Gaining ground on mental health

Mental health issues of women are gaining ground in the women’s studies discourse. The women’s movement has provided fresh inputs in terms of individual and group counselling, popularly known as “Consciousness raising” exercise, a form of mutual counselling that enables women as a group to share experiences, problems, feelings, dreams, utopia and action plan for rebuilding shattered lives. This process of attaining feminist consciousness allows women to recognise that what they perceive as personal problems are shared with others in a non-threatening and non-power oriented atmosphere. It also enables women to realise what they think of as resulting of living in patriarchal society. “Consciousness raising can be seen as enabling women to overcome false consciousness.” It empowers women to come to a realisation of their own potential, makes them autonomous, self–dependent in their decision-making power and emotionally self-reliant. It is an ongoing process that brings about personal and collaborative change as opposed to structural change. The need for small groups and informal group discussion is emphasised in this method.

Manifestations of depression

Depression in women manifests in headaches, sleepless nights, constant tension, detachment, irritability, loss of appetite, dryness of mouth, fear, self-blame, lack of concentration, lack of interest in any kind of activity. Although chronic headaches may not be psychosomatic, they can be caused by depression or anxiety. Thus, counselling can help you identify and address emotional concerns and should be considered as part of your treatment.” There are two types of stress leading to mental disorder. Biochemical stressors are hormonal fluctuations at the onset of puberty, pre-menstrual phase, post partum phase and menopause. According to Dr. K Ravishankar, Estrogens have an effect on brain chemicals like serotonin and/or epinephrine that are involved in headaches. An imbalance in serotonin levels has, in fact, been implicated in disorders like migraine and depression.”

Psychosocial stressors originate from the external social environment such as women’s inferior social position, lack of power, homelessness, economic hardships, man-made or natural disasters. They create learned helplessness (women’s seeming passivity in the midst of crisis such as domestic violence, accidents, etc) and reduce motivation to lead an active life. Stress related mental health issues are illness in the family, death of one’s spouse, divorce, accident that might reduce or destroy women’s ability to shoulder responsibility. After marriage, women get displaced which brings about cultural loss and bereavement, loss of social networks and supports, loss of traditional healing sites. Psychological stages through which women pass are -– enduring, suffering, reckoning, reconciling and normalising. The successful completion of therapeutic cycle depends on how conducive the physical and emotional systems are. Sometimes hysteria can also open up more opportunities and increased freedom/space with added costs. Women cope with tension by crying, talking it over, praying and engaging in creative work-music, art-craft-reading-studies-community work, team building.

Approaches to mental illnesses

One universalist approach uses diagnostic categories of mental illnesses such as neurosis, schizophrenia, psychosis, mania, phobia, paranoia so on and so forth. Psychiatric labelling does not take cognisance of material reality faced by women on a day-to-day experiential levels. It obscures social reality such as riots, natural disasters, fire and accident while dealing with phobia among women. While working with women victims of riots, we should know that their phobia about men has a basis in the fact that they have witnessed killings and rape. Hence, medicalisation of mental health in the Draft National Health Policy 2001-III has been criticized by women studies.

The philosophical basis of psychiatry as a bio-medical discipline prevents mental health professionals to take into consideration larger reality and macro issues resulting from socio-economic and political factors. Psychiatry focuses on treating the individual symptom while ignoring the disease. ‘Diagnosis’ frequently arouses protests of indignation about labelling people as ill and treating them as impersonal objects. Limitations of bio-medical perspectives lie in their narrow focus on somatic and psychological factors in their diagnostic efforts, ignoring the impact of socio-cultural and socio-demographic factors. In India, the focus is more on the treatment of the illness, not on preventive and promotive efforts. Marginalisation of mental health concerns results from the understanding that mental distress is a manifestation of an individual problem, not directly related to social oppression and not common to all women.

Another, different approach emphasises cross-cultural psychiatry and evaluates phenomena of mental illness from within a culture. Traditional treatment of the mental illness used to be meditation, yoga, group singing and listening to the discourse. A culturally sensitive counselling on mental health consequences of trauma takes into consideration women’s socio-cultural environment.

The two approaches gave way to new cross cultural psychiatry where the emphasis lay on the different contexts of mental illnesses in different cultures, not on bio-medical categories. Now, there are no two opinions about the statement that psychotherapy should keep into consideration multicultural aspects of women’s existential reality.

Psychiatrists use chemotherapy i.e. administration of anti-depressants and sedatives, shock therapy which induces shock, with or without convulsions, in a patient by means of insulin or electric current through brain. Individual psychotherapy includes hypnosis, suggestions, supportive therapy, re-education, desensitisation and other forms of consultation, group psychotherapy, family therapy and psychoanalysis.

Four phases of Healing Cycles are:

1. Enduring - anxiety, grieving and loss of past
2. Acceptance - reality testing, preparedness and reckoning of the future reconciling, evaluation of self and resources, recuperating
3. Recovery - rebuilding life, maximising options, setting new goals, healing
4. Normalising - stability and routines, building relationships and community

Unequal relationship between professional counsellor, who is UP THERE and the seeker, who is DOWN BELOW creates a communication gap. In case of women, this inequality is compounded by subjugation of women by the patriarchally structured psychiatric system. The focus on ‘feminine qualities’ pathologises all physiological changes of a woman, in childhood, adolescence, reproductive age and menopause.

Worsening socio-economic, political situation and mental health of women

Experiences from both industrialised and developing countries have revealed that the prevalence of common mental disorders or minor psychiatric morbidity is high among the urban low income and marginalized population. Women among them are even more vulnerable. Globalisation, Structural Adjustment Programmes, increasing conflict with neighbouring countries and ongoing sectarian violence on caste, ethnicity and communal lines within the country have put the population of our country at high risk of mental illnesses.

Alert India is a large NGO with 550 community workers working among the marginalized sections of Mumbai metropolis. Their women health workers found that women who have to deal with financial hardship, experience tremendous stress. Moreover, women within community are affected differentially depending on their own place in the Indian socio-economic hierarchy. In this regards, female-headed households are most vulnerable to mental distress. The mental health professionals are only geared for the episodic disasters and not the enduring disasters. Hence, there is a need for interdisciplinary mental health interventions.

Professional counsellors act as facilitators in Self Help Groups (SHGs). They use the technique of mutual counselling to identify areas of strategic interventions.

Need for Culture Specific Approach in Counselling

From respect for basic human rights it follows that the counsellor addresses the issues concerning cultural mindsets and behavioural variety that determine women’s mental responses to tragedies. If this variety is not appreciated, counselling will end up being reductionist and homogenising. Here the soft wear is not formal education, but life. Mental health of women victims and survivors of tragedy demands multifaceted approach. Individual counselling by the professional counsellor can be helpful in breaking ice. At the same time, women with similar experiences can empower each other by narrating their problem areas and finding solutions.

Patriarchal biases of the mental health establishments

The mainstream mental health professionals are unable to impart the required counselling to women due to misogyny. Stereotypical understanding about women’s role in the family and society governs their psyche and if the so-called “mentally ill” woman does not fit in that mould, she is declared ‘socially incompetent’ woman. Witch hunting of lesbians by the mainstream psychiatrist is so strong that even All India Institute of Medical Science has a special package for counselling, “to correct deviant behaviour” of the lesbians. Subordination-domination relations between men and women are re-emphasised in the mainstream counselling.

Sexual violence and mental health

Sexual assault, molestation, rape, sexual harassment at workplace, child sexual abuse, nuisance calls cause psychological disturbances among girls and women. The trauma of sexual violence sparks off tension and anxiety at a dangerous level. Their mental health problems are manifested in anxiety, fear, avoidance, guilt, loss of efficiency, lack of coordination, depression, sexual dysfunction, substance abuse, relieving the traumatic incidents through memory, suicidal attempts, eating disorders, disturbed sleep patterns, fear of encountering such situation once again. It is found that “women who undergo extreme sexual violence experience a loss of self and self-esteem following the shock inflicted on them. When there is a continuous period of traumatic stress, it becomes chronic, lessening the individual’s ability to do any kind of constructive work.” Hence, this form of male violence towards women is an important issue that demands public attention. Indeed, women’s organisations have taken up this issue at a local, national and global level.

Domestic violence and mental health

Discourse on mental health of women in the family situation gained serious consideration in the context of campaign against violence against women. In domestic violence situations, predicament of women is determined by their position in power-relations vis-à-vis the rest of the family members. Research which attributes deviant behaviour of adolescent girls to their working mothers place women on a guilt trip by narrowly focussing on single parameter and ignoring factors such as peer–pressure, media, overall standards of morality in our society and power relations in the family. Such research is used by some counsellors to cage women into domesticity and divert the attention from generation of genuine support system for developmental needs of the daughters of working mothers. Women’s rights organisations which are doing support work for women in distress have started giving due importance to counselling.

Adolescent girls and counselling

The most mind-boggling problems faced by adolescent girls are decision-making in the day-to-day life, self-dependence and career. Rapid changes in the socio-economic and cultural reality, parental expectations, values and norms, rising levels of competition and pressure during examination time and a break down of traditional family structures are factors that accelerate this alarming trend. Examination related anxiety results into sharp rise in girls hurting themselves deliberately, leaving homes or killing themselves. Fear of failure is a root cause of all qualms. Large number of students and their parents are seeking professional help. Consulting a psychiatrist is no longer a taboo as the psychiatrist responds to cries for help from a crippling academic burden. According to them, we have more problem parents than problem children.

Providing good and healthy role models is very important. Parents who want their children to develop high self-esteem should make a point of treating them with respect and dignity. Concept of fiscal hygiene is important for girls to understand the value of clean money earned through hard work. Today’s adolescent girls are at the crossroads. But every crossroad leads to new roads. Information revolution has made adolescent girls more aware and precocious. They have to enhance their knowledge base. Broadening one’s personal horizons is a sure way of tackling the crisis within oneself. Today, girls find that the values instilled in them since their childhood are hollow in real life. Romance is found utilitarian and consumerist. The economic security is bleak, emotional security is becoming a victim of uncertain times. Globalisation has led to the emergence of apparently homogeneous life-styles, necessities and comforts through media-images, whereas the reality of life is at significant variance with resources required to maintain such a life. This has further deepened the crisis of the youth. A dictatorial atmosphere in the family, educational institutions and in the community life, make adolescents feel left out of the decision-making processes affecting their lives.

Hence it is very important to understand that,

“Inclusion is trend,
Such as democracy,
Freedom and justice for all.
All means all,
No buts about it.

Inclusion is opposite of exclusion.
Inclusion is no to boycott.
Inclusion is a battle cry.
Challenge to the parents,
Child’s cry for his/her existence…
For welcome, for embrace,
To be remembered fondly…for award
For gift of love…like surprise,
Like treasure.

Inclusion means clean game,
General knowledge, courtesy, hard work.
Inclusion is great in its simplicity,
And surprising in its complexity.
Instead of investing in jails, mental asylums, hospitals, refugee camps,
To canalise resources for creating true homes,
True life, true human beings…
For humanising life.


-- Marsha Forest

Both in private and in the public spheres, we need to give more space for development to the adolescent girls.

Counselling for substance abusers

Support resources for substance abusers are counsellors, family members, significant peers and school or treatment staff. Group therapy is an effective intervention method with abusers. It facilitates the process of recovery of addicts. Sharing of experiences by the abusers shows them ways to empower each other. Self-help groups of abusers are more effective as they avoid problems generated due to different wave-lengths.

Counselling for HIV-AIDS patients

This is very important issue faced the 21st century. Counselling for dealing with social stigma and creating an alternate support network are the most important aspects of providing emotional support to the HIV-AIDs patients. The Lawyers Collective HIV/AIDS Unit holds monthly drop-in meetings, with an objective of sharing information, experiences and resolve mind boggling issues affecting the lives of HIV/AIDS patients. It also provides legal aid and allied services to the needy. “The main objective of the unit is to protect and promote the fundamental rights of persons living with HIV/AIDS who have been denied their rights in areas such as healthcare, employment, terminal dues like gratuity, pension, marital rights relating to maintenance, custody of children and housing.”

Electronic media and mental health

People engage with the T.V. because there is vacuum outside. Different standards of morality for men and women, are present in messages from the film, television serials and advertisement industry. Boys and men who watch pornography are on the look out for innocent adolescent girls. These girls are the victims of pornography, blackmail and physical/psychological coercion. Adolescent girls working, as domestic workers don’t have any emotional support, as there are hardly any television and radio programmes for non-student urban youth. Dehumanisaton of women can be prevented by promotion of women’s agency in the media so that women can lead intellectually, psychologically and emotionally self-sufficient life.

Counselling in the shelter homes for women

The most promising solution to confusion and disorientation among the women inmates of shelter-homes is a democratic space for brainstorming as autism is one of the main problems faced them. Informal set up is more congenial to their personal and career counselling. Workers at the shelter homes for women and girls need to be made to understand that behind every behaviour, there is a story. It is important for them to know the story. Panel of psychotherapists and psychoanalysts in the shelter homes should also conduct the staff development programme so that the staff can handle post trauma stress disorder among the inmates with empathy rather than resorting to victim blaming.

Mental health and reproductive rights

Societal attitude towards Indian women as son-producing machines creates painful mental problems for women. A woman’s body is de-linked from her subjectivity. Premenstrual syndrome (PMS) and Post Partum depression (PPD) are regarded as general complaints concerning women’s reproductive abilities. The weapon of premenstrual syndrome as a debilitating factor has been used to run down women in the family and at the workplace. PMS is a political category, which conveys that biology is destiny for women. Instead of focusing on the genuine issues concerning premenstrual discomfort in terms of fatigue, headache, cramps, headaches resulting in to depression and crying spells, PMS provides reductionist and reactionary explanation for women’s discontent. Women don’t have right to decide, how many children should they have and at what interval.

New reproductive technologies (NRT) have robbed women of their individuality and reduced them into spare parts for either scientific experimentation and/or sale. NRT values women only for their ovaries, uterus, foetus, that too preferably male. NRTs have caused tremendous psychological burden on women in the arena of sexual activity for procreation or only for recreation without procreation with the help of contraception or abortion. Research over last 3 decades has highlighted mental problems associated with repeated induced abortions, long acting hormone based contraceptives or conception inducing drugs.

Instead of using humane healing techniques of music, fragrance, get to gathers to deal with discomfort during pregnancy and post-partum depression, bio-medical intervention of giving tranquillisers and electro-convulsive therapy are promoted by the psychiatrists. This is the most vulgar example of the medicalisation of the natural processes of women’s bodies. Gender sensitive training programmes should be organised for medical officers of primary health centres and women health workers adopting perspective promoted by the UNFPA.

Menopause and mental health

Many psychologists have attributed harassment of daughter in law by her mother in law to menopause. But it is not true for all women. Many women find it a liberating experience to stay with their in-laws. It all depends on how society and family treat an aging woman. Pathologisation of menopause and negative attributes given to “old hag” (sadeli buddhi) experienced by women are responsible for identity crisis and depression among women during this period. Here, the role of counsellor is to recommend activities for self-actualisation and a healthy diet and vitamin supplements to menopausal woman. Exercise is very important to increase conversion of androgens to estrogens.

Women and epilepsy

Disability and impaired quality of life caused by epilepsy can be reduced by “psychiatric and psychosocial referral counselling on how to live with refractory seizures and advise on vocational rehabilitation.” Persecution and discrimination against epileptic women should be prevented by giving scientifically accurate public education through mass media. For the curriculum of community workers training programme, module on epilepsy, seizure, convulsions should be incorporated.

Mental health of women senior citizens

The most talked about problem concerning mental health of elderly women is dementia i.e. “loss of cognitive functioning, memory, language abilities, abstract thinking and planning”. Dementia is often reversible. Irreversible dementia can arise due to amnesia, Hutington disease and Alzimer’s disease(AD). Modern medicine treats this problem with estrogen replacement therapy, non-steroidal anti-inflammatory drugs and vitamins. Feminist senior citizens deal with mental problems of elderly women by providing spiritually rich and emotionally and intellectually stimulating group life to them. Discourses, singing, outing, social service, meditation and mutuality and reciprocity in human relations make great contribution towards their mental health. Vardhana, a group of feminists has defined women above 60 years of age as “Women of Age” and has provided a democratic and development oriented platform to Women of Age.

Mental health of women in mental hospitals

Pathologisation of women by using diagnostic labels is a major cause of stigmatisation and ostracism for women. Women’s groups are demanding that pigeon-holing of people into set slots must stop. Interaction with the mental health professionals is used by the family members and the community to declare the concerned woman “unfit” to live in the family, be a parent, function as an autonomous individual or take up a job. Husband’s family uses the episode to dispose her of or debar her from property right or right to live in a matrimonial or parental home. “Madness certificate” of the mental health professionals are used by husbands to divorce, desert or throw out wives from their matrimonial homes. Women are admitted in the mental asylum as per the directives of the Mental Health Act, 1987 and Lunacy Act, 1912.

Once dumped in a mental asylum, it is impossible for her to get out of it even after complete recovery. “ Women in the mental hospitals have fewer visitors, are abandoned or tend to stay on longer than men within the institution. There are fewer voluntary patients among women than among men. Even in adjudication for a woman’s institutionalisation, the official discourses are often coloured by the sex role stereotypes that the judges, police officials and the staff in mental hospitals uphold.” Remarks of a social worker after the visit to the mental hospital are apt, “The interaction with female patients made me sadder. Almost all of them were abandoned/dumped by families or the police and court got them admitted after they hit the rock bottom. Most of them were forced to face violent situations in their lives and had painful and atrocious account to tell. In many cases, one could see (although without an in-depth study, one can not claim and prove) that the mental distress, ill health had its roots not in a person’s biology or psychology, but in society, in our social environment”.

The iron wall of secrecy about the administration of drugs, surgery and ECT and their side effects needs to be condemned by citizens initiatives and ethical medical practitioners. The long lasting side effects of biomedical approach need to be highlighted. Our mental hospitals need to focus on psychotherapy and counselling which involve therapies that produce positive results and no negative side effects.

Psychological problems of women in the police custody and prison

Activists working on prison reforms have demanded humane code-of-conduct for governance of police custody and prisons, so that the inmates are not afflicted with permanent psychological scars. Solitary confinement of women prisoners takes away verbal articulation from them. Inter personal violence among prison inmates can be reduced by counselling, group discussions and creative expressions. Women political prisoners should not be forced to stay with hard-core criminals in the custody or jail.

Role of Support and Self-help Groups (SHGs)

SHGs provide democratic space for rebuilding broken lives. Non-power oriented special interest groups provide stimulus for canalisation of creative energy. Mutual counselling focussing on experience sharing without preaching or giving sermons can help psychologically distressed women reorganise their life and enhance their potential. Speak Out Centres can provide platform for community mental health intervention. Here comes the endorsement from an expert, “At the height of feminist activism in the 1970s and 1980s, there was excitement in the air as women shared experiences about themselves, their families, their lives and encounters. The growth of women’s confidence and self esteem knew no bounds as they challenged established theories about law, work, justice, equality and medicine. They talked late into the night, wrote pamphlets, stuck wall posters, spoke at public meetings, filed writ petitions. They felt reassured that theirs was not an isolated or individual problem. The group’s endorsement and sharing of painful experiences perhaps did much more for mental health than all medicines in the expert’s books. The women’s movement helped avert many breakdowns.” Enduring therapeutic engagement at community level can be group singing, festival celebrations, discourses on women’s issues and public meetings.

Developmental inputs

Cosmetic counselling offered by agony aunts is of no use. Breakthrough counselling is need of an hour. To make women’s material reality more secure, liberating and healthy is the only alternative to get out of repeated attacks of mental illnesses. Developmental counselling aims at removal of chronic conflict situation in women’s lives that is associated with high mental health morbidity. It is more than a remedial service. It believes that involvement, readiness and commitment on the part of the counsellor are necessary and basic conditions for counselling success.” It is concerned with the development and facilitation of human effectiveness. It increases self-direction and evolves better problem solving and decision-making abilities. This is the central axis around which feminist therapy or counselling revolves. It emerged in the wake of the women’s movement as an alternative to hegemonic patriarchal mental health establishments which depended on bio-medical approach to deal with the innate feeling of unhappiness in women. At the same time to evolve safety nets in the community and criminal justice system for protection from physical abuse.

Budgetary allocation for medical aid to treat mental illnesses of women should be enhanced. Mentally ill women need legal protection in terms of property rights and right to dwelling place. We need to create protective environment in personal and public life to prevent mental illnesses among women. E.g. efforts to prevent man-made disasters such as riots, loot, rampage. Mental illnesses result into deskilling of the individuals concerned. Hence, there is a need to evolve a plan of action for the re-skilling based on their preferences and abilities. Half way homes should be created where, the mentally ill women can do productive work during the day and go home in the evening. After the recovery from the mental illnesses, they should be employed. Financial security helps in rebuilding their sense of self-esteem. The most successful healer is one who avoids victim blaming and provides patient listening. After talking / catharsis, the seeker feels better.

Girls and women with communication disability need special help. At the same time, “Reversing the process of alienation by consciously building community networks is a must. Mental health professionals should be seen in the community rather than in the secure institute or clinics” avers a well known psychiatrist, Dr. Harish Shetty.

Training programmes on counselling

Sensitization and training of general practitioners and other health personnel to mental health, particularly, minor psychiatric morbidity (anxiety-depression) is a must. There is a need for social counsellors at health posts and public hospitals who are in touch with NGOs providing institutional support to women in social distress. Sensitization of teachers, community workers, youth groups, women’s organisations is extremely important. Training sessions for professional and para-professional volunteers should focus on supportive networks, group cohesion and solidarity. Training should include modules on interviewing skills, history taking, mental status examination. Electronic and print media should be trained in sensitising the general public about psychological response to violence and providing information about referral services as women and children affected by domestic violence, man-made or social disasters have special psychological needs.

Counselling ought to make women more aware about their problems and the oppression they face. Therapy can provide alternatives to deal with their problems. Counselling can be used to bring to the fore the cognitive facility required to recognise danger and threat to life, to assess the options and to leave if necessary, among women victims of violence. Counsellor’s have become astrologers. Counsellor should be proud with the arrogant and humble with the courteous. Supportive counselling alone won't do. At times, provocation is necessary. Role-playing is an excellent procedure for learning about counselling. Role- playing situations can be easily developed from the experience of people. The ethics of valuing and respecting others must be observed by the counsellor. Common characteristics required from the counsellor are concern, emotional investment, cognitive detachment, sensitivity and introspection. The counsellor should know that healing is a part of empowerment.

Conclusion

Civil society and the state should provide more and more opportunities to women of all age groups for self actualisation so that women can achieve high level of mental health. Respect for diversity, plurality and multicultural outlook ensure a democratic and tolerant milieu that is conducive for mental health of women. As compared to institutionalisation based mainly on bio-medical intervention, community or family-based rehabilitation of mentally ill women based on human touch is far more effective.