Director: dr. E. Reale

Tidsskrift for Norsk Psykologforening,

Journal of the Norwegian Psychological Association

1 september 1987 vol.24, 565-569.

Elvira Reale

The existence of a "female question" in the field of mental health is still a subject of controversy. Traditionally, psychiatry has not accepted a sexual and biological difference between the sexes as relevant to psychiatric treatment. From our point of view these differences are highly necessary components in analyzing mental illness. This way of thinking derives from an awareness that the sufferings of men and women are specific, both in historic and in cultural ways. Subsequently, the problems of men and women neither can be analyzed nor treated using instruments and methods that do not discriminate. This experience was developed from organizing a service for women patients in a psychiatric hospital and from organizing mental welfare facilities, both entirely administered by women. We considered the use of female assistants as a guarantee of a better relationship between assistant and assisted, minimizing distance and neutrality. Further, it was important in our work that there was an increased awareness of specific female symptoms and that female sexuality has an impact upon mental health.

The, experience of the Women's Mental Health Centre (WHMC) in Naples.

We began working with women in a psychiatric context in Naples toward the end of 1977, with the creation of a ward for female patients in the provincial psychiatric hospital «Frullone». This immediately highlighted the problem of the competence of female helpers with their particular understanding and approach to problems underlying the mental condition of the women in treatment, considering the way women traditionally are met in psychiatric hospitals, we started to organize an alternative treatment outside the hospital in the district where the women lived. This led to the organization of a policlinic service for women only, and to the proposal of a methodology specifically applied to women's welfare. Thus, in 1978 the WMHC was established in an urban area of Naples.

The Centre is used in the following way:

Each year about 140 women contact us for the first time (estimates from 1979-84). The frequency of therapeutic sessions differs from once every fortnight to three times a week. The assistance period varies from one to eighteen months. Apart from these periods of systematic meetings with regular attendance, a woman may contact the WHMC sporadically for discussions of new, specific problems. Moreover, she can keep in touch by attending the open meetings, where she will encounter other women directly, without any specific therapeutic contact.

The WMHC takes care of all women who, for whatever motive and regardless of their case history, contact the Mental health Service of the Local Unit, or are referred to it by other services.

The women treated by the WMHC differ widely in several respects, both regarding age, social-economic and cultural background, occupation, and marital status. With respect to type of pathology, the women vary from those defined (from a nosologic point of view) as «neurotic» to the «psychotic», both in the status and in the crisis situations.

Thus the WMHS is liable to receive any woman, regardless of cultural, economic, gene- rational or other differences. The characteristics of the therapeutic activity of the WMHS essentially are as follows:

The goal of the intervention is not to return to a situation defined as «normal» before the appearance of the symptom, but on the contrary, to create a new way of living, more in harmony with the individual's own interests, whether economic, emotional or social.

Recognizing a correlation between illness and the woman's role means firstly highlighting the «pathogenic» content of this role. Secondly, it means re-evaluating mental illness as the expression of the unhealthy relationship that exists between a women and her social role.

The social functions expected to be fulfilled by women are of two categories: one covering material productivity, the other physical reproduction. The reproductive role is recognized by society, while the other is not. The reproductive role is considered as an affirmation of feminine identity, while the productive role is not. The combination of the two roles and the intricate interplay between them determine a range of models and obligations which do not overlap, and - even more frequently - are in complete contradiction to each other.

The principal models for these two functions are that of the housewife and that of the emancipated woman. Such models may coexist in each woman, but the co-existence is never a peaceful one. One model is always perceived as an imposition, while the other is accepted as legitimate.

Faced with this choice of roles that society presents and even imposes on them, many women feel helpless and may develop a split self image. In this situation there seems to be no escape.

The consciousness of mental illness arises out of the realization that one's living condition has become unbearable, as well as out of the conviction of its immutability. At the same time the conditions appear unchangeable for the given reasons. Then illness becomes the only way out. The experience of illness is clearly linked to the impossibility of the living conditions, and thus to an interruption in the playing of a role which promoted and reinforced those conditions. But this interruption itself is experienced as something illicit and creates its own sense of guilt . Hence the affirmation of one's illness actually means: «I am ill because I don't want to be given the blame».

The link between the interruption in a woman's fulfilment of her role and her conscious- ness of getting ill is perfectly evident in the experience of the WMHS. «Before I used to do everything, now I don't do anything the way I used to, I get tired, I do things differently, I neglect my children, my work, etc».

The previous equilibrium has been destroyed, and the responsibility for all this can only be attributed to the external event, i.e. the illness. Thus the illness itself becomes the possibility to escape from the role and its obligations. lf this escape generates a feeling of guilt, fear of losing one's identity, fear of no longer being recognized as a woman, - the illness takes on the function of supplying a reassuring and legitimate motivation for the actual change. The model of an ill woman releases her from the contradiction between the necessity to change and the impossibility of doing so.

The complete picture of the state of a woman who believes she is ill, only emerges as we investigate how, when and why she began to believe she was ill. She speaks of her incompetence weakness and lack of autonomy as factors which came on with the illness and which made it impossible to fulfil all her functions. What she does not realize is that these factors are part of her personal history as a «healthy» woman, acquired as she was trying to accomplish her role. Nor does she realize that the interruption in her functions represents not so much incompetence and weakness as the need to change.

This process begins with the woman's construction of an identity by means of all the obligations which make up the feminine role, and arrives at the conviction of being ill and different. In this process the WMHS may intervene. Our aim is to unmask the false escape which the illness offers. Mental illness carries the risk not only of the loss of personal identity, but also of the complete devaluation of the person and of her actions. It becomes a further loss of power and social dignity, even more serious than the losses deriving from her subordinate role.

How can a woman escape from mental illness? From our point of view this becomes possible when she, together with another woman who stands to suffer the same loss, examines the aspects of her own role which until now have made her suffer.

This work of giving legitimacy to a different way of behaviour is the essential function of the Service. Its fundamental point of reference is the reconstruction in which (in both social and individual spheres) the feminine role is structured and reinforced. Retracing the historical roots of this role means being able to but it into question, and even perhaps not respect the role completely, without thereby feeling «unnatural», «without identity», «wrong», or «ill». In this way the therapy offered by the Service aim to change the perception of illness.

It was precisely the way of life to which the woman attributed wellbeing, good health and normality that on the contrary led her to believe she was a sick person. She could no longer live up to her own standards of normality. Therefore we have to move towards a new perception of what is defined as «healthy» and «normal», and at the same time bring about a change in the various aspects of a person's daily life, of her way of setting up the personal, social, or professional relationships which make up her own conditions of life.

In order to no longer see herself as a sick person, she must be helped to discard and change the models acquired in the «correct fulfilment» of a feminine role, such as that of the good mot- her, the good employee, the good housewife etc. These changes are not pre-established, but come from the woman herself as she reviews the things not done, not said, stifled by others or not carried out because «this must or must not be done, be said, be thought, etc.».

As a part of a more general study administered by the Italian National Research Council (CNR), the Women's Mental Health Centre carried out a research project during the years 1980-81. The aim of the project was to define typical patterns of female disorders and to evaluate the effect of the treatment.

As a general hypothesis we postulated a relationship between the woman's perception of the female role and the risk of becoming mentally ill. Since the role consists of complex elements; and cannot be reduced to a unique typology, our hypothesis could be verified only if no specific links were found between the observed mental disorder and social, economic or biological conditions.

Consequently the women who received assistance and participated in the research project differed with respect to age, socio-economic status and even socio-biological conditions (such as puberty, motherhood, menopause). The data were matched against the total female population in the same catchments area.

The data were collected from an interview administered to every help-seeking woman. Information from other persons, such as family members, was not considered.

The information concerned the following four topics:

Finally, the evaluation programme had a follow-up study six months after the treatment was finished.

This presentation does not allow a thorough discussion of our statistical material and result analysis. Therefore, I will only present a few examples of our findings:

The efficiency of the treatment is measured according to the following two parameters:

A) Data concerning change in psychiatric condition, - such as less symptoms, decrease or end of drug treatment, and change in the initial demand of care or professional help.

B) Data of socio-economic interest, - such as initiating or expanding social relationships, and change in behaviour connected to the role-imposed duties.

Shortly summarized, there seems to be a strong link between change in the way each woman perceives her social role, and the change in her image of herself as an «ill» person. Whenever a clinical improvement takes place, the organization of everyday life improves, too. This event is attributed to the therapeutic work of establishing a personal role identity that serves both the material and emotional side of life in a more positive way, - less linked to the role-imposed schemes.

In our opinion, these results from the research project in Naples confirm our hypothesis that psychic disorders in women inevitably are linked to an unfavourable organization of emotional and relational life defined by the traditional female role. Therefore, any therapeutic attempt to change or improve the mental situation of a woman has to take the impact of the female role into consideration. lf this way of thinking is not integrated in one way or another, we believe therapy will not develop successfully.