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RISK FACTORS IN WOMEN’S MENTAL DISEASE
E. Reale
The Research in Women Mental Health Centre of Naples
We began working in Naples in 1977. The centre offered clinical help to women who turned to the public mental health services. A research project -- under the patronage of the National Italian Research Council (CNR) – also began investigating how women become ill and what treatment is given. We investigate and reflect the causes of the problems and daily life, paying special attention to limitations on women, and the oppression they suffer at the hands of society due to their role model.
An understanding of the problem involved analysing:
the social demands made on a woman because of her natural role;
the negation of her own identity in favour of demands made by society and the family;
the real role of being a mother;
the experience of dependence and incapacity by society on the female sex.
From this new perspective mental illness manifested by body anomalies was secondary and only an artificial explanation of something whose roots lay elsewhere. The symptoms, or rather the physical and mental sensations of which women complained, were not indicative of any pathological development but symptomatic of the unbearableness of a life style in which a search for one’s own identity is given up in favour of adhering to a role model.
But a destabilizing element of a woman’s personal identity was evident behind the reassuring neutral "front" of mental illness. Maternal role imposes women to do much for others and to limit their own needs and personal desires. Playing this role means any personal requirements remain unfulfilled with unpleasant results: tiredness, boredom, detachment from everyday life, loss of happiness and interest, short attention span.
These reactions are considered pathological in that they are not justified by normal maternal occurrences. In reality neither society nor, consequently, psychiatry, realises the existence of another female identity over and above that defined by a woman’s natural and maternal role. This identity is not recognised by society but it acts quietly and undermines a woman’s state of mind, especially when she is under pressure, and leads to what psychiatrists call "mental illness".
A "therapeutic" attitude, which heeds into consideration the difference of sex and gender, thinks of this role model as a shell which must be cracked in order to reveal the underlying identity.
Our work is based on this principle and concerns the ways in which woman fall ill and how risk factors are present in their everyday lives. We treated about 1.200 women from 1981 to 1987 with different pathological problems (ranging from neurosis to psychosis). They were of different ages and backgrounds.
THE RISK FACTORS
A study of therapeutic work with women in the period 1981-87 (1.113 women in all) brought to light specific risk areas with particular reference to the performance of social and sexual roles.
We examined specific risk areas, (in which factors are themselves connected within the dynamics of everyday life relationships) which could act as means of defining the mental condition of the woman in treatment, in her social context. The identification of these areas and their components was made possible trough the work of the service and the formulation of the instruments for the analysis of everyday life. This very analysis of a woman’s daily life reveals the source of illness to be the relationship between work in the home/work outside the home and feelings of adequacy/inadequacy.
The examination of these two categories was carried out through the analysis of the mechanism of a) demand b) response where a) is represented by the socio-domestic context and b) by the woman (
table 3).This ‘demand’ is that the woman assume her duties and responsibilities. The demand is made in the name of the model of a ‘natural’ role, that of maternity. For this demand to be implicated in the development of mental illness it must have certain characteristics which are understood and justified only when seen in relation to the model, and then it takes on social legitimacy.
The main characteristic of this demand is that the woman offer up her work gratis since it is supposed to be work which is given on the grounds of emotional attachment or natural predisposition. It is essentially a ‘non-work’ in so that as it is a part of the very process of women’s social and individual identification, and part of the acquisition process and the process of strengthening and developing basic personal and biological characteristics.
It is nearly impossible to refuse a demand which has all the weight of social approbation. The system of response is upset when a woman becomes aware of her own limitations in meeting the requests and expectation of the context. When this occurs the woman’s response is it self a ‘demand’ , a request for help, is a lightening of the burden. This request for help does not in any way take away from the legitimacy of the demand but does mean a suspension of the process of response
The request for help creates conflict between the woman and her context. The conflict ends with the re-assumption of duties as a result of the judgement of inadequacy and incompetence passed by the context. Others factors contribute to the victory of the context over the woman. She does not have any other viewpoint from any other group of reference. The woman adopts the context as a point of reference in order to validate her abilities.
2 . The risks in the daily life
All the factors which lead to mental suffering and give to the definition of a woman as a sick person can be found in this relationship between woman and her context:
a) an excess burden of work and responsibility
b) disparaging judgement of the social context
c) absence f external groups of reference
d) subjective perception of inadequacy
e) restrictions on personal interests and activities
f) a reduction of personal plans and aspirations
g) the presence of physical ailments
Excessive burden is the main feature of the context demand along with disparaging judgement in the case of a woman who bas difficulties in performing the tasks and the acceptance of the judgement passed by the context in the absence of alternative points of validated by other groups or individuals.
The major consequences of accepting the burden of work are: the restrictions of personal space and interests; the diminution of goals for personal development and as expression of self-esteem; tiredness expressed in terms of physical symptoms.
These seven factors are analysed in the context of the woman’s personal history. The development of what comes to be labelled ‘mental illness’ may occur in one or more stages of the woman’s life: stages in which the demands of the context take the form of an increasing number of imperatives and ‘musts’.
In order to determine the nature of these factors life history is looked at according to a progressive increase in work load and responsibility. In this respect the history can be divided into a series of phases including adolescence (including pre-adolescence), marriage and maternity, menopause and the end of reproductive life, which the demands of the context mean the performance of tasks for others ( parents husbands, children, grandchildren, etc.).
Clinical research which aims at identifying the develop of the disorder and illness therefore covers all these phases of a woman’s life from adolescence onwards. It is phase that a boy/girl are expected to perform duties as a kind a f apprenticeship for their -respective sex roles. The role imposed tasks of childhood do not have the same legitimacy and are of a much more limited nature. They are to be seen as precursory to the official demands on pre-adolescents and adolescents.
So clinical research examines the history of these phases and analyses: the increase in the work load; disparaging judgements of the context; the presence or absence of support groups; feelings of incompetence; the possible reduction of personal interests and plans, as well as inertia and the presence of physical complaints. This kind of study on the risk factors in an individual case can be identified and plotted as revealing the development of illness and facilitating and understanding of the illness.
3. Life’s stage at risk: Adolescence
The road towards the illness itself can be divided into different stages, which correspond to the intensity and degree of discomfort experienced in terms of feelings of inadequacy during the training period for the role (adolescence) feelings of inadequacy in other phases of life; the unendurable nature of incompetence, and as such propaedeutic to mental illness. These different stages which lead to the gradual awareness of the mental state can be spread over different phases (eg. adolescence, marriage, maternity, etc.) or be present in just one (during the adolescence, for example). This depends on how or be present the factors already mentioned present themselves. For example, if certain factors are only partially evident and lead to only a partial diminution in certain sectors (personal interests, reference groups, plans) but not their total negation then , in this case the course of mental illness will run trough more than one phase of the woman’s life.
When the illness does encompass the different phases of a woman’s life it displays the following typology of factors in the adolescence phase:
a) the excessive work load is in answer to the psychological or material needs of a parental figure, usually the mother
b) the judgement of the context forces the adolescent to perform the supporting role requested at the cost of personal interests which clash with the role;
d) an external point of reference is present thanks to which the ruling of inadequacy is mitigated;
e) there is a reduction of personal space but spirit of rebellion pervades with regard to context;
f ) the demands of the context with the inevitable restrictions lead to the formulation of plans which are an alternative to those of the home. As a result the adolescent is freed from the negative judgements of the context and it demonstrates ability succeed in the future in one or more areas of life: emotional life and/or marriage, maternity,-study, work or careers, etc.
g) physical complaints not defined as mental illness but used by the context to represent the adolescent as weak and in need of family protection. In successive stages the presence and the intensity of these factors is measured by a quantitative and qualitative comparison of the factors present in adolescence, and by what the woman says herself of personal plans which still have to be put into action and which are an indication of individual resources and capacity.
4. Following life’s stages.
In the phase following adolescence (earliest courting, engagement, first work experience outside the home, etc.) other areas of excess burden and reduction of personal space can be identified. When these factors are not completely present and there is still room for the expression of individuality, this particular phase cannot be considered the final stage of the development of the illness. However, it does form and deepens the awareness of inadequacy preparing the way for the perception of illness.
In this stage which we have defined as the stage of the formation of ‘the perception of inadequacy preceding the illness’ the following conditions should subsist in comparison to the training for role stage:
a) h) an intensification of the demands of the role with a clear imputation of inadequacy where the woman bas difficulty in performing her duty;
c) d) an absence of points of reference outside existing context (the existing context should coincide with the alternative point of reference in the adolescent phase) ; a restriction (but not complete) of personal space for the development of personal interests;
f ) an acceptance of the judgement of the context and, as a result, the abandonment of one or more of the plans from the adolescent phase. A calling into question of the individual’s abilities on the part of the familial context;
g) the increase in/ increased attention to physical complaints.
4. An unbearable situation
Finally, the stage we have labelled ‘the unbearableness' defines an objective and subjective situation of imminent risk of illness. In this phase, which could coincide with all the stages of a woman’s life but generally coincide with that of maternity, and the bringing up of children (with or without external work), the risk factors are present in the following way:
a) b) an increase of the work load accompanied by further accusations of inadequacy in other areas of life;
e) d) absence of external points or groups of reference and collapse of the support from the alternative point of reference in the adolescent phase; complete loss of space for the development of personal interests (comparison made on the basis of previous history);
e) f) failure of the demonstrative plans of the adolescent period. The adoption of the judgement of inadequacy and acceptance of sole means of fulfilment and expression of self-worth;
g) presence of general tiredness and fatigue and heaviness.
The move from the state coined ‘the unbearable' to that of subjective/objective definition of illness, is relatively brief. It is the result of the collapse of the only means left of self realisation.
5. The stage of falling ill
When a woman begins to see her situation in terms of illness, her perception of her existence is turned upside down. Her daily life with its problems and conflicts ceases to be of any value she concentrates all her energies on the evaluation of physical complaints and projecting the image or herself as an ill person. Physical symptoms and tiredness are not considered to have any connection to her daily life but are thought of in isolation, and so, only in terms of illness. They are therefore no longer symptoms of an unbearable living situation but of a pathological state.
Since the risk factors are connected to daily life they are also lost in the context of the illness. They cannot be perceived, since the illness negates any correlation between the illness and the home situation. For this reason, the analysis of factors is carried out with two different models and two different goals.
The clinical work with the woman who sees herself as ill; and preventive work with subjects at risk, e.g. adolescents, women under excessive burdens, with external work as well as work in the home, women with small children, etc.
In the first case, the woman receives individual attention and is treated in terms of the illness; looking at the physical and mental symptoms as perceived and codified by the subject (generally, this codification corresponds to the official psychiatric codification and depends on what experiences the subject has had of a psychiatric or mental institution).
This work also aims at identifying the risk factors through a study of the woman’s everyday life. The stages in which overwork and excess demands of the context are most evident are examined (analysis of daily life and personal history,
table no. 1), starting from the definition of illness and working backwards, the different stages (inadequacy in the training for role stage, inadequacy in other phases, 'the unbearable phase’) in which the different factors manifest themselves and develop, is traced, (analysis of the perception illness, table no. 2)In the second case, work is carried out in group session and the aim is the identification of the risk factors of the particular phase the individual in experiencing (the group is homogeneous as far as this is concerned). An open questionnaire is used which includes specific examples of risk situations which are discussed collectively by the group. This work on the identification of risk factors in female mental illness does have wider applications. It is relevant to other social groups who find themselves in a subordinate position in which they have to cater to the needs of others. The model of ‘maternity’ as a model of social behaviour which implies the sacrifice of self to satisfy the needs of others, while being the most complete incarnation of the model, it is a model which can be applied to any person in a position of social subordination. Maternity is a state which is synonymous to need and protection and entails the carrying out of tasks which are considered a natural duty and a such contributing to a woman’s self realization.
The risk factors we have considered are to be found in the above mentioned kinds of relationships. Although they refer mainly to women they are also relevant to categories of individuals.
A Clinical Case,
Let us now give an example of this by showing a scheme of a clinical case that typifies the female risk condition of which we have spoken. (
see tab. no. 4). It is the case of Silvia, a married, working woman with three children under the age of fourteen. When she arrives at the our Centre she is 34 years old, not long after her last maternity.The following schema shows the various stages along the pathway to illness in Silvia' s history the two phases of ‘unbearableness’ : 1982--85: till September 1985 when she begins her crucial reflection on her own renouncement and incapacity which comes to an end in January 1986 when she arrives at the Service worrying about an illness.
When Silvia arrives at the Service she no longer mansions her daily life, present and past. She refers only to her own symptoms (forgetfulness and fear of losing her memory) as a pathological interruption of her psyco-physical functionality. This change in her point of view is a turning point in her pathway to illness.
What has happened in the past has lost all meaning to Silvia who does not relate it to her present sickness. The Wornen’s Centre, on the contrary, aims to reconstruct the link between symptom and history and brings discussion to bear on how the woman relates to her context in the light of her personal history as a whole. The scheme also identifies the stages that precede the pathway to illness, adolescence, the relationship with the mother and the first years of marriage. For each stage the events and relationships in the context are sub-divided and classified in the seven risk conditions that have already been listed.
Thus it can be seen how already in adolescence there is an overload on account of her supportive role in relation to her mother. As a result of this there is a partial closing with regard to friendship, except where her fiancé is concerned. Later on her relationship with her fiancé/husband will be to a large extent the object of her personal aspirations. She will also need to demonstrate to her mother her ability to succeed in the field of sex and affect - an area in which she is subjected to considerable criticism - .
It is precisely this personal project for which she has no alternative, which she must gradually abandon over the years. On the other hand her overload remains constant and it concerns her function as a mother. Silvia, though working, is not allowed (by herself or by others) to feel she is able to do less work in house.
Indeed she thinks that she should perhaps be even more dedicated and cheerful about her tasks than other women because by going out to work she feels she has stolen time from a function considered to be of prime importance. By the time Silvia perceives that she is physically ill, the restriction of her personal space and interests has completed its course. She is further overloaded by her latest maternity. She has completely abandoned her project for a fulfilling relationship with her husband based on equality and is subsequently judged incapable by others and then by herself too.
In the end she must renounce the last part of her project, that of being a good worker. The risk of illness which has been present since her adolescence with the overload from her mother, the restriction of her opportunities for friendship and the forming of a demonstrative project emerges when she has her last child.
This is the time when the areas where the risk factors lie are at their most oppressive. One overload is addend to another: the re is a total limitation on her personal interests; there is a total lack of any point of reference outside the family; her perception or herself is negative in every respect; her personal project is a failure in every aspect; her context judges her negatively and she even considers her body as non-functional; finally physical symptoms become manifest in a pathological state.
ANNEXE Tab. 1.2.3.4
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