the voices of community members into the research.

“This work provides empirical evidence for longstanding feminist theoretical critiques of psychiatry,” says Daley. “It offers a feminist, critical race, post-colonial framework for challenging psychiatry’s role in regulating gender and sexuality.”

Daley wants to continue researching the ways that psychiatric narratives “reproduce and sanction idealized versions of particular femininities and masculinities: white, heterosexual, middle-class notions of femininity and masculinity, and marginalized femininities and masculinities mediated by sexuality, race and class.”

She hopes to look at more charts of women psychiatric in-patients and an equal number of men’s charts, to study how femininities and masculinities are constructed through psychiatric practices. The project will continue to focus on ways to share the findings with health care institutions and communities to encourage critical self-reflection for mental health care providers and improved health practices for people using psychiatric services.

Jane Shulman is a Montreal-based health researcher and journalist. She has worked as CWHN's webinar producer and director of knowledge exchange.

Journal article (abstract only):

Andrea Daley, Lucy Costa & Lori Ross (2012): (W)righting women: constructions of gender, sexuality and race in the psychiatric chart, Culture, Health & Sexuality: An International Journal for Research, Intervention and Care, DOI:10.1080/13691058.2012.712718