Featured Article
Article Title
Working with Women in Forensic Mental Health Care: Guidelines for Gender-Responsive Assessment and Treatment
Authors
Vivienne de Vogel - Maastricht University, The Netherlands, University of Applied Sciences Utrecht, The Netherlands, De Forensische Zorgspecialisten, Utrecht, The Netherlands
Marije Keulen de Vos - Maastricht University, The Netherlands, Forensic Psychiatric Center de Rooyse Wissel, Venray, The Netherlands
Julia Leong - FPK De Woenselse Poort, Eindhoven, The Netherlands
Ester Robbe - De Forensische Zorgspecialisten, Utrecht, The Netherlands
Abstract
Important gender differences, relating to trauma history, offending and mental health needs are not sufficiently considered in most (risk) assessment and treatment procedures in forensic practice. We developed guidelines for gender-responsive work in Dutch forensic mental health care. The experiences of practitioners and forensic psychiatric patients were collected and analyzed by means of an online survey (n=295), interviews with professionals (n=22), female (n=8) and male (n=3) patients. Guidelines regarding gender-sensitive (risk) assessment and trauma-informed care were rated as most relevant in the survey. In the interviews we focused on experiences and wishes for trauma treatment and gender-mixed treatment. Practical guidelines were written based on the results of the survey, interviews and literature, and presented in expert meetings with patients and practitioners, and further refined based on their comments. Applying these guidelines may contribute to improved treatment for female patients thereby preventing relapse.
Keywords
gender bias, gender-responsive, mental health needs, forensic, guidelines, Forensics, Transgender, Evaluations, Ethics, Gender diverse, Testing, Interviewing, Pronouns, Informed consent, Bias, Advocacy
Summary of Research
“...Gender bias [exists] in forensic care, potentially leading to the misinterpretation of risk and mental health needs… Gender bias may be particularly problematic for justice- involved women from minority groups, with respect to cultural background or gender identity” (p. 2).
“Acknowledging gender differences and potential gender bias in forensic mental health (risk) assessment and treatment is important, also because it affects subsequent risk management strategies. Most of the current treatment programs are not considered sufficiently gender-responsive, a fact recognized by both justice-involved females and Professionals… Logan and Taylor (2017) discuss the challenges for practitioners and organizations in working with women with personality disorders in high secure settings. They emphasize the importance of practitioners’ skills in understanding and dealing with emotions and in being able to establish a safe therapeutic relationship with the women in treatment. They also explicitly mention that not everyone is suitable for this job and that a good selection of professionals is important. In addition, they discuss characteristics that an organization must meet to be able to offer gender-responsive treatment, for example, having a clear, accessible, and up-to-date policy on gender-responsive work and offering support for staff in working with justice-involved women… There are also questions and lacking policies on gender identity and how to treat transgender patients...
Concluding, there is a need for more gender-responsive approaches in both assessment and treatment and practical guidelines in working with women admitted to (gen- der-mixed) forensic mental health settings. Gender-responsive approaches take into account and respond to differences in characteristics and life experiences of males and females…
The overall aim of the present study was to develop guidelines for assessing and treating women in (gender-mixed) forensic mental health care to promote gender-responsive treatment in the Netherlands… In the current article, we focus on three research questions: (1) Which themes are important to include in the guidelines for the treatment of women in forensic mental health care?; (2) What are the benefits and disadvantages of gender-mixed treatment, and what recommendations can be made for safe gender-mixed treatment?; and (3) Is trauma sufficiently addressed in current treatment models and should gender differences relating to trauma be incorporated in gender-responsive treatment guidelines” (p. 3– 5).
“This study applied a mixed-method approach, comprising both quantitative data from an online survey and qualitative data from interviews and expert meetings. Three forensic mental health care settings admitting both female and male forensic psychiatric patients located in different areas in the Netherlands participated in this study which took place between April 2021 and May 2022…
First, an online survey about working with women in (gender-mixed) forensic settings was completed by 295 participants working in forensic mental health services… Second, semi-structured interviews were held with 22 professionals and 11 forensic psychiatric patients… The interviews with eight female and three male patients lasted 20min on average and were conducted in one session at the forensic setting in a private office… Next, the draft guide was presented in several expert meetings; two with professionals and one with patients, and there were two individual meetings with female patients. Based on the critical reflections and feedback of all these experts, the guide was subsequently revised into the final guide” (p. 5- 6).
“From the survey question What do you prefer: gender-mixed or separate treatment? it was found that most professionals prefer treatment in gender- mixed hospitals (n=191, 77.3%), only 22.7% (n=55) preferred women only wards. A significantly higher preference for gender-mixed wards was found for professionals working in inpatient settings versus outpatient settings… Most participants of the survey stated that trauma is an important risk factor that should be addressed during forensic treatment. On average, on the 0–100 scale, participants agreed to 81.67 (SD=17.87, range 6–100) with the statement… Furthermore, it was indicated that mental health care professionals should become more aware of gender differences in trauma prevalence, symptoms, and cognitive appraisal and that there is a need for gender-responsive trauma interventions” (p. 9- 10).
“Acknowledgement of gender differences and potential gender bias in the forensic mental health care should result in gender-informed policies and gender-responsive practices. In the present study, practical guidelines were developed for treating women in (gender-mixed) Dutch forensic mental health care on the basis of the literature, and experiences and needs of both practitioners and forensic psychiatric patients. These guidelines may contribute to better tailor treatment in the forensic mental health field for female patients” (p. 16).
“Acknowledging gender differences and potential gender bias in forensic mental health (risk) assessment and treatment is important, also because it affects subsequent risk management strategies. Most of the current treatment programs are not considered sufficiently gender-responsive, a fact recognized by both justice-involved females and Professionals… Logan and Taylor (2017) discuss the challenges for practitioners and organizations in working with women with personality disorders in high secure settings. They emphasize the importance of practitioners’ skills in understanding and dealing with emotions and in being able to establish a safe therapeutic relationship with the women in treatment. They also explicitly mention that not everyone is suitable for this job and that a good selection of professionals is important. In addition, they discuss characteristics that an organization must meet to be able to offer gender-responsive treatment, for example, having a clear, accessible, and up-to-date policy on gender-responsive work and offering support for staff in working with justice-involved women… There are also questions and lacking policies on gender identity and how to treat transgender patients...
Concluding, there is a need for more gender-responsive approaches in both assessment and treatment and practical guidelines in working with women admitted to (gen- der-mixed) forensic mental health settings. Gender-responsive approaches take into account and respond to differences in characteristics and life experiences of males and females…
The overall aim of the present study was to develop guidelines for assessing and treating women in (gender-mixed) forensic mental health care to promote gender-responsive treatment in the Netherlands… In the current article, we focus on three research questions: (1) Which themes are important to include in the guidelines for the treatment of women in forensic mental health care?; (2) What are the benefits and disadvantages of gender-mixed treatment, and what recommendations can be made for safe gender-mixed treatment?; and (3) Is trauma sufficiently addressed in current treatment models and should gender differences relating to trauma be incorporated in gender-responsive treatment guidelines” (p. 3– 5).
“This study applied a mixed-method approach, comprising both quantitative data from an online survey and qualitative data from interviews and expert meetings. Three forensic mental health care settings admitting both female and male forensic psychiatric patients located in different areas in the Netherlands participated in this study which took place between April 2021 and May 2022…
First, an online survey about working with women in (gender-mixed) forensic settings was completed by 295 participants working in forensic mental health services… Second, semi-structured interviews were held with 22 professionals and 11 forensic psychiatric patients… The interviews with eight female and three male patients lasted 20min on average and were conducted in one session at the forensic setting in a private office… Next, the draft guide was presented in several expert meetings; two with professionals and one with patients, and there were two individual meetings with female patients. Based on the critical reflections and feedback of all these experts, the guide was subsequently revised into the final guide” (p. 5- 6).
“From the survey question What do you prefer: gender-mixed or separate treatment? it was found that most professionals prefer treatment in gender- mixed hospitals (n=191, 77.3%), only 22.7% (n=55) preferred women only wards. A significantly higher preference for gender-mixed wards was found for professionals working in inpatient settings versus outpatient settings… Most participants of the survey stated that trauma is an important risk factor that should be addressed during forensic treatment. On average, on the 0–100 scale, participants agreed to 81.67 (SD=17.87, range 6–100) with the statement… Furthermore, it was indicated that mental health care professionals should become more aware of gender differences in trauma prevalence, symptoms, and cognitive appraisal and that there is a need for gender-responsive trauma interventions” (p. 9- 10).
“Acknowledgement of gender differences and potential gender bias in the forensic mental health care should result in gender-informed policies and gender-responsive practices. In the present study, practical guidelines were developed for treating women in (gender-mixed) Dutch forensic mental health care on the basis of the literature, and experiences and needs of both practitioners and forensic psychiatric patients. These guidelines may contribute to better tailor treatment in the forensic mental health field for female patients” (p. 16).
Translating Research into Practice
“It is therefore important that treatment in forensic mental health care is gender-responsive (i.e., that gender differences are taken into account as much as possible). It is necessary to formulate clear policies about gender-responsive work in (gender-mixed) forensic settings…
We formulated two basic principles: (1) Trauma-informed care is the foundation. Trauma awareness is the core principle in this model with an emphasis on safety within the institution, providing sufficient options, good cooperation and connection, and working on the basis of strengths and building skills…
… (2) Relational working and security. Knowing someone well in order to be able to pick up on signals that things are not going well, showing interest, and offering support with emotional problems are important…It is recommended to use gender-sensitive (risk) assessment tools or additional guidelines as much as possible” (p. 11- 13).
“Future research is recommended with respect to minority groups, for instance, ethnic minorities and transgender several new qualitative studies were initiated, for instance, on working with transgender patients and on the potential risk and protective influences of having children and how contact between mother and child should be organized in forensic mental health care” (p. 15- 16).
We formulated two basic principles: (1) Trauma-informed care is the foundation. Trauma awareness is the core principle in this model with an emphasis on safety within the institution, providing sufficient options, good cooperation and connection, and working on the basis of strengths and building skills…
… (2) Relational working and security. Knowing someone well in order to be able to pick up on signals that things are not going well, showing interest, and offering support with emotional problems are important…It is recommended to use gender-sensitive (risk) assessment tools or additional guidelines as much as possible” (p. 11- 13).
“Future research is recommended with respect to minority groups, for instance, ethnic minorities and transgender several new qualitative studies were initiated, for instance, on working with transgender patients and on the potential risk and protective influences of having children and how contact between mother and child should be organized in forensic mental health care” (p. 15- 16).
Other Interesting Tidbits for Researchers and Clinicians
“Recommendations for Gender-Sensitive Diagnostics and Risk Assessment.:
Transgender persons:
- Structured assessment by experts in the field of gender is needed to classify Gender Dysphoria (and possibly transdiagnostic factors).
- Violence risk assessment: be careful to use the FAM when a trans woman identified as male at the time of the index offense; possibly use only for risk management guidelines (especially the dynamic factors).
- Sexual violence risk assessment: Static-Stable-Acute may only be used if person was biologically male at the time of the sexual offense or if the transition from female to male was generally acknowledged” (p. 15).
Transgender persons:
- Structured assessment by experts in the field of gender is needed to classify Gender Dysphoria (and possibly transdiagnostic factors).
- Violence risk assessment: be careful to use the FAM when a trans woman identified as male at the time of the index offense; possibly use only for risk management guidelines (especially the dynamic factors).
- Sexual violence risk assessment: Static-Stable-Acute may only be used if person was biologically male at the time of the sexual offense or if the transition from female to male was generally acknowledged” (p. 15).
Additional Resources/Programs
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