1. INTRODUCTION

• 1.1 Why is gender an issue in Mental Health?
• 1.2 The workshop agenda.
• 1.3 Women’s movement and mental health.

Mental health professionals have always assumed that there need not be any differentiation made between men and women when they present themselves for treatment. Based on the assumption that human beings across the world are the same, clinical practise usually does not recognise cultural, gender or other differences among them. However, in the last decade, more and more data is coming up which show that such differences must be taken note of. Psychiatric epidemiologists have shown some interest in ‘sex’ as a demographic variable of illness presentation in community surveys in India. Thus some sex differences in the prevalence of illness has been noted in the literature from the ‘60s in India, especially with respect to the common mental disorders (CMDs), including major depression, anxiety, panic and phobias, the conversion disorders, somatisation and possession. Prevalence of CMDs among women is much higher than among men / the general population. These trends reflect patterns noticed the world over.

The availability of qualified mental health professionals in Pune being quite low compared to the needs of the community, everyone seems to acknowledge that community mental health is the only option at present. This is taken for granted in nearly all circles. However, there is a gap in the professionals’ perspective and the community perspective, especially about women’s mental health issues. At community level, there is lack of clarity about mental health as a scientific discipline and what it offers by way of healing. From the professionals side, there is scope for better understanding of the cultural and socio-political basis for mental health, and how sex and gender are significant at the level of the community. The workshop hoped to close this gap to some extent, by creating a forum for liaison between mental health professionals and community health activists, advocates and women’s groups.

Sir Dorabji Tata Trust gave a support grant of Rs. 25000/- to Bapu Trust for the workshop. We thank Jasmine Pavri, the Programme Officer, Tata Trust, for her interest in our work and in this workshop. This report was edited by Bhargavi Davar for Bapu Trust.

The aims of the workshop were:

To evolve a platform for better networking among professionals and NGOs in Pune on women’s mental health, both relating to intervention as well as advocacy. The workshop aimed to be local and the participants were mainly from Pune. The ‘hidden agendas’ of the workshop also need to be highlighted. The forum was to give space for NGOs and women’s groups in Pune to decide who were the local professionals that they would liked to associate with in their own future work, for purposes of referral, technical inputs, etc. Secondly, the forum was also to be used by women’s groups in Pune, as a substantial power group, to make assertive demands for woman-friendly professional practise. So we had asked for detailed introductions to the RPs whom we had invited and also allotted a great deal of time for discussion. The drawback was however that the professionals could not all engage with the group for the whole of the 2 days due to other practical commitments. Networks with the professionals have however been established, we hope that there will be continuing dialogue and collaboration to work out some minimum common platform for addressing women’s issues in mental health and psychiatry.

In the women’s movement, earlier there was a reluctance to talk in terms of ‘mental illness’. The left ideological position of the movement saw women’s ‘insanity’ as ‘political dissent’ and as a type of protest against patriarchy. Earlier feminists resisted pathologising or ‘diagnosing’ normal female forms of expression. For example, if a woman is depressed following a beating by the violent husband that is a normal response. How can it be right to medicalise it by putting her on antidepressants and letting him go without sanctions or penalties? Women who were oppressed, used subversive talk (as in ‘Hysteria’) and what seemed to be bizarre bodily behaviour (as in ‘Possession’) do upturn the oppressor’s logic. Beyond a point, psychiatric labelling makes no sense! However in the last few years, it has been realised that the ground level realities that NGOs and women’s groups see in their day to day work cannot be ignored. For example, the after effects of violence:

Is it surprising that the women’s movement should be concerned about the mental health area also? Women’s movement is something which we should look at as an attempt to heal at the societal or at the group level. Just as within the body and the brain and the human system as a whole, there are ways of coping, the women’s movement too should be looked upon as a mechanism of coping with social change. The women’s movement itself is a mental health movement, as it gave multitudes of women the psychological strength to grapple with the social realities of their lives. By making systemic changes it has enabled better lives and emotional experiences for thousands of women.

However, there has existed and continues to exist a tension between psychiatrically diagnosed women and the ‘mainstream’ ‘women’s studies’. Some of the social attitudes attached to psychiatrically diagnosed people, for example, denial of legitimacy, lack of space for ‘acting out’ and outright paternalism, are sometimes equally experienced within the women’s collectives. Within women’s collectives, there will be one or two psychiatrically diagnosed women who have had an ambivalent relationship with the group because of her diagnosed status. Sub-texts about her ‘illness’ do tend to float around and her behaviour evaluated in the terms of those sub-texts.

Discussion has been going on to extend the scope of the women’s movement to include the diagnosed women also, by a systematic critical inquiry into ‘mental health’. We realise that while it may be necessary to guard against pathologising female ways of being, you really cannot also ignore the experiential realities of psychological distress. For example, a friend may be a part of the movement and the political struggle, but there are times when you know when a depression takes on its own logic and form. Women do go through these despite the social struggle and they are often missed during these times. Then it needed to be treated in individual terms as something that is happening because of certain things that may have happened to this particular woman. The women’s movement has taught that the ‘personal is the political’, but it still has to clearly articulate how the ‘political is therapeutic’. As a movement that has made its networks with other socially vulnerable groups, we would like to extend the scope of feminism to also offer psychiatrically diagnosed women the necessary supports, understanding at the outset that there are tensions between the feminist agendas and the advocacy agendas in mental health. The mental and behavioural sciences must confront feminist questions so that it can offer studied explanations and solutions for women’s poor mental health status in India.

Two major moves have been made towards a woman friendly mental health discourse: (1) Critique of mainstream practises in mental health and (2) Creating alternative woman-centred thinking in mental health. While some may take the position that critique alone is a reasonable enough goal of feminism vis a vis mental health, others take a mid-line position that critique should be accompanied by real time provision of alternatives.

Other than critiquing diagnostic practices, an overall concern has been expressed on the limited options for psychotherapy, the over-prescription of drugs and the lack of guidelines for the use of ECT. Service priorities have been questioned as being woman-insensitive and concern has been expressed about the gross misuse of the law in institutionalising women for vested interests (getting divorce, economic gain, etc.).

About the women in psychology - For a small number who are in academic disciplines such as clinical psychology and working from university or teaching departments, it has been important to try and maintain a comfortable balance between academics and activism. Their colleagues will tell them that ‘women & psychology’ is a subject for ‘Women’s Studies’ not Psychology and so they have to resist being marginalised in their departments by fighting such biases. They are usually ideologically outnumbered in their departments and suffer the double bind of not being considered activist enough by their activist friends nor being considered academic enough by their professional colleagues! The ‘critique / alternatives’ feminist paradigm has been important for them, but more so, making a dent upon the mainstream discipline (by reaching out to students, working on student attitudes at the informal or level, improving or changing curricula, etc.).

For the women psychologists working within the mental health services, they are constantly overshadowed by the privileged mental science, psychiatry, and have to defend their role and functions all the time. If they are harassed in any way by their more difficult male patients, the institution may not rise to the occasion in resolving the moral dilemmas. It is a pity and a paradox -- that while the medical administrators are all the time bringing forth ‘data’ to show how few mental health professionals are catering to how big a population, they are doing very little to make the working environment conducive or empowering for the (usually female) clinical psychologists and social workers.

These days ‘woman’s issues’ is a thrust area in the mental and behavioural sciences and is being introduced into university psychology departments as well. But the question remains whether having a lot of women work on women’s issues necessarily makes the discipline ‘feminist’. The aims and contribution of the women’s movement in mental health so far have been:

• To highlight the cultural, social and political basis of women’s mental distress experiences

• To enable woman centred interventions

• To bring the planning & service focus on common mental disorders, especially following victimisation by violence

• To enable women to use mental health services more assertively and pressure for policy which is woman friendly

The problem areas have been:

• Effective networking among community activists and mental health professionals

• Involving the community in the women’s mental health agenda through effective self-help strategies and support groups

• A more informed knowledge base on the various technical aspects of mental health

• Better understanding of sensitivities, rights and protocol issues in community mental health

More and more NGO involvement in mental health has led to the creation of ‘alternatives’ for women, especially in terms of women’s counselling and therapy. A data base is slowly emerging on women’s mental health, linking social stress with mental health. The present staggering data on women’s victimisation by violence has fore-grounded mental health in woman focussed community work. Other than this, the collaborations between women’s collectives and professionals in the mainstream has resulted in an internal evaluation of mainstream practise and the tentative steps to introduce these there. A few projects, some Ph. D. theses, dissertations, reports, etc. have also been initiated in the area of women’s mental health. Professionals attest to the ‘clinical fact’ that against the backdrop of the women’s movement which can give mature and effective strategies, women in distress have a far greater chance today of more affirmative social attitudes and rehabilitation possibilities. Women’s health groups are trying to extend the scope of their programs to include mental health aspects also and self help books in health and women’s health are starting to feature ‘mental health’. The NGO involvement in the area of mental health and the growth of curricula in women & mental health, is another growing area of debate and concern, given the present scenario of complex relationships between the NGOs, states and donors.

What is the ‘Indian’ ‘community’? Defining this first becomes crucial in the context of a multi-class/religious nation-state and cultural pluralism. A socio-politically aware definition of the ‘community’ will have to be the basis of ‘community mental health’. The statist programme (installed through the NMHP, 1982) in community mental health (CMHC) has to be questioned from this front, whether it really can address the multi level psychological needs of diverse cultures in communities. It takes a demographic view of the ‘community’ and ignores ethnic variations and cultural inequalities. Can the CMHC really address the needs of the dalits or of the dalit women or of the dalit poor? Does it give enough space for local communities to define for themselves, in their everyday language, their own mental health and use their native coping skills to deal with them? Any programme on community mental health will have to address issues of culture, caste, class and gender before it can deliver the service goods. As more and more NGOs get into the mental health realm, these issues are going to be crucial. The statist initiatives in community mental health are likely to be out distanced by the NGOs on this front. It is the NGO perspective(s) in mental health that is likely to be closer to ground level socio-political realities of class, caste and gender.

Until recently, there have not been many specifically designed studies in India linking social cause and psychiatric pathology at a very profound level. The earlier community surveys made correlations between socio-demographic variables and mental illness but these are only statistical associations, not causal relations. The greatest drawback of psychiatric research in India is in the psycho-social area. Studies such as by Brown and Harris in the UK, linking social events with mental illness, are sadly missing. Of course we cannot automatically relate to Western data as if it was appropriate in our context : the response to medicine could be different, the therapeutic process could be different, and the deeper ‘archetype’ or the unconscious (or the mental dynamics between perception, emotion, cognition and behaviour), could be different. It may not be surprising if there are some special dimensions to the ‘Indian’ mind, which may have more to do with our particular kind of ethnic background, upbringing, social relations, etc. rather than the universality of our physiologies.

2.13 Work & mental health. ... ‘mother is God but no maternity leave’ ... The unorganised sector, which employs 90% of the women who are working, provides no maternity leave. Even in the organised sector, women have had to fight for maternity benefits. The private sector does not take these issues seriously. The MNCs in the private sector are saying unabashedly that they do not want to employ women except in the housekeeping department. Sexual harassment at work (universities, colleges and work places) are becoming increasingly visible. There are also various social stereotypes and other barriers withholding women from getting full satisfaction or the full benefits from their employment.

The link between women’s work and mental health is complex. It is known that women in the unorganised sector, economically dependent, or poor, suffer more psychologically. Household labour, not being recognised as legitimate or paid work, is also known to be linked with common psychological symptoms in women. The mental health of working women is significantly linked with the quality of married life, the support received from spouse and whether child care support is available or not. Having to get a job and work when the family needs that extra income, and having to give up a job when the family decides ‘enough is enough, we now need children and someone to take care of them ...’ Without being judgemental, we can imagine the emotional convolutions that women must grapple with, when her avenues to economic independence and self-fulfilment are juggled around always in the name of the ‘larger good’. For women in the labour force, the situation is even more difficult, for example, the case of domestic help workers, their exploitation within their own homes and the homes they work for and insecurity of their jobs.

The administration in a local mental hospital had revealed that people who are treated and discharged come back ill within 3 years. If these people are sent back into the same social situation, illness becomes precipitated again and they are turned away from their homes, back into the mental hospital. A family can easily bribe the staff at the hospital to get an inconvenient relative institutionalised. Even though the law requires certain protocols to be followed for institutionalisation, these are not followed to the letter in practise and abuses and wrongful confinement are prevalent. Women institutionalised in Yeravada, for example, have languished there without any family support for the last 10 to 15 years. Most of our mental hospitals are shelters where over 50% to 60% of ‘patients’ are ‘long-stay’, i.e. they have been there for over 20 years.

Most mental hospitals in India work on the ‘custodial’ model where care is not the primary concern, but custody of persons from becoming a law and order problem. Most of the meagre government budget allocations in mental health go to the upkeep of the state mental hospitals, but the conditions of the hospitals are abysmal to the extent that ‘horror stories’ are regularly reported. Reports by SC commissioners in West Bengal and the more recent NHRC report on ‘Total Quality Assurance’ highlights gross rights violations inside the mental hospitals including sexual abuse and large scale neglect.

The hospital reform movement of the 70s and the 80s has obviously not resulted in the overall changes that professional bodies recommended. The few hospitals that made the changes were the ones that had show case value as model national institutes or were progressive anyway. Training, research, teaching programmes, community outreach, state mental health authority, etc. have remained so many words on policy papers as most states have resisted even SC directives.

Government run hospitals, the general hospital psychiatric units, OPDs and private practise show a predominance of men. Some of the progressive hospitals such as NIMHANS show greater gender equity for access to services though this does not necessarily imply gender sensitive intervention. There could be many social reasons for seeking psychiatric care but these are not very well studied. While violence, joblessness and other economic motivations, substance abuse and other types of deviance are probably the more common reasons why men are brought for treatment, a woman’s ‘deviance’ is considered a moral problem and she is punished for it subtly or grossly by her family and society. However it is a debatable issue whether seeking ‘treatment’ for her distress is a better option given the gender bias with which the mental health services function.

The NGOs face a dilemma when using state psychiatric facilities. As a policy some NGOs take the stand that people have the right to public sector facilities, they have paid the taxes, these facilities belong to the people and health care is a right due to them from the State. However the people served by these NGOs do not want to go anywhere near these and prefer private practise because of the fear that they will get treated by ‘shock’. A villager due for shock treatment by a visiting team of community mental health professionals will be hidden away in safety by the other villagers upon seeing the jeep. Most hospital facilities for ‘shock treatment’ are still using poor, outdated technology making the procedure unsafe and hazardous.

In pre-independence India the emphasis in the mental health field was mainly on asylums where the nature of care was custodial. This trend continued till 1946 upto the advent of the Bhore committee which put forth some suggestions in keeping with which, the NIMHANS (Erstwhile ‘All India Institute of Mental Health’) came about. Suggestions and recommendations for hospital reform have been made from the 1930s onwards by various professionals such as Girindrashekar Bose and Vidyasagar. Evaluations of the services for mental health, mental hospitals, general hospitals etc. were made, along with the training for mental health. The Mudaliar committee recognised that each region needed to be self-sufficient in terms of training and personnel, otherwise there would be showcase centres like the NIMHANS, PGI, AIIMS, etc. Psychiatric wards were set up in the general hospitals, along with reform of procedures for staying in the mental hospital. Shorter stay was suggested with the involvement of the patient’s family to reduce stigmatisation. Manpower increase was stressed with the greater engagement of para-professionals such as social workers, nurses and psychologists. The disparity between the rural and the urban in terms of the number of mental health personnel still remained very stark. The increase in the total number of health personnel was concentrated in the urban centres while rural mental health services were neglected. Simultaneously however starting from the 1960s, small units (like the STRIMHANS in Pune) were being established. These units were sometimes established as pure mental health units and at other times were attached to the district hospitals in many states. In states like Kerala and Tamil Nadu, every district hospital has a psychiatric unit. In the early 1970s, Bangalore and Chandigarh took up community mental health as an agenda. Upto the 1970s, we have observed that mental health was seen as separate from physical health or health per se. For the first time in the 1970s, Chandigarh and NIMHANS tried to incorporate it into general health care. In 1975 NIMHANS set up the CMH unit. This growth and transition of mental health to health care implied a shift to community care, eventually embodied in the national policy of 1982 (NMHP, 1982). The objectives of the NMHP were : (1) Ensure availability and accessibility of minimum mental health care to all, particularly to the most vulnerable and under privileged sections of the population (2) Encourage application of mental health knowledge in general health care and in social development and (3) Promote community participation in mental health services development and to stimulate efforts towards self help in the community. The people who were responsible for writing up this program have not even read (b) & (c) since it was written!! By the mid 90’s, about 60% of medical colleges in India have a department of psychiatry. The fact that the community program was very much urban was recognised and the need to bring in rural and local perspectives felt.

These changes were not taking place in a vacuum, however. The ideology of ‘Primary Health Care’ has been around since Alma Ata, 1978 and has influenced health policies the world over. In the area of mental health, the shift was intended to be from the bio-medical model to social outreach and utilising the general health system already in place. In the area of general health, a community health guide was instituted in 1975, the multipurpose scheme in 1972 and ICDS in 1975. Concepts such as ‘anganwadi workers’ ‘ANMs’ etc. came about. There were now many more health personnel in the field, in the community. A new philosophy came about which talked of accessibility, acceptability and community participation. This emphasis on ‘community participation’ was missing earlier, since the bio-medical model only talked about a hierarchical model of provider and consumer. Against this community health scenario, the concept of ‘mental health camps’ came about. Organised community care initiatives started in Bangalore and Chandigarh led to the development of training manuals and the integration of mental health care with PHCs and general practise. Community mental health care, according to well known spokespersons of the program from Bangalore : (1) awareness of community needs in clinical work and involvement of families, etc. (2) awareness of community resources in the organisation of mental health services and the utilisation like integration of mental health work with primary health care, involvement of schools, teachers, anganwadi workers, general practitioners, etc. (3) awareness of interactions and developments of interventions at the community level for preservation and promotion of mental health. This last has not even been touched upon.

In 1974, a world expert committee was set up which made a few suggestions, talking of mental disorders as a problem of high priority. India, being a signatory was to take up research and in 1975 the NIMHANS set up the CMH unit. A multi-country study on minor psychiatric morbidities was done in the 1980s which showed a high incidence of CMDs in India too. For the first time, the term ‘community’ was introduced in a psychiatric institute. The major emphasis was on training personnel for work in this field. Thus several training programs were held including training for district level medical officers, PHC staffers, GPs, etc. the 1993 World Development Report of the world bank took an interest in the fact that has been recorded in surveys for at least 2 decades in India, that the CMDs formed 90% of the mental illness in community settings. Neuropsychiatric diseases, especially depression, formed a high percentage of the total burden of disease in the developing countries. The recent works on CMDs by Vikram Patel and his colleagues in the Indian context [in Goa] highlight the extent of the links between socio-cultural factors and distress in the community.

However the training done through the community mental health program in India gives out only diagnostic information to NGOs. However what is the expectation in doing so? Are the health activists in NGOs to become mini-psychiatrists? With meagre training in mental health & diagnostics, who are they competing with : experts with MBBS and MD or DPM? Unless the role of NGOs in mental health and with respect to diagnosis is more clearly defined, it is likely that the NGOs will only act as weak satellites of the medical and psychiatric professions. The enormous potential that they have to act as ‘local therapeutic enclaves’ will be missed if they act only as unsystematic diagnosticians. The ICMR initiated studies on ‘severe morbidity’ and the training of psychiatrists, primary care doctors, clinical psychologists etc. This has proved to be a landmark in the field of mental health. In the last few decades, CMHC units have come up and several studies were done. Based on these efforts, a need was felt to have a national mental health programme like the ones for TB, malaria, etc.

There remains a wide gap in understanding between the health provider and the person who reports with distress. A major cause of this is the ingrained ‘bio-medical’ model which is what the health personnel are trained in.

• A typical community mental health ‘team’ of a mental health institute will comprise of a psychiatrist as head of the team and a couple of ‘paraprofessionals’. Even a psychologist is seen as a ‘paraprofessional’, thereby limiting the great potential they have in the realm of social psychology and psychopathology. Psychiatrists, who work within the medical framework, therefore colour the programme with their bias.

• The idea of ‘community’ central to the NMHP is demographic in nature, that is, it is defined with respect to population size, based on the community health model. The program is enumerative and not qualitative in its understanding of or interventions with ‘the community’.

• The policy prioritises the severe and chronic illnesses and not minor psychiatric morbidities. The average practise in the treatment of severe and chronic illness is heavily psycho-pharmacological / bio-medical.

• The training given through the model is diagnostic and does not touch upon the social aspects of mental health at all. Therefore, the model tends to be paternalistic and repeats the doctor / patient, expert / illiterate hierarchy often seen in the health services in the community also.

Many problems have been noted in the context of the CMHC, that the PHC staffers who are at the very bottom of the apex are non-performers, their case-identification skills are poor, etc. The model is very much clinic based, except the professionals have carried the clinic to the non-hospital setting. The doctors are not really going out there, and working in the community, it is the women who come to them in their ‘outreach’ clinics, only the size and location of the clinic is different.

The facilities for psychiatric or mental health services in rural areas is extremely poor, as most professionals are in private practise in the city. Whatever is supposed to be there through the Primary Health Care is defunct and vestigial. However there is a great need for mental health facilities in rural areas and some NGOs are starting to do planned work on this front.

Violence is a community problem and is of immediate and central significance to any community mental health program. It is complex behaviour, caused by familial and structural inequalities in the community; it victimises the vulnerable sections of the community and it causes multiple medical, psychological and social effects and varying degrees of psychological and social disability.

Violence is the use of power, the threatened or actual use of physical, emotional, sexual or social force against oneself, another person or against the community. In the feminist context, such power is oppressively directed against women in order to regulate her life and behaviour. It always involves the loss of a person’s personal liberty.

In discussing violence and mental health of women, it is essential to distinguish primarily the violence by women and the violence against women. The two are however not water tight compartments and are often deeply linked. Nevertheless it is useful to distinguish the two. The anger, the aggression and the violence that women show towards the males, both domestic and outside, women who are not psychologically disturbed, no illness prima facie, who batter their children and their husbands, who seem to have a pervasive bias against men, what to say of them? Certain types of rage and anger must be understood in a ‘proactive’ way.

We may speak of proactive and reactive biases. A rich man’s anger cannot be compared to the poor man’s anger. The poor man’s anger is a voice against the system and against the oppression that he is subjected to. The anger about the lack of a job is an anger which we want, should remain. It is a coping mechanism and a survival strategy against the basic anxiety of survival. Women too are agents of violence in a proactive way either within the family or aiming at the community. Their anger is a resistance of their oppression.

Psychoanalytic theory explains women’s depression as ‘anger turned against oneself’. However in the clinical experience, depression in women may be expressed as extreme and volatile anger against others causing confusion of understanding. Depressive rage is an emotion about powerlessness and hopelessness, and of having no way to go forward, and of not being able to do anything fully or successfully. That is why perhaps it is understood as anger against oneself, in terms of content of the anger and not in terms of its effects. In a difficult marital or social situation, the depressive rage may actually help the woman cope and survive, indicates to the counsellor that the woman is conscious of her self boundaries and may keep her from suicide.

There is something a man inherits as soon as he is born : his name. Women are not even granted this small privilege. Something as basic as the identity is at stake for women. Further she has to accept negligence, malnutrition, violence, only few options for self fulfillment, only to be married off and have sons. So a woman who is a mother in law is one who is at the end of the race in which somebody has been trying to trip her all the time. She feels that she has ‘proved herself’ and thus expects the daughter in law to do the same. In Panjab, there is the saying, ‘The mother who has sons is a queen’. So the victim of this tyrant queen becomes the daughter in law. This is only an example given to understand the violence by women against women and not to justify it, nor to minimise its effects. Mainstream psychologists tend to trivialise the issue of violence against women by saying that ‘well, women are violent against women’ and comparing that injudiciously with male violence against women.

The statement that ‘Women are more often victims and seldom perpetrators of violence’ remains unchallenged, not only by experts on the subject but also by the common man who would reflect on the news reports on violence. 20% of women worldwide report violence by an intimate partner. In 1996, the National Crime Record bureaux showed a total of 1,09,259 cases of crimes against women. The reported number of eve-teasing of 1996 over 1995 data showed an increase of 17.7%. Rape and dowry deaths during the same period showed a 7.9% and 8.3% increase respectively. A study in the Casualty department of the Bombay GH by Dhavale and others showed that 22.4% of adult women (over 15 yrs.) reported abuse; 22% reported domestic violence including assault by husband, family member or known person. ‘Possible violence’ was noted in 44.3% of cases, and ‘possible abuse’ in over 66% of cases. 15% had attempted suicide. In an ante-natal clinic in Bombay of 600 women, 25.3% showed a history of violence during pregnancy, all of which was by her family, 75.8% was by the mother in law, 8% by the father in law, the maximum violence was by the husband. 10% experienced recurrent violence. Head and neck injuries, foetal injuries, etc. were common. We must also be talking about issues of differential access to food, education, health care; the ‘fair child’ being given preference even among daughters and the neglect of the dark child because all this affects who will fetch a good husband later on; child marriage; genital mutilation; childhood sexual abuse.

It has been said by health experts that violence against a woman, to a greater or lesser degree, creates the same traumatic life environment for her as a disaster does. While physical violence and sexual violence to a great extent is visible, emotional violence is invisible and insidious. Violence against women occurs across class, caste, educational and age differences. No woman is exempt from the threat of violence. Even the pre-natal and infancy period is not spared, nor are the elderly women, women who are single, without husbands, or women with different sexual preferences. The rural face of violence is as ugly if not more so, as the urban.

While in general it may be said that ‘patriarchy’ is responsible for violence, some specific factors operational within patriarchy may be listed : The man’s unemployment, alcoholism & substance abuse, his economic dependency, poverty, economic insecurity, a broken home, his lack of engagement within the family, a generalised hostility towards women, expectations that ‘women should be like that’, dependency, low self esteem, low tolerance, will to power, enjoying power and basic anxiety in relationships may all increase his aggression in the home. Women’s poor self esteem in the family, her lack of power, her infertility, bearing female children only, the premium on good looks and ‘being well-behaved’, control on her sexuality and various other factors linked to patriarchy and women’s roles within that, may make her vulnerable to abuse within the family.

Women within patriarchy accept the violence silently because of -

• Their internalising of gender roles and the prescribed morality of ‘what is good for us women’ making them feel guilty and anxious about transgressions

• Privacy is considered to be a ‘virtue’ and so the disclosure of violence is taboo

• The perpetrator’s swing of mood between extreme violence & extreme affection confuses the woman

• The woman’s life (and that of her children) has been one of dependency leaving her with few options

• The woman’s emotional life is built around caring & giving support so breaking bonds is far more difficult for her

‘Victimisation’ is the invasion of one’s private boundaries, leading to ill health effects physical or psychological. The physical effects could range from a black eye, a broken arm, bleeding etc. But the psychological scars take much longer to heal, causing a significant amount of morbidity in the community.

It must also be noted that in the talk about ‘morbidity’ certain quantified indices and diagnostic criteria (such as PTSD) are used, either from the DSM-IV or the ICD-10 as they are a necessary framework for making clinical measurements of ill-health and to start intervention. The WHO has evolved criteria for use especially in the developing and low income countries. Mental health, according to these criteria, is not just the absence of mental illness, but the stress is on personal growth and development, actualisation of full potential of a person, feeling good and positive about oneself and having equal social power as any other person in the community.

3.31 Anxiety disorders are seen often as a response to victimisation. Anxiety is the inexplicable feeling of impending doom, the unfounded worry of numerous things, an irrational fear, a situation, an activity or an object. Anxiety, which may be exhibited in various forms, is basically an ‘systems alarm’ which alerts an individual to anticipate the threat of a traumatic situation and prepare for it. A person without anxiety would not be equipped to face a threat. Anxiety puts a person on the ‘be alert’ mode and is a basic coping / survival mechanism. Anxiety also occurs as a response to the cognitive processes, such as the perception of indicators of potential danger and memory of past experiences of psychic trauma.

3.32 Manifestations of anxiety disorders Anxiety is characterised by palpitations, chest congestion or pain, tremulousness, sleep and appetite disturbances and lack of concentration.

Panic disorder: Recurrent and unexpected panic attacks characterise a panic disorder. Psychologically, there may be subjectively experienced utter terror, fear of dying, of going crazy and of losing control. There may be physiological symptoms such as palpitations, sweating, trembling, shaking, breathlessness, feelings of choking, chest pain, nausea, abdominal pain, discomfort, feeling dizzy, unsteadiness, derealisation or depersonalisation, numbness, tingling sensations, flushes, chills and parasthesias. Often, unless it is already known that the person is anxious, these symptoms may be misdiagnosed as a cardiac, neurological or respiratory problem. The clinician must be able to discriminate a panic attack from these other medical problems. Conditioning (behavioural) theory and cognitive theory both explain panic disorder and offer interventions.

Phobias: A phobia is a persistent and irrational fear of an object or a situation. Persons with a phobia show avoidance behaviour as they will try and avoid situations which will lead to the phobic situation.

PTSD: PTSD is a severe stress reaction in persons who have been subjected to extreme or unusual and unexpected traumas. Traumatic stress disorders cover the after effects of situations that fall ‘beyond the range of human experience’ such as disasters, accidents or assault. There are 2 types of stress disorders (a) an acute stress disorder and (b) PTSD. Acute Stress Disorder occurs within 2 days of a traumatic event and lasts for a month or less, while PTSD begins within a month but not more than three months.

A diagnosis of PTSD is tied to the occurrence of a particular traumatic event that immediately preceded the symptoms. However in the case of domestic violence, there may not be a single, precipitating traumatic event; symptoms may not follow immediately; symptoms may be diverse and diffuse and spread out over a long time. Complex PTSD is a diagnosis meant to account for the diffuse symptoms that may begin after 6 months and may last for months after the traumatic event has occurred. Free floating anxiety may also receive a diagnosis in the clinic. Cognitive-behavioural therapy and psychodynamic therapy have both been effectively used in dealing with PTSD.

3.33 Somatoform disorders.

These are characteristically somatic complaints with no associated, serious or demonstrable organ disorder. Thus any sort of medical demonstration is not possible. Psychological factors or conflict seem important in imitating, exacerbating or maintaining the disturbance.

Conversion disorders: Earlier: known as ‘hysteria’, conversion disorder is a disturbance of bodily functions that does not conform to the current concept of anatomy or physiology of the nervous system, central and peripheral. The problem here is related to neurological disorder such as elective mutism.

The symptoms in the case of conversion disorders are usually like neurological symptoms, i.e. they are either sensory (parasthesias), a limping gait or fits (pseudo-seizures). There is a conflict at the subconscious level. This conflict, between the conscious and the subconscious is something that the mind cannot accept and is thus transferred onto the body. The person will have a fit which will not conform to any of the known epilepsies.

Somatisation disorder: A somatisation disorder is a recurrent, multiple, somatic complaint. The diagnostic criteria say that there has to be a minimum of four pain symptoms, two gastro intestinal symptoms, one sexual symptom and one pseudo-neurological symptom. Women complain more of the somatoform disorders.

The risk for suicide, self harming behaviours, hypochondriasis, depression and minor psychiatric morbidity increases with victimisation by violence. Health problems are also compounded by victimisation so that the women have to use medical and hospital facilities much more than women who have not been victimised.

The role of a counsellor goes beyond the counselling room. Her duty begins from accessing help to the victim and goes on to helping her find avenues and alternative ways of survival and living. The counsellor is an agent of social change and not just behavioural change. Counselling is not yet fully accepted by society and so it’s vast potential for community intervention is not fully realised. In counselling, sessions with abusers are aimed at sensitisation and enhancement of quality of relationships. Pressure techniques and confrontation has to be used in cases where survival of the woman is in question. The irony of the situation is that, under such circumstances, it is the victim of violence who has to withdraw silently and be placed within confinement in a shelter and the abuser goes free. He is out on bail in no time, if at all an arrest has taken place. The woman who has chosen to go for separation is not allowed to live life peacefully by the society. She becomes vulnerable and exploited for various ends by other elements in society and often has to face a spate of violence immediately after she has come out of one : from her parental family, her brothers, sisters in law, society and community at large. In such cases, co-counselling and the formation of support groups of women having similar problems comes of aid. There are also cases where the woman is deprived of basic survival needs. At such times the counsellors have to resort to some kind of social action like collaboration with activist groups, etc.

One such issue is that of ‘Stree dhan’. Stree dhan is the movable asset of a woman, a gift given to her by her father at the time of her marriage and it is solely hers. When the woman is thrown out of her house, the Stree dhan is denied to her. By law a denial of what is hers could be termed a ‘theft’ but it is not considered so, as the assets are in the matrimonial house. When the woman applies to the court for the restitution of conjugal rights, she can even be denied entry on the ground that the house belongs to the father-in-law. However when it comes to Stree dhan the argument runs that it is her house after all and so not giving her assets back cannot be considered ‘theft’. The women’s movement is making demands that these contradictions and double standards in law must be set right. In such circumstances counsellors do take the help of police, women’s groups, etc. and forcibly make the family give the stree dhan back. Social education, legal literacy, advocacy, influencing the policy, and sensitisation of social enforcement agencies : these and other such activities which will create a social atmosphere conducive for the good mental health of women also form an integral part of the counsellor’s duty.

The objectives of counselling is definitely to raise her own potential to handle the problem. When the woman comes to the centre, they evaluate what state she is in, seek support in the community, approach the spouse and his family for negotiation, and in doing all this, her own self confidence increases. She is enabled to handle the situation and she does slowly wean away from the centre. The capacity to confront and handle situations of violence increases and she becomes empowered.

Women in spite of the worst kinds of subjective experiences, have done a great job in society, their families and the community, and even at the national level. For eg very rarely does a woman with depression in India have the leisure to withdraw into her own world and not do the ‘duties’ expected of her. Her depression happens, alongside a host of other innumerable activities that she is involved in, child care, cooking, domestic work, taking care of elderly parents in the household, pregnancies, etc. etc. Her work happens despite the depression, much to her own neglect. This also speaks of her resilience and the grit to keep going at any cost. The working class and dalit women, while they maybe down below on social and economic score, bounce up much faster, because they have been used to taking care of the household, being economic heads of the house in many ways. This is not to justify or glorify poverty or economic insecurity or women’s social circumstances, but to highlight the fact that women are survivors.

Through intervention, women can be taught skills for dealing with their social problems. Even though a professional may not be an activist, by using sound techniques, the effects on the distressed woman’s psyche may nonetheless be the same as activism. For example, a victimised woman may learn how to be assertive in the relationship, how to communicate assertiveness, how to protect boundaries, how to deal with anger and how to be safe from therapy, which may itself be socially empowering, even though she may decide not to seek the intervention of the social agencies such as police or law.

Women’s literature and ethnographic writings by women (such as Ram’s Mukkuvar women, to give only one example which is of relevance to the mental health issue) are rich in giving a profound understanding of the multiple textured and experiences of women as they live out their lives in the ambivalent atmosphere provided by their ‘community’. A community is women’s ‘space’ as well as women’s ‘place’. It is in this community that women make families, have children, form friendships, negotiate the schools, stores, the temple, the parks and the ‘neighbourhood’ in general. It is in this same community that they most closely experience loss of self, powerlessness and victimisation. As more and more qualitative methodologies become incorporated into research studies in the mental and the behavioural sciences, women’s ways of experiencing distress, their coping mechanisms and ways of overcoming, their lived experiences in the community may become articulated.

There are indications that the incidence of depression is rising all over the world especially among the socially vulnerable groups, such as the children & adolescents, women and the elderly. It may be observed also in the form of rising alcohol and substance abuse in the community. Yet, depression is highly under treated. Depression is a syndrome, i.e. a group of symptoms and signs occurring frequently in an individual or in a group. Recent thinking on depression is that it is a ‘mood disorder’, rather than ‘affective disorders’, which implies a temporary state of felt emotions. ‘Mood’ refers to an all pervasive state. Depression is not a disease or an illness, but it is a state of mind and body which is experiencing subjective distress.

For every one who is diagnosed with clinical depression, there are so many who are ‘sub syndromal’, but nevertheless their lives are impaired to some extent. For every one who seeks treatment, there are probably another ten who do not, and another 100 who are sub syndromal. Community recognition of depression is very low, and depressed women are usually neglected, as their behaviour is seen as part of their nature or personality. Clinical depression needs active intervention and CBT (Cognitive-Behavioural-Therapy) works very effectively as cure though finding sensitive professionals trained in the technique are hard to find.

Depression has been explained and treated in a variety of ways by professionals. However in practise, as they see depression only in the context of clinical practise, it is seen more medically, as an illness, and rarely without jeopardizing the life, health and interests of the woman. More therapy oriented perspectives must be brought in India for managing depression. Also, for community psychiatry, it is not enough only to speak of depression as a disease / illness. The view from the clinic is never truly representative or comprehensive of what happens in the society and the culture. From the prevention point of view community intervention for depression will have to be more broad based and include preventive therapy.

Psychoanalysts would consider the ‘aggression turned inwards model’, the ‘object loss model’, etc. The ‘integrated bio-psycho-social model’ is also popular and assumes that the ‘nature-nurture’ debate is a false dichotomy as far as depression is concerned, and that, heredity, environment and the individual interact in complex ways to respond to stress. (The ‘nature-nurture’ controversy has done maximum damage to medicine because the issue polarised the discipline and partisan groups came down to fighting over resources, ownership of official fora, etc.) Depression is a ‘system in stress’ response. The ‘cognitive model’ is also contemporary and is based on the view that depression is the result of a negatively skewed mind-set which can be replaced into a more positive mind set using certain clinical techniques, some of it including behavioural modification. The popular concept of ‘learned helplessness’ is based in cognitive theory. Behavioural therapies are based on the simple assumption that if you keep doing / feeling a certain thing ‘A’, ‘n’ number of times over a period of time, in substitution for another unpleasant thing ‘B’, which you curtail, then that ‘A’ becomes ‘you’ and your ‘self’ has changed from doing / feeling ‘B’. Whether or not this assumption is politically correct or theoretically acceptable, the fascinating aspect of the model is that it works, especially in the case of dealing with fears, phobias, stress and anxiety.

Some biological factors are said to be relevant when speaking of ‘women and depression’. Some types of depression are heritable. Women have shown a higher level of a brain chemical called MAO (mono-amine-oxidase) Inhibitor which is a mood regulator. Their thyroid status is also more precarious, with the thyroid thyroxine levels being more mercurial than in men. Neurotransmitters such as serotonin, epinephrine, etc. may also show imbalances. Post-natal hormonal and premenstrual hormonal changes also accentuate depressive moods. The steroidal contraceptives also may cause mood change in women. With the hormone linked mood changes, spontaneous remission of symptoms often happens and only in a small percentage is there a ‘syndrome’ severe enough to be treated. Some syndromal depressions are dysthymia, major depression, rapid cycling mood disorders and ‘SADS’ or ‘Seasonal Affective Disorders’. In the atypical depressions, there is more sleep, more appetite, more of irritability and hostility. Many medical problems (such as temporal lobe epilepsy) may clinically present like a depression and there are attempts to understand and prevent the ‘misdiagnosis of women’, especially depression.

Often anxiety and depression present together confounding diagnosis. Drugs which treat only the anxiety are prescribed, leaving the depression aside, which then becomes chronic. Women may claim that their distress is on account of household duties or work outside the home, children, etc. This may also be true. However this may confuse the doctors and the focus of their attention shifts from the medical aspects of the problem and the needed medication. On the other hand doctors may simply assume especially with respect to menopausing women, that depression is because of a ‘hormone’ problem and simply give oestrogen. Oestrogen has some positive effects for the women , such as improved thinking and memory, lessened vulnerability to disorders such as dementia. But it does not cure the depression. Anti depressants (especially some SSRIs) are useful in certain women but they cannot be indiscriminately prescribed during pregnancy because of deleterious effects on the foetal brain. Women seem to require smaller doses of the antidepressant for relief, probably because they are more compliant as patients or probably because their physiological / metabolic make up is such. A co-occurring panic disorder may complicate the treatment and confound prognostic issues. Therapy is known to be effective in curing depression but sometimes medication may be necessary. The drugs / therapy / depression complex is a grey area for women’s groups and NGOs and more clarity is needed in order to make informed user choices.

Studies by people such as Paykel, Brown, etc. have highlighted the fact that instrumental roles linked to task performances, the expressive, emotive roles, roles that demand maintaining emotional relationships, particularly within the family, increases the risk of depression. Some researchers opine that sadness and depression are more a facility to the woman and that while women express genetic disorder as depression, men show it as alcohol or substance abuse. According to these researchers women have personalities that are more of the ruminative, introspective types as opposed to the active cognitive styles of the men. Interpersonal frictions, anger, inhibited communication, submissive dependency in marriage, a variety of self-blaming feelings, all contributed to unresolved emotions which may lead to a depressive state later on.

Treating the depression with medication alone may not cure it. Physiologically, the effects of emotional disorders may linger on for months or years together. Residual effects of depression may be more prevalent in women. One depressive episode may further decrease the physiological stress threshold increasing vulnerability, and frequency. For these reasons one-off treatments with medication is not enough and therapy is needed. Emotional disorders are linked to a cognitive schema (about self, life and relationships) and those must be addressed as well. An environment which precipitates depression may result in a relapse.

Doing research in the area of common gynaecological morbidity is not easy. Certain issues are culturally sensitive to women, leading to a ‘culture of silence’, for example, white discharge, which could be very severe. Associated with this problem is the myth that it is caused by having a lot of sex and that all women who are married get white discharge. The women therefore ignore it. Secondly, if it is reported, you are announcing your sexuality [the fact that you are having sex] and so the problem is not shared with other women, leave alone with the male health providers. Euphemisms are used, such as ‘I have back ache’, ‘I feel weak’, etc. and the woman keeps going back saying this, while the health provider keeps giving her placebos (or vitamins, etc.) and calling it ‘psycho-somatic’. The women are also not familiar with the interview method of yes/no, their communications are not in these terms and so they do not respond in the way required of them for the study. Participatory methods (e.g. body mapping) are far more successful with them. These methods were used in the study to bring out the women’s concept of the body and the problems they are facing with their bodies. In this study, 18% of the women in the general community had CMDs, irrespective of whether they had gynaecological morbidity. 27.5% who reported at least 1 or 2 gynaecological morbidities also reported psychiatric morbidities. The sample size was 780 and simple random sampling was used. Women were in the reproductive age group.

World over, anxiety, panic and phobic disorders are more common among women than among men. Some writers on women and mental health have emphasised that the violent ambiance of women’s lives, especially the perceived or actual threat of rape in society and the social regulation of their mobility, makes them more vulnerable to fears, anxieties and phobias.

Women’s fears and anxieties are instilled and encouraged by society in many ways. For example, a recent sequence of advertisements leading up to the serial ‘Darr’ is presently being featured on Star Plus. The sequence showed utterly terrified women in very everyday situations (opening the door, using the lift, being out for a walk in the night) reinforcing the fact that an average woman had better be afraid of doing even ordinary things like being at home or using an elevator.

Paternalism and protectionism, deterrence of risk taking behaviours and deterrence of retaliatory aggression by women all leave the women with sanctions against full expression of their assertive emotions and of those emotions which will preserve her self boundaries, survival skills and life. Society considers a woman frail by nature and encourages her fears. Violence against women, perceived or actual, also keep her in a situation of anxiety and threat. A study showed that the one thing that women across the world feared most was rape. This fear intruded upon their life and activities so much making them choose safety above anything else. It is not surprising therefore that women receive more diagnoses of the stress & trauma related disorders.

Women tend to express their distress physically. Professionals have always seen this as a lower form of self expression. They feel that ‘this woman does not have any physical problems so let me dispose her off as quickly as possible and attend to the next patient’. Diagnostic concepts such as ‘hysteria’, ‘somatisation’, etc. have been used by the professionals to undervalue women’s manner of expressing themselves by saying that such women are suggestible, have a neurotic personality, a weak will, malingering and things like that. In a famous medical college OPD in New Delhi, the many (Muslim) women patients complaining of somatic symptoms were joked about among the resident doctors. The doctors used to say that these women, being in ‘purdah’, were starved of the male touch and so came to the hospital to be touched! They even had a name for it, the ‘Jama Masjid Syndrome’! The ‘Begum syndrome’ in the West ‘observed’ among the Asian population has similar degrading connotations. Though the area of minority women’s experiences of the health system has not been studied, we may get a fair picture of what may be happening from the above example. What the doctors fail to understand is the possibility that a woman may have come there looking for assistance, knowing that a doctor belongs to the caring profession, so he will care! Her expectations are belied when she is treated as no more than a sexually frustrated social fraud. Trust the masculine cognition to sexualise everything, the scientific ‘objectivity’ notwithstanding! Doctors who are fairly sensitive health providers, when asked about psychological distress in women with gynaecological problems, will usually say that ‘it is psychosomatic’.

A writer on victimisation, Judith Herman, has said that ‘hysteria’ is the combat neurosis of the war between the sexes. Earlier, thousands of women were being burnt as witches and Freud rescued them from the stake by saying that they were suffering from an illness, ‘hysteria’. It was a big contribution by Freud to have seen that women’s hallucinations which could kill them, could at least now bring them to the clinic or the hospital. Come 20th century, however, feminists have found hysteria to be a foul word used to beat women back within the line of social order. Women with ‘hysteria’ have been talked about in the Indian psychiatric literature up to the mid-1990s and even today the diagnosis is being given out, despite the fact that recent manuals have made some changes in the diagnostic framework, calling them ‘conversion disorders’, ‘dissociation’, etc. The links between hysteria and childhood sexual abuse are becoming clearer today.

A woman showing somatisation complaints are also similarly treated by the medical system. They are either given up by the system in disgust or they are prescribed unnecessary medication, placebos such as vitamins or iron, simple surgeries and other medical treatment as a way of extracting money. Somatisation is seen as an ‘unsophisticated’ and simplistic way of responding to life stress. Professionals say that women (or men) who somatise are deficient in introspective skills and do not have the ‘higher’ cognitive abilities required for expressing oneself in mental terms!