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Wednesday, April 13, 2011

Depression, Mental Illness, Women's Mental Health and their Sex/Gender/Social Rôles

The relationship between women's mental health and their sex/gender/social rôles.

This was a discussion paper I wrote years ago when I was studying Women's Issues. Some of it is rather dated, therefore, but I hope that readers will recognise the continuing relevance of most of it, e.g. here.


Let us consider what constitutes 'mental health' and 'mental illness'.

In Law, Liberty and Psychiatry, (British Edition, 1974), Professor Thomas Szasz notes that mental health lacks the integrity of a scientific definition and has simply come to mean conformity to the demands of society, viz. "mental health is the ability to play the game of social living, and to play it well." But in Schizophrenia, (1979), he concludes that it "has a great deal to do with competence, earned by struggling for excellence, with compassion, hard won by confronting conflict; and with modesty and patience, acquired through silence and suffering." This seems a good definition to me.

The orthodox psychiatric view of mental health is that the brain is organically and functionally healthy. The 'anti-psychiatric' (Laing, Foucault and others) view is of an authentic or true self.

Similarly, mental illness is variously attributed to social deviance, variation from the norm, organic brain defect, organic brain disease, problems in living, criminality, dangerousness, etc.

Certainly it is the case that mental illness or madness manifests itself in contexts peculiar to the society/culture which contains it.

A woman's gender rôle encompasses the attitudes, qualities and abilities expected of her by the society in which she lives and the social rôles she is expected to take on, e.g. wife, mother, nurturer rôles, exhibiting compassion, selflessness, passivity and other 'feminine' traits.

Since these gender rôles are in the main learned and culturally determined, they can impose stresses on women, extrinsically by being arduous in themselves, and intrinsically when they are at variance with the woman's personal needs, aptitudes and aspirations.


Because of my personal interest in medical/psychiatric oppression, especially of women, I should .like to start with this as a particular topic and then broaden the discussion later.

Throughout Szasz's writings he asserts, and I agree with his assertion, that there is no such thing as 'mental illness.' "Psychiatry is 100% juridical," he stated in a television interview with Jonathan Miller. When there is something organically wrong with the brain, as in tertiary syphilis, this should be called organic brain disease. This is not what is usually meant by the term 'mental illness'. Problems in living should not be called illness, should not be medicalised, should not be treated with drugs or incarceration. These responses are unjust and inappropriate.

In the Autumn term of 1985 I attended Tim Kendall's Politics of Madness course run by Sheffield University's Department of Continuing Education, and there I learned that it is only relatively recently in the history of civilisation that madness or deviation from a supposedly desirable norm came to be thought of as a medical problem. Up to the 17th century Court Jesters, for instance, with their 'madness', fulfilled a social rôle and were considered wise in many ways. Madness was often thought of as a creative gift. Also villages might have their village idiots but they were not excluded from the life of the village and their foibles were tolerated.

With increasingly crowded urban groupings and with the growth of capitalism and the profit motive, and the parallel growth therefore also of pauperism and the desire of wealthy rate-payers to keep down charges on the rates, social 'dregs' began to appear. These were variously placed into 'hospitals', workhouses, madhouses, etc. e.g. the Hôpital Général in Paris. Within months of its opening, 1% of the population of Paris was in it. No longer was it acceptable for people to be odd. And their oddnesses took on an ethical hue. Anyone who did not fit in - criminal, mad, sex offender, etc. - was incarcerated.

At first there were manacles and chains for the mad. Gradually these were replaced by different forms of restraint. At the York Retreat, for example, moral restraint imposed silence; there was no dialogue with the mad. There were observation and assessment, reliance on self-discipline, perpetual judgment and reassessment by the Guardians.

Responsibility and authority came into play: tone of voice, etc. Doctors as respected members of society tended to be appointed Guardians. Thus came about the medicalisation of madness and the birth of mental illness. During this period of recent history, medicine has been a patriarchal and paternalistic profession, except for midwifery and the wise women with their herbs and folk medicines. Rowbotham in Hidden from History, 1973, writes:
"... women healers were increasingly associated with witchcraft and the practice of the black arts. As medicine became a science, the terms of entry into training excluded women, protecting the profession for the sons of families who could afford education."
The barring of women from access to medical schools and universities effectively stopped them from entering the medical profession until the end of the 19th century. More women are now being admitted to training as doctors, but because of the hierarchical power structure of the medical profession and because of the prevailing male ideology and authoritarianism this is not as helpful to women as it might be.

The management of health and sickness is effectively almost a male preserve. The profession is dominated by men. This means that the medical system is strategic to women's oppression. As Ehrenreich and English, in Complaints and Disorders, 1974, state:
"Medical science has been one of the most powerful sources of sexist ideology in our culture. Justification for sexual discrimination - in education, in jobs, in public life - must ultimately rest on the one thing that differentiates women from men: their bodies. Theories of male superiority ultimately rest on biology.

...Biology discovers hormones: doctors make public judgements on whether "hormonal imbalances" make women infit for public office. More generally, biology traces the origins of disease; doctors pass judgement on who is sick and who is well.

Medicine's prime contribution to sexist ideology has been to describe women and sick, and as potentially sickening to men."
As far as women are concerned, medicine's spurious scientism still retains covert and overt sex prejudice.

Women's' physical problems such as painful periods, heavy periods, pre-menstrual tension, exhaustion after childbirth, fatigue from too much caring for others, etc. are nowadays more likely to be diagnosed as psychological than to be physically investigated. If men consulted the doctor about heavy bleeding, excessive clumsiness, exhaustion, etc. it is far more likely that they would be physically examined and physically diagnosed and helped.

To this existing plethora of medical sexism, Freud and the other psycho-analysts added their new 'diseases' with their respectable Latin names - hysteria, neurasthenia, et al.

Societal reaction theorists (says Gove in The Labelling Perspective in The Labelling of Deviance, 1975) have found that people who have little power and few resources are those least able to resist labelling. And, says Erickson (Notes on the Sociology of Deviance, 1962) in our culture, labelling is almost irreversible.

Women in our society often are those very people 'who have little power and few resources' and are therefore easily labelled.

Put together then the long sexist prejudice and oppression of women by doctors, the evolved rôle of the doctor as an agent of social control, the fashionable predilection for ascribing more and more problems to psychological causative factors, the widespread urge to label, the relative powerlessness of women, and you have in part the explanation of why women, rather than men, are so often labelled 'mentally ill', if they get into the hands of doctors. - And women 'get into the hands of doctors' more often than men, necessarily, because of their biology and their child-bearing (child-bearing in our society being a medical matter). Many women are also by now conditioned to see themselves as mentally ill.

Williams in Women, Sex-Rôle Stereotyping, ed. by Hartnett, Boden and Fuller, 1979, in her summary of the findings of Gove, 1972, and Landau, 1973, tells us that:
Compared with men, women are significantly more likely to seek help and be treated for mental disorder, and this applies whether the diagnosis is neurosis, psychosis, transient situational disorder, or attempted suicide.

The incident rate of these disorders in women has been increasing in the last few decades.

These findings seem mainly related to the types of social rôle women are expected to fulfil.
Let us now therefore look at Social Origins of Depression: A Study of Psychiatric Disorder in Women, by Brown and Harrison, 1978, which examines the social rôles of women as causative factors in mental ill-health. They write:
"We have concentrated on demonstrating that there is a link between clinical depression and a woman's daily experiences."
One description of depression: Feeling worthless, outside world meaningless, future hopeless, easily reduced to tears by fairly trivial matters, feeling of sadness, loss of interest in things and people, restlessness, indecisiveness, weariness, possibly suicidal thoughts.

Loss and disappointment are the central features of most provoking events which bring about depression. Long-term and not short-term threats are important. Separations or deaths seemed the most unpleasant events.

Ongoing self-esteem is crucial in determining whether generalised depression develops.

Failure to work through grief can lead to clinical depression. So can denial of the loss, failure to weep and failure to talk about the loss. (Young children do not readily mourn, and reaction to later losses is influenced by earlier reactions. This may account for the increased vulnerability to depression of women who lost their mothers before the age of 11.)

The main lesson which emerges from this study is that the causes of women's depression in our urban society are largely social and largely the result of being wives and mothers as such. The authors found that there are vulnerability factors which predispose to depression, these being: having three or more children under the age of 14 at home, losing one's mother before the age of 11, paucity of close confiding relationships with ready access, low self-esteem, a negative cognitive set and lack of work outside the home. Clearly most of these are part and parcel of the rôle of wife and mother which is forced onto many women. And equally clearly it is wrong to diagnose an individual woman as suffering from a medical complaint, viz. mental illness, and to give her medication for it, when what is really the case is that social, economic and cultural reforms are necessary.

Social factors are clearly causes of depression. Attention to a person's environment may therefore be effective in treating it.

Working class husbands tend to view housework and childcare as easy and thereby trivialise them and lower the wife's self-esteem.

It is probably fair to say that the working class wife and mother is the female 'norm' in our society. The work of Brown and Harris shows that being a working class wife and mother is a literally depressing rôle.

Typically, a woman's conditioning would tend to leave her with lower feelings of self-esteem and mastery than a man. Also her great involvement in interpersonal relationships, again the result of conditioning, means she will tend to be more affected than a man would be by separations and deaths, which we have seen are the most unpleasant life-events. Among people clinically diagnosed as depressed, there are from two to six women for every man (Arieti, 1979, and others).

(Also on a political level, sexual discrimination and inequality lead to economic and legal disadvantage and dependence on others, in turn leading to low self-esteem, low aspirations, low achievement and a tendency to depression.

It is the poor, the unproductive - in terms of a Capitalist economy - the rebellious, the disadvantaged, the unhappy, the social misfits, and the socially inept who tend to be labelled as mentally ill. Women are often in these categories.

So women are likely to be given demeaning labels and to have their suffering trivialised rather than receive real help from the patriarchal society which fostered their distress in the first place.)

Brown and Harris, despite their evident compassion, fail to appreciate that the label 'mentally ill' can bring a depressed woman extra problems in its wake. They do not think it really matters whether depression is called mental illness or not. - But it does matter.

"Mental illness designations are highly stigmatising and thus impose reductions in power and social standing." (Schur, The Politics of Deviance, 1980).

He goes on to say:
Psychiatry has been attacked by women's liberationists on a number of grounds - for adopting and perpetuating untenable theories of basic female passivity and dependence: for over-diagnosing women's problems as being personal rather than institutional in nature: for treating women as though they should, in all situations, be the ones to 'adjust'. Even if these critiques have not yet led to substantial changes in psychiatric practice, they have publicly exposed the previously latent gender politics of psychiatry.
As we have seen above, the medical system is a prime source of sexist ideology and a reinforcer of sex rôles.

Broverman et al. 1970, (1) and Abramovitz et al. 1973 (2):
(1) Traditionally there has been an almost mythological belief that mental health is contingent on the successful adoption of the appropriate sex-typed personality characteristics.

e.g. (2) that passivity, dependence, nurturance are healthy female attributes and that assertiveness is a sign of neuroticism would seem to prevail among mental health professionals.
If any conclusion can be reached, it is that whereas the adoption of sex-appropriate traits in males as associated with mental health, the same does not hold for females. High levels of femininity in women are positively associated with anxiety and negatively with adjustment, ego strength and autonomy.

The results of a study by Spence, Helmreich and Stapp (1975):
showed that high androgynous people were the highest in self-esteem, followed by those high in masculine qualities, and then those high in feminine qualities, while those who were low in androgyny were lowest in self-esteem.

It can be speculated that women who possess a high level of feminine traits are likely to deal effectively with interpersonal relationships and have a passive orientation to many aspects of the environment - both these factors contributing to a reduction of stressful life events. In contrast, women who possess a high level of masculine traits are likely to have an active orientation to the environment, and also be less likely to deal effectively with interpersonal relationships - both these factors contributing to an increase of stressful life events. The possession of high levels of both masculinity and femininity in the high androgynous (HA) group lead to effectiveness in both expressive and instrumental domains and is reflected in the low life stress reported in this group.
Androgyny then gives a woman a flexible, wide repertoire of behavioural possibilities and a more autonomous life. But typically, women are not brought up to be androgynous, autonomous people.

'The primary source of women's pathology is social, not personal: external, not internal.' (Rawlings and Carter, 1977a, quoted in Women: Psychology's Puzzle, Rohrbaugh, 1979.) As we have seen above, the overwhelming causes of women's depression are social and environmental, yet depressed women are treated as individually mentally ill medical cases.

David Hill in The Politics of Schizophrenia, 1983, emphasises that this individualisation of social disadvantage masks the need for social change programmes and keeps women subjugated in a patriarchal society. Psychiatrists are basically white, middle class males who seek to maintain the patriarchal status quo. He says that assertive females tend to be 'punished' by psychiatrists by being diagnosed as mentally ill because they have stepped outside their 'normal' sex rôle. But the normal subordinate female rôle leads to low self-esteem and the likelihood of depression.


Women's traditional sex/gender/social rôles in our society militate against their mental health, and mental health professionals tend to reinforce those very rôles which are damaging to the self-esteem and autonomy of the individual woman. The medical model of mental illness as individual pathology often serves to hide social injustice and the need for reform. This is particularly the case when we think of the social causes of depression in women.

Along with political goals of more and more equality of opportunity and equal pay and status for women, an end to sexual prejudice in all its forms, we need personal goals of more autonomy and self-fulfillment for women. This means in particular educating parents, future parents and teachers to avoid sexist conditioning in bringing up children.

Feminist re-appraisal of mental illness would help not just women, but all the disadvantaged, oppressed by psychiatry. It would be more caring of sufferers. It would be more sensitive in treating them - i.e. it would eschew the idea of "treating" them as such, and more expressly set itself the task of helping them. This might mean social help like being re-housed, say. It might mean personal help in the form of assertiveness training, say. Where medical help is offered it should be autonomous psychotherapy (if desired by the patient) rather than psychotropic drugs.

As we move towards a more equal society made up of more autonomous citizens, so women's lives will become less dictated by their gender, and their mental health - whatever we mean by that! - will improve.

Margaret Wilde © 2011