A feminist ethnography of secure wards for women with learning disabilities: locked away

With the current debate over the purpose of specialist National Health Service ‘Assessment and Treatment Units’, A Feminist Ethnography of Secure Wards for Women with Learning Disabilities provides a timely insight into the daily lives of women living within such units. Purportedly, these units are intended to support and ‘rehabilitate’ people who are considered to be a risk to themselves or others, so that they can progress through the service and eventually be discharged into a community setting. Interrogating the ways in which progression is understood, Rebecca Fish fundamentally challenges the purpose of these institutions without dismissing them completely. Based on two women-only secure wards in a National Health Service learning disability forensic trust, Fish recounts the everyday experiences of the people who live and work there. Through doing this, Fish demonstrates how the staff understand the aims of the institution and the ways in which these understandings filter through and shape the lives of the women with learning disabilities who live in secure wards.

Underpinned by a feminist disability studies approach, the book carefully considers the complex power relations that are at work within modern institutions for people with learning disabilities. In doing so, Fish draws upon the social model of disability and intersectional feminism to highlight the types of discrimination that women with learning disabilities can face. Crucially, she argues that there are normative ideas and values that exist within society regarding how women with learning disabilities should behave. These, then, influence the ways in which they are treated, both in the institution and in wider society. Her central argument being that ‘gender and disability cannot be disentangled from women’s experiences and the accounts that are used to understand them’ (153).

Fish skilfully draws upon complex theorists, such as Michel Foucault and Judith Butler, in ways that a lay reader would be able to understand. Her accessible sociological account is pierced with rich segments from her ethnographic research, including lengthy quotes and extensive fieldwork notes from observations. Hence, Fish allows space for the (usually silenced) voices of women with learning disabilities to be heard. At the same time, Fish also gives space for the (often undervalued) voices of people who provide ‘care’. Through this, Fish offers a comprehensive picture of secure wards, which accounts for the agency of women with learning disabilities as well as the logics and discourses that are drawn upon by the staff. In taking this approach, Fish firmly locates problematic practices and disabling assumptions at an institutional and societal level.

Throughout the book, Fish effectively uncovers the power relations that are at play within the institution. Following Foucault (1980), Fish evidences the ways in which knowledge and power are intertwined within the secure wards. She details how support staff retained control by keeping certain information from the women in the secure wards. This was often based on the logic that providing such information would create a disturbance. Thus, the women were repeatedly not ‘informed about important changes in their lives’, which ultimately ‘resulted in significant distress in the long term’ (48). This ‘paternalistic filtering of information’ (119) seemed to rest on the deep-seated societal perceptions that women should be relatively passive and people with learning disabilities should be controlled. Consequently, Fish suggests, the women with learning disabilities were being actively encouraged to be compliant and passivity was seen as representing positive progress. These techniques that were used to manage the women, Fish argues, are incompatible with national policy that advocates for people with learning disabilities to be supported to live as independently as possible.

Further tensions regarding the purpose of these institutions are revealed within Fish’s detailed account. One of her most significant findings is related to the aim of forensic units to provide both treatment and security. These aims leave support staff in a difficult position, in which they have to negotiate two contradictory elements of their role – ‘therapy and containment’. Fish indicates how the containment aspect of the role can damage the therapeutic relationship between the staff and the women living there. Yet she shows how this can remain unproblematised, as assumptions relating to gender and disability inhibited the value of positive therapeutic relationships from being seen.

Nevertheless, Fish does not solely focus upon problematic practices that exist within the secure wards. She exposes the ways in which women with learning disabilities exercise practices of resistance in response to the power relations that they are situated within. She confirms that the best way to improve the lives of people with learning disabilities is to speak to people with learning disabilities. Her book offers various examples of good practice, indicating how support staff can work together with people with learning disabilities to improve their support. Also, perhaps most crucially, Fish highlights ‘the contextual contingence and socially constituted nature of what is classed as “difficult” behaviour’, in order to demonstrate ‘how supportive relationships could transform this behaviour’ (159).

In providing such a comprehensive picture into a part of our healthcare system that is often left unaddressed, A Feminist Ethnography of Secure Wards for Women with Learning Disabilities makes an essential contribution to both academia and wider society. Fish’s work attests to the utility of a feminist disability studies approach when researching in health and social care settings. The ‘features and peculiarities’ of forensic services for people with learning disabilities that she identifies are used to suggest recommendations for the unit in which she did her fieldwork, as well as for policy more generally. Thus, this book is not only a valuable resource for academics, but also for practitioners and policy-makers.

Although this book focuses on secure wards for women with learning disabilities, it addresses fundamental issues that are relevant to wider sections of society. By recognising that the disabling and gendering experiences uncovered by the research were not limited to the institutional setting, Fish’s book speaks to a broader societal problem – in which people with learning disabilities are undervalued and societal support structures for them and their families are currently limited.

Josephine Sirotkin
Centre for Disability Studies, Sociology and Social Policy, University of Leeds, Leeds, UK
[email protected]
© 2018 Josephine Sirotkin
https://doi.org/10.1080/09687599.2018.1471815