Director: dr. E. Reale

Methodology

The woman’s illness condition derives from her perception that she is unable to control her thoughts and behaviour. Its symptom is the manifestation of this inability and is characterised by lack of control, unpredictability and involuntariness.

Whether it is anxiety, depression, panic attacks or obsessions that she suffers from, the woman feels she is dominated by them. The symptom appears to be something extraneous, independent of the individual herself, and its effect is one of change in a life which was once normal. The symptom is experienced as something which prevents the person from living the kind of life she has lived up to now (“I just can’t do what I used to do, or be as I was before”; “I’m blocked by anxiety” or “I no longer get pleasure from the things I used to do and everything is an effort”).

            From the point of view of subjective perception, a distinction should be made between anxiety symptoms and depression symptoms:

·                     Anxiety symptoms impede activity that the woman is motivated to carry out; such motivation, however, is not personal, but comes from a sense of duty.

·                     Depression symptoms are experienced as a loss of motivation to do things, and loss of motivation is felt as something to be guilty about, or as unwarranted.

In both cases, the person sees herself as not functioning psychologically and socially, and attributes this inability to function to illness. Illness perception includes the idea of the non-justifiability and illicitness of behaviour, and is closely connected to models and norms of social behaviour. In women, the models of behaviour are closely related to their role, as characterised by the job of attending to and satisfying the needs of others.

            The treatment we use, which takes as its starting-point what is known about the role of women and criticism of that role, diverges from the psychiatric approach, whose aim is to reinstate women in the very model of behaviour that the symptom has thrown into crisis. Here, we view the symptom not as extraneous to the woman’s previous way of life, but as a sign of a way of life that has become unbearable.

            There is evidence from our clinical and research work that the conditions of the unbearableness of a woman’s life are brought about:

·                    on the one hand, by family work which, because it requires total dedication, often results in work overload and stress

·                    on the other, by the attitude, so typical of those whose job it is to look after the family, to make the needs of others the centre of attention, so losing sight of their own needs.

In our view, the symptom becomes a sign of an unbearable situation of which the woman is not aware. We consider the symptom as the expression of the impossibility of carrying on a given function or way of life. For this reason, we refrain from using drugs against symptoms. At the most, a light medication in the form of minor tranquillisers might be used. These always have a supporting function, and are self-administered.

            Through this approach, the woman is encouraged to acknowledge her symptoms as a sign that she can no longer bear her way of life. The aim, therefore, is not to treat the symptom, but to use the symptom as a guide to explore the woman’s way of life before the onset of the disorder.

We use a method that we call the “concreteness method”, on the basis of which we analyse daily life, events, changes, oppression relationships between the woman and the context in which she lives.

            For example, we give attention to the common patterns of single events in everyday life: what time the woman gets up, how long it takes her to get the children, or meals, ready, and so on. We also concentrate on the different tasks carried out by the woman, the men, and by the other members of the family. We focus, too, on the relations of dependence of women on men in adult life, and on parents in adolescent life.

            In short, the evidence of our clinical and research work suggests that other health care providers should include the following criteria in their methodologies of treating women:

·                    an objective criterion aimed at identifying the concrete and observable workloads and responsibilities attached to the events and changes in the life of the woman

·                    a subjective criterion designed to highlight, in terms of the woman’s response to life’s events, her cultural tendency to take on responsibility for others, to respond at any cost to their needs, to try to meet the requirements of others.

In conclusion, this is the typical response of the female role, of those who do family work: not to satisfy their own needs, but to adapt their way of life to the needs of others (the partner, children, etc.).

On the basis of these goals, criteria and methods, the treatment tends to make the woman who is unwell aware of:

·                    the material and psychological load of work in the family, either by itself or together with an outside job – the physical and psychological effort it requires.

·                    the dependence that housework creates in women when the criteria of satisfaction of this activity is measured exclusively in terms of others’ wellbeing, and of recognition by others

·                    the strength and tolerance of hard work expressed in the tendency to take on other people’s problems

·        the exhaustion and impoverishment of one’s strength that come about as a consequence of taking care of others. Such exhaustion is partly due to the fact that there is no possibility of recuperating physical and/or psychological energy (there are no recognition of work made for others or exchange advantages). What is more, the lack of strength and energy makes it impossible to achieve personal empowerment objectives.

By using these new ways of interpreting illness, women are able to modify their initial perception of themselves as weak and ill, and arrive at a different image.

Thanks to this interpretation, women no longer need to become strong because they used to be weak, they have no need to get well because they were once ill. They need only:

·        to divert their energies and attention, first towards themselves, and then towards others;

·        to modify the cultural tendency to feel an obligation to face events, being in front line;

·        to learn avoidance strategies, so as to feel justified in  refusing tasks and demands made on them which are either excessive or not directly related to their wellbeing.

Phases of treatment

Treatment ranges from 4 counseling sessions, or 8 sessions (a short psychotherapy cycle), to more than 8 sessions (medium-term psychotherapy cycles).

The treatment can be subdivided into 3 phases.

Phase 1

The first phase consists of listening to the client talking about the symptom and her perception of herself as an ill person. The history of the symptom is analysed, focusing on the times, modes and circumstances of its appearance (how, where, when).

            The aim of this phase is to enable the women to exercise more control over the symptom and not be afraid of it. It is important for her to understand and experience, with the help of the specialist, that having a symptom does not mean that she has lost control of herself or her behaviour.

Phase 2

In the second phase, we work on the part the symptom plays in the woman’s everyday life. We begin to establish a disassociation of the symptom from personal history, and a repositioning of the symptom in this personal history and in everyday life. In this way, the symptom comes to be interpreted as an escape response from an insoluble conflict between personal needs and the needs of others.

            The tools adopted in this phase, which we have described in two volumes published by the CNR (the Italian National Research Council) are two Protocols: Analysis of daily life and Analysis of getting ill.

            Analysis of daily life presents the set of operations used to collect the facts of personal history around significant events in life (adolescence, motherhood, menopause) because during such events the social and family context exercises specific pressures. By using this tool, the therapist highlights the distinction between facts representing the interests of the woman, and facts which express the interests of others (particularly those of the family context).

            Analysis of getting ill shows, in a concrete way, the relational dynamics between the context and the woman herself. This tool focuses on the ways in which the others in the context request or impose tasks and the ways in which the woman responds. The request modalities most often involved in causing disorders are those which undermine the individual’s ability to be autonomous. The response modality most often involved in mental disorders is facing indefinitely  and the tendency always to satisfy the demands of others, while at the same time perceiving the self as weak and incapable of autonomy.

            The pathway goes backwards from recent events to those most remote in time. And at every stage of this pathway, we point out the presence or otherwise the absence of mental disorder risk factors.

            Mental disorder risk factors have been identified both in clinical research on depression and in research on stress in the daily lives of women carried out for the CNR (Italian National Research Council).

They are: work overload, reduction or absence of personal interest and activities, reduction or absence of external relationships, reduction or absence of personal plans, lowering in self-esteem perception, negative judgments from the family and extra-family context, tiredness, and being unwell.

Phase 3

In the third phase, the woman reconstructs a new point of view: she overcomes out of the perception of illness. The woman comes back in contact with the practical problems to face, but now with the support of a new and different vision of her role, of her resources and abilities, and with the very personal goals. The work in this phase also gives psycho-social support in changing attitudes and behaviour so that they are more conducive to the woman’s wellbeing. 

Prevention

Before concluding this brief description of our approach in woman mental disorders, we would like to add some details regarding the prevention since it is the driving sector of our activity. Years of clinical observation of the mechanism related to the process of disease led us to intensify prevention actions and improve tools available to stop or reduce the risks of illness.

Particularly in collaboration with of CNR (Italian National Research Council) we have worked out  and accomplished  a five-year plan on the psychosocial elements of risks related to   high incidence of   illness  in the female population, such as Depression, breast Cancer  and Hypertension.

            In addition we have intensified the work of prevention relating to  adolescence disease by expanding the relations with the schools . At the same time we have worked out national and international  projects regarding both the prevention of mental disorders  and vocational guidance, by means training for teachers, parents and students.

            We have concluded a research on mental disorders in adolescence. Its main purposes were:

-         promoting information about specific elements of mental risks factors among  adolescents;

-         avoiding symptomatic patterns, on the contrary suggesting an interpretation of those behaviours as  signals which are  precursory to  frequent mental disorders, especially among teenagers, such as  eating disorders (Anorexia and Bulimia) and state of anxiety and depression .

The activities of Counseling and Brief Psychotherapy  of the Youth Centre have been implemented since 1992   for  this kind of users who  seldom apply to specialist centres for prevention and cure of mental  illnesses.

            The great attention given to adolescence is due to the belief that this age is  particularly at risk  for the beginning of mental  illness. In this  period of life the individual   undergoes conditioning, social and family pressures which can damaged adolescent's self-image and his planning for future; they do not promote the tendency to  autonomy  which is typical of this age.  Our study shows how this happens especially in family contexts where the natural tendency to autonomy of teenagers is in conflict with the expectations and demands of the members of that context.

The demands expressed to the adolescents can be particularly oppressive and not in accordance with their age. They lead the teenagers in taking care of adults' problems. That is: hi is inclined to give psychological or material support to one, in preference to the mother, or both parents.

            Our case histories show that the female adolescents - the eldest especially – are more exposed than males to above-mentioned overburden and, as a result, more entangled in the problems of adults.

             Therefore, our work on adolescents focuses on early assumptions of adult roles and on  the individual  and social efforts in order to reduce or to stop the dragging on of difficult life situations. 

Being both women and health workers we have tried to apply our experience in the field of research and clinical observation to expand and refine the tools of  prevention, intensifying information –  even beyond health-care system  – on what we consider to be  the main elements of risks related to mental disorders among women and trying to make them aware of  its   precursory symptoms and mechanisms of getting ill.   

Appendix

The procedure of the development of the illness pathway

This procedure aims to show the steps of transfer from being well to being unwell. These steps, analysed by the tools and the methodology above indicated, lead the woman back, from the event nearest illness onset to adolescent age.

Step n. 1

It concerns the analysis of a time extension of the 3 months before the onset of the symptoms and ill condition defined by the patient's perception.

It’s important to find out the so called “drop-event “, an event not severe but  enough to unbalance a psychological system.

Starting from the “drop event”, it’s important to take in consideration the time, before from 6 months to 1 year ( 2 step). This period (1 year) shows a substantial and a complex change in the life conditions, which could explain how a single and/or not severe event (drop-event) could cause a break in the personal balance.

The result of the changes in daily life during the recent year is a change of prospective; the person goes from the point of view of self-control capability to the point of view of incapability of self control.

Step n. 2

It concerns 1 year time before the onset of the symptom and the request for help.

The analysis of this period of time should find out a more important event  or a group of events that have influenced the life organization of the person. In this contest it’ll be possible to find out a group of changes related to different life areas (work, interests and projects, supports and relationship, oneself and other’s perceptions).

This analysis aims to clarify: a material and psychological overload; a reduction in supports, in self-esteem, in projects, capabilities and expectations. Particularly we focus on up the last and the one project or expectation, which is still in progress.  This project is the field the “drop-event” will falls in. It will happen in  the last period  before the onset of the symptom and request for help.

Step n. 3

This step concerns the analysis of an earlier time period, from 5-10 years before the onset of symptoms. This period is analysed focusing on the main phases of life-cycle or other events leading changes in life-conditions.

Step n. 4

The last step of this sequence will be the adolescence. This phase is considered the field where the woman builds the personal style of response to events. In this phase the woman begins to hold role models and make plans for the future.

The analysis of this period focuses on the projects and models which the woman has carried on in relation of the pressures of her family.

If  the woman lives the adolescence with a psychological  pressures on her projects she  mortgages  the future.

 This mortgage constitutes a specific risk factor, that is:  a lack of freedom in planning and in confiding to personal resources and capabilities.