labrys, études féministes/ estudos feministas
juillet /décembre / 2014  -julho/dezembro 2014

 

 Problematizing gender and mental health in a Brazilian psychosocial care center [1]

Ionara Vieira Moura Rabelo

 

Abstract

From the perspective of gender as analysis category, this paper proposes to debate the interfaces with mental health in a Psychosocial Care Center, in Brazil. Throughout two years, accounts from women attended in this centre were analyzed, in a group that took place weekly. It is noticed that not only the bodies, but also the symptoms of psychological suffering derive from an engendered context, as well as the attempts to eliminate the pain. Only a careful contextual analysis can propose a confrontation of the situations of inequality and illness lived by Brazilian women. It is questioned whether the female derangement occurs as a response socially shared by women, in order to cope with the situation of violence, constantly fueled by excluding relationships.

Key-words: gender, mental health, psychosocial

 

 

The aim of this paper is to reflect on the experience of women being treated for mental disorders in a Psychosocial Care Centre (abbreviated as CAPS in Portuguese), in a city in Brazil. They were part of a group of women transversalized by the perspective of gender, in a city with more than one million inhabitants, in the central region of Brazil. This proposition takes place in the feminist psychology field, which adopts a political commitment with change, straining the nonjudgmental positioning of traditional positivist psychology (Narvaz & Koller: 2006).

In the everyday operation of a CAPS, located in an area of the city with a population density and insufficient number of public policies, the case discussions showed life stories that mixed poverty, intrafamilial violence, ethnic-racial prejudice, unemployment, low education levels, and finally, situations of intense psychological suffering.  With the aim of avoiding the trivialization of such stories, an attempt to understand what brought them closer led the team of workers to consider the gender category as an important axis of the activities accomplished.

From that finding, it was chosen to form a group of women with the aim of broadening the concept of mental health, enabling the discussion of themes related to gender in a systematized way. We consider gender a category to analyze social relationships, where the differences between genders are used as a way of organizing the society. According to Joan Scott, gender must be understood as an analytical category in order to understand the perception and organization and historical knowledge, as well as the relations of inequality and power initiated from these constructions (Scott, 1995). It is important to clarify that CAPS is a open public mental health service (patients are treated in their own community), which is part of the Brazilian mental health network. This network has been built since the psychiatric reform initiated in the eighties and has tried to modify the paradigm of insanity, avoiding admission to psychiatric hospitals and stimulating social reintegration. The Brazilian psychiatric reform is based on the Italian precepts of deinstitutionalization and creation of new care models based on patient and family autonomy, questioning the psychiatrization of lifestyles. Thus, we use the term users of mental health service in detriment of the term patient, as we consider that not only the designation, but especially the theoretical/political positioning in the mental healthcare field can build the empowerment of women in treatment at CAPS.

The group of women, proposed from the theoretical foundation above, was coordinated by a psychologist and a social worker, with weekly meetings of approximately two hours in length. The group had the participation of eight CAPS users, which were nominated for this group after case studies and the construction of the therapeutic project. It was established that only the capacity of elaboration and verbal comprehension would be pre-requisites to participate in the group, while the state of psychotic crisis or mood alterations were not considered impeditive situations for participation. The permanence or exit from the group was based on the case discussions performed as a team and the therapeutic project revisions between referent (one of the mental health staff assigned to follow the case) and user.

This text uses accounts of themes discussed over two years, having the concern to preserve the identity of the users, but highlighting important points so that healthcare workers could access this experience developed in the CAPS, from the theme gender and mental health.

 

“I’ve stopped suffering, now I’m only sick in the head”: connecting suffering and illness

 

In the first meetings, we had already explained that we would try to talk, in this group, especially about life, the difficulties faced in the main affective relationships, the suffering they were experiencing, but we stressed that at all times we should be aware of one question: does this happen to me because I am a woman? Such question was formulated due to the need to work the concept of gender, from daily life, sensitizing the users to the engenderment imposed to female and male bodies, which imposes on the users the duties of housewife, mother and carer, instead of reinforcing the fallacy that women perform these roles because they are part of their female nature.

In this paper we consider the genders (in plural), and not only a single determinant, as the social construction of the domination over the female body has been used even as feminist discourse to generate public policies that have concealed and deepened gender and class inequalities (Giffin, 2002). From this perspective, Karen Giffin clarifies that the feminist discourse has been absorbed by international organizations and neoliberal governments, but in practice, there is a dominance of medical technologies that, beyond the advancements in the area of female reproduction, have continuously controlled and medicalized the female body (Giffin, 2002).

As soon as the group began, the first stories told by them started with the repetition of the typical discourse of the biomedical model, where they list the symptoms in a way totally disconnected from their daily lives.

“I have depression, the medicine hasn’t worked yet, but the doctor told me that I have to wait a little longer.”

“…I have a nervous thing, something bad, a voice that tells me to run away, I don’t know where it comes from…”

“…there’s this urge, this itch, a desire to go and break everything, then my mind blanks and I don’t remember anything, it’s my girls who tell me later what I’ve done.”

 At first, many mental health workers, reading the accounts above, will have a clear impression of having heard such stories, so what? What is the difference in hearing them with the transversalization of gender?

The first possible answer might be that, when listening to such complaints, we start to ask the group if they had an explanation for what happened to them. Once again, the social representations of insanity emerge in the women’s speech, stressing medical and psychological disciplines as most frequent theories to explain their illness. They state: “it’s a problem of the nerves in the head, she was born this way”, “it must be a trauma from when she was very little, when her mother hit her”. It can be noticed that they search for something external to their life experiences, i.e. in the scientific theories, in order to explain their health problem.

From that point, we started new questionings that there could be more elements that they might have forgotten to mention, and that these probably were also related to the current suffering. We urged the group to tell their stories, respect what was being said and, most importantly, accept each and every account. Such a proposition echoes the reflections of Ana Paula Muller de Andrade, when she proposes that, in the healthcare service strategies based on the psychiatric reform, it is necessary to denaturalize the female body and stimulate the comprehension of experiences, senses and meanings, built singularly in the processes of illness and health (Andrade, 2014).

Initially, it can be observed that many of them described how they worked helping their parents since they were very young, and the accounts of abandoning school for financial reasons were frequent. Another justification for not staying at school was because the father didn’t want a “girl-woman” (colloquial language used in inland Brazil) to go to school, because it was not necessary to learn to read and write to survive, or even to take care of the house (expression used to refer to domestic services). It was also common accounts of living in rural areas most of their childhood and adolescence, where they helped in the crop, raising animals, doing domestic services and taking care of younger siblings. This situation reproduces in the women’s body the submission and subservience associated with the feeling of fear and inability to think, to have a voice, in an environment filled with such violence and hostility.

From these stories, we used one of their accounts to problematize what they had been saying. We asked: what is a women’s job? What are women good for doing?

Obviously the dominant discourse emerged and still emerges in several moments of the group, trying to justify why housework, raising children and being a good wife would be female attributions. However, when we proposed to think of new marital arrangements in terms of distribution of duties, or even of the new job posts that women have taken, the group was gradually able to make their concepts more flexible, to an extent that they doubted if the question should be what the “woman is good, or not, for doing?”, changing it into “what is each person able and willing to do?”      

At this point, a retelling of life stories began, although this time, the be-make woman, already denaturalized from numerous problematizations in the group, became reconfigured in a new territory: “how difficult it was to be the daughter, wife, mother, sister, neighbor, sister-in-law, aunt… that everybody expected”. The perception that there had always been a pressure for them to conform to these social roles, already previously established, brought the possibility of connecting life-discrimination-suffering.

There was also an amplification of their perception of discrimination towards women when they listed which professions there were more women performing. At this moment, they noticed how badly-paid most of them, and the people they knew, were, especially without the technical qualifications required by the job posts available in public spaces.

Brazil has one of the highest indexes of social inequality in the world, and it is important to stress that this phenomenon does not happen in a uniform manner throughout sexes, social classes, ethnic groups, urban and rural groups, and those with different schooling levels. On the contrary, Lourdes Bandeira (2005) reminds us that the studies on poverty demonstrate that it is accentuated among black women and other ethnic minorities. Women are the majority in less privileged social strata and minority among those of higher income, even when they possess the same educational level. There is inequality between the income of men and women, even when they perform the same function, and this inequality increases if we consider the criterion ethnic group / skin color: the black woman will have the lowest salary level. It is interesting to add that even among unemployed people the rate of women overcomes that of men out of the job market. With the scenario, the author states that it is clear why households headed by women, which have increased in the last years, are also the most vulnerable to poverty and therefore susceptible to the precarization of health and life conditions (Bandeira, 2005).

Therefore, it was perfectly understandable the presence, in the group, of stories about how housework is not valued. These stories were repeated continuously, and it was even said that only after falling ill the rest of the family started to “value them”. Even in this utterance, there is an ingrained violence, as they claim that it was only after deranging that someone from the family stopped to take them to receive treatment, but they hardly notice that in this first moment the expression of care is equivalent to “taking a fridge to fix” (metaphor elaborated by the group). “If the fridge becomes faulty again frequently, the family ends up replacing it. But what if the fridge is me?”

With that question, the group was able to notice how much the depreciation of housework, which is performed predominantly by women, and the consequent discrimination of the housewife, had affected their lives, to an extent that many of them reported abandonment by their partners and disrespect from their children.

The suffering of being abandoned after 40 years of marriage, of being admitted in a mental asylum by a relative, saying “this one’s not good enough to fry an egg”, of being call “crazy” by her children, are scenes that start to emerge, connecting the current suffering woman to the woman who has always suffered, but until that point had always thought that life consisted only of suffering.

From this discussion, we observed that the women in the group reproduced in the statements the devaluation of housework, when they would say that “I wanted to work, I’ve never worked”. Domestic work, due to not being paid, was not considered work in the women’s accounts. That is because, historically, this valorization was not built. When we reflected on the importance of this labor that they all performed and that, actually, we needed to demystify the fallacy that housework is the woman’s duty, some women stated that they had never thought of this aspect of their daily life.

The next step was to connect the suffering and the gender discrimination accepted by the group, as in each of their stories there were clear examples of how they were forced to do what their parents told them to, married to whom they appointed, assaulted by their partners, impeded to study and work, raised their children reproducing the gender inequalities. They finally noticed that this was a story of struggle to survive and not a story of a woman who “didn’t do anything at home and now decided to go mad to be even more useless in life” (account of one of the users’ relative).

The life trajectories of the women who took part in this group reproduced very similar stories to those experienced by the participants of Isalena Santos Carvalho and Vera Lúcia Decnop Coelho’s study. In this study, the participants valued themselves when linked to marriage and maternity, but the same situations also produced the feelings linked to depression (Carvalho & Coelho, 2005).

In many moments we used the technique of dramatization of the situations narrated, attempting not only to retell them in the past, but also to live them in the present, in the group. Such experiences showed that there was a relationship based on trust, making it possible for new stories to be told, because, until then, we had noticed that even in the group there was still not space for such pain to be shared.

At this point, another statement attracted our attention: “…I’ve stopped suffering, now I’m only sick in the head…”, made by a woman whose husband, who beat her for 40 years, had already abandoned her and that, now, living alone with the youngest child, still felt very afraid of everything and only had thoughts of tragedies happening to her children. This account made the group, finally, ask themselves: does such suffering lead to illness? Is it possible that once again the linearity-causality, celebrated by the scientific method, is also present in this group in order to respond their aspirations?

It must be said that at first we were not so daring. We agreed that intense suffering really can be a triggering factor of the illness. However, even at the time of the statement, we realized that something was not going well. Was it just that? Can we connect suffering with life, with falling ill and that’s it? Could it be that such logic on its own only reaffirms the hegemonic knowledge, which for so long contributed to produce and accentuate the inequality in relations between men and women?

And, once again, we resumed the problematization of our own concepts of derangement. The first perception is that it is not possible to provide a yes or no answer to the question if suffering leads to falling ill. From then on, we started to question if we were not asking the question the wrong way, because, if a causal nexus question is asked, the answer will not differ from the same biomedical attention model that was being questioned in the group in the first place.

Therefore, we started to worry about the concept already built socially that illness can be the result of female suffering, as the gains coming from this relation can be numerous, including reassurance of the ideological discourse on female fragility and medicalization of women.

With that perspective, we raised questions that we, CAPS workers, could problematize: what logic is this that forms the equation suffering leads to illness? Why does “it have to be a serious case to be treated at CAPS”? Or can it be that some people would say that it is already known that “violence generates depression”? Alternatively, some technicians may simply reply in a bureaucratic way: what is there to be done then?

Is it possible that behind this logic lies the legitimating of the female illness? Even though it is stated that this ‘mild’ suffering is an attribution of the basic healthcare teams, we notice that these teams also come across women that accentuate gradually their complaints and that, also gradually, start being listened and medicated.

The discourse that expresses the women’s pain, located in the body, will result not only in new domination methods, but also profit. The illness generates health intervention technologies, whether demonstrated through appointments, laboratorial exams, drugs or surgical procedures. Some studies consider that the naturalization of suffering works as an ideological strategy, questioning if the violence suffered by women can alter not only hypertensive processes, deteriorating the condition, but mainly, the way the anxiolytic drugs become part of the continuous prescription medication as a tool to strengthen and soothe in the moments of higher emotional exhaustion (Carvalho & Dimesntein, 2004).

 

“I correct my daughters and give advice to my sons” _ violence and discrimination between generations.

 

            In many moments, the background to start a discussion based on gender transversalization was popular sayings used by the women to describe a given event that had happened to them, or even to justify a certain behavior.

A debate referring to power over the female body started exactly after the following expression: “watch your mare because my stallion is loose” (popular Brazilian proverb). Such expression initiated the debate on the right to exert sexuality in and out of marriage, on behalf of both men and women. There was an increased animosity, most users being mothers who considered that women were not allowed to do everything men were, fact illustrated in the popular proverb cited in this paragraph.

There were several weeks in which we, as group coordinators, tried to accentuate how the female body was always object of male dominance, and that the values established in the family only reaffirmed such dominance. We brought historical components which problematized the appearance of the bourgeoisie family, the right to inheritance and how the economic model and social values were deeply interwoven.

At this point, we noticed how much the distance between discourses had generated an impasse in the group, a feeling that our proposition had failed, considering that we hadn’t managed to generate sensibility to the theme that allowed us to question the sexuality imposed on women. However, their life stories once again allowed us to deepen the issues discussed up to then.

One of the women in the group created an opportunity for us to open new paths to the impasse. She started to tell us how she had always raised her daughters giving advice, warning them about what they could do or not, and even so her daughter had a teen pregnancy, fruit of sexual violence on behalf of her boyfriend, who then disappeared. At this point, we started to retrieve the stories of affective-sexual involvements of each of the members of the group, most of them accounts of psychological and sexual violence by boyfriends, partners/husbands, or even of other relatives and strangers, both in their first affective involvement and throughout their life. Such accounts emerged with the nuances of violence described in the workshops that took place with women in an extension project in Rio Grande do Sul (Meneghel, et al 2005).

It was only then that the understanding of the subjugation of the female body to male will was possible in the group, as they were the living proof of this violence. The comprehension of this notion of male power brought ambivalent feelings to the group, as it also remitted to the role of the mother who always legitimated such power. Below are some examples of utterances from users in the group:

            “In my house, the husband’s food was served first, then the sons-men and the leftovers were for the daughters-women.”

           “My daughters had to marry virgin, but I wouldn’t keep an eye on the boy, his girlfriend’s mums had to worry about it.”

Maybe this assumption regarding the legitimating of the power of decision only granted to sons was one of the barriers that were raised previously and prevented the group from equalizing the differences. How could they question the role of the mother who kept her daughters virgin and let her “stallion” son indulge himself? How could they perceive that this situation ended up victimizing themselves, because in many moments they were the “mares” of other “stallions”, and therefore, felt used and disposed of, as “stallions” learnt so well to do? How can they feel proud of the “stallion” son if the “stallion” father, brother, boyfriend, partner is the one who most torments them currently?

  Such reflections helped the group to grow and rethink the issues of gender that were being imposed to future generations. Even the continuous violence they submitted their daughters to, when these did not follow the non-verbal agreements of female submission, could be discussed. It was also possible to work with the situation of vulnerability of children and adolescents (the users’ children) who were already working, and who had also been victims of sexual violence. At this point, the use of Brazilian judicial material was of utmost importance, namely The Child and Adolescent Statute and the Maria da Penha Law, as it brought complementary information regarding female citizenship.

The account of one of the group members about an experience of violence for more than 40 years, the spouse being the perpetrator, impressed the group, because for all this time she was married the situations of physical, psychological and sexual violence were constant. In this period, she did not seek for help at any moment because he would say that “…in the sky you leave a shadow, on the ground you leave a track”. This statement makes a clear reference to the possibility of him hunting her down and killing her, and, even if she managed to disappear from his life, there would always be relatives who would stay behind and would suffer the consequences for her.

Violence and mental health are themes that cross over in several moments of these users’ lives, many of them confirming they only used violent strategies when they needed to face a given conflict. There were several debates in which they justified that only by “smashing his face” or “breaking the furniture” they would be heard. Then we questioned: were they really heard or had they managed to impose the empire of fear, as they partners had done with them? The perception that they leveled with their spouses brought suffering to some and the feeling of power to others, to the extent that we asked if the role of “stark-raving mad” (expression used in the group when they described the use of violence) did not guarantee, minimally, what they couldn’t achieve being “normal”. Does it pay off to be crazy?

Being “crazy” gained a new meaning, as a way of expression used by them to manage, in many moments, to express pain, loneliness, anger, anguish and despair when facing situations in which they did not perceive to have the power of modification, not even the right to verbalize what was happening to them, either because they could not understand it themselves, or because they didn’t find space to strengthen their argumentation power.

With the possibility of resignification, many of them found new strategies to deal with conflicts only by noticing they already had the tools which would help them: they knew their rights and where to look for them, they were not alone anymore, they knew how to identify and express feelings. On the other hand, the feeling that “being crazy” was “liberating” also emerged, and that concerned us. Could it be possible that the power of madness in itself would be enough for some women to cope with relations of inequality?

Once again we questioned if derangement appeared as a socially shared response to the situation of violence continuously fueled by excluding relationships. In which moment talking, shouting the pain, leaves the spectrum of normality? Does shouting or silencing require a temporal relation? That would be to say that, if a woman has just been beaten, she should soon develop a depressive disorder. On the other hand, if this condition only appears in two years’ time, when the husband is already good, and she cannot claim family problems, will the healthcare team then diagnose her as having endogenous depression? This last question is a clear reference to the use of psychopathological diagnoses for the binding of the user to CAPS.

Another possibility to consider the female derangement, as a coping strategy socially constructed to deal with the problems experienced, also emerged when they said that it was necessary for voices to continuously threaten to kill them for them to seek treatment. Treatment in this case means taking sleeping pills, once it was not possible to divorce their alcoholic husband because they would face famine. Between taking medicine and being homeless and hungry, there is only one viable choice. Let’s madden, “much better than starving to death” (statement from one of the users).

 

Final considerations

The proposition of a gender discussion in mental health is raised here as a way of resizing the concept of health and mental illness. There is no pretension to formulate a new psychopathology, but rather to question how the current psychiatric nosology fits perfectly into the female suffering and has an adequate response to it: medicate the pain. But what can be said of social relations that trigger such pain? What can be done? Medicate everyone?

  We stress how the construction of a deranged female identity works as an instrument of expression, in many moments, disaggregated and delirious, but which denounces relations of inequality and violence to which they have been historically submitted. Even in the moments when the crazy-depressed identity counters the role of female warrior already taken in other moments, it is perceived that the warrior was gradually massacred in the countless affective and work relationships to which a woman is submitted. Being a female warrior is not socially valued, but being an elastic woman, that indeed would mean perfection.

Is there a chance that the female identity of elastic woman will become the next psychiatric syndrome to be discovered? Or can it be that the Burnout Syndrome already incorporates this function, as it is related to the care roles which are knowingly composed mostly of women?

Another important aspect to be considered was raised by Solange Rocha and Veronica Ferreira’s study (2005), when they questioned how the implementation of the Family Health Program, in the nineties, reinforced the emphasis on healthcare to the family. They stated, at the time, that this process exacerbated the role of the woman as family carer, and therefore, only reinforced the gender inequalities, not succeeding in changing this scenario (Rocha & Ferreira, 2005). The same can be happening when the CAPS manage to remove women from psychiatric hospitals, but cloister them in the dyad housewife-CAPS user.

We definitely highlight the importance of accompaniment and research, emphasizing that the construction of female identity, and even of female illness, does not occur in an epistemological void. On the contrary, there are rather unclear rules regarding being a woman / being a sick woman, and only in-depth scrutiny of these rules can help us cope with new situations of inequality and violence.

Finally, we would like to stress that this text does not propose the creation of a group that would discuss gender in the CAPS, on the contrary, we understand that this theme must pervade all the moments of a therapeutic project that addresses citizenship. However, knowing the possibility of diluting the theme in the ocean of situations that users bring us daily, we believe that in the search for therapeutic projects which approach this theme, or in the case discussions, this category can be dealt with, bringing advancements to mental health discussions.

 

References

Andrade, Ana Paula Müller. 2014. (Entre)laçamentos possíveis entre gênero e saúde mental. In: Zanello, Valeska e Andrade, Ana Paula Müller (orgs). Saúde Mental e gênero: diálogos, práticas e interdisciplinaridade. Curitiba: Appris, p. 59-77.

Bandeira, Lourdes. 2005. Brasil_ Fortalecimento da Secretaria de Políticas Públicas para mulheres: avançar na transversalidade da perspectiva de gênero nas políticas públicas. Document elaborated from the agreement between the Economic Center for Latin America and the Caribbean  (CEPAL) and Special Bureau for Policies for Women

(SPL-Brasil). Brasília: CEPAL.

Carvalho, Isalena Santos e Coelho, Vera Lúcia Decnop. 2005. Mulheres na maturidade: histórias de vida e queixa depressiva, Estudos de Psicologia, Vol.10, no 2, pp. 231-238.

Carvalho, Lúcia de Fátima e Dimenstein, Magda. 2004. O modelo de atenção à saúde e o uso de ansiolíticos entre mulheres, Estudos de Psicologia, Vol 9, no 1, pp. 121-129.

Giffin, Karen. 2002. Pobreza, desigualdade e equidade em saúde: considerações a partir de uma perspectiva de gênero transversal, Cadernos de Saúde Pública, 18 (Suplemento), pp. 103-112.

Meneghel, Stela N; Barbiani, Rosangela e Brener, Camila. 2005. Cotidiano ritualizado: grupos de mulheres no enfrentamento à violência de gênero, Ciência & Saúde Coletiva, Vol 10, no 1, pp. 111-118.

Narvaz, Martha Giudice e Koller, Silvia Helena. 2006. Metodologias feministas e estudos de gênero: articulando pesquisa, clínica e política, Psicologia em Estudo, Vol.11, no 3 (set-dez), pp. 64-654.

Rocha, Solange e Ferreira, Verônica. 2005. Reformas do Estado e Seguridade Social: o caso da saúde. In: Villela, Wilza; Monteiro, Simone (orgs.). Gênero e saúde: Programa Saúde da Família em questão. Rio de Janeiro: ABRASCO- Associação Brasileira de Pós-graduação em Saúde Coletiva; Brasília: UNFPA- Fundo de População da Nações Unidas, pp. 63-70.

Scott, Joan. 1995. Gênero: uma categoria útil de análise histórica,  Educação e Realidade. Porto Alegre, Vol 20, no 2, pp. 71-99.

 

Biographical note

Ionara Vieira Moura Rabelo_ is a psychologist, Doctor in Psychology by UNESP-ASSIS (2011), with sandwich work experience in the Dominican Republic (INSTRAW/ ONU Women). Adjunct Professor at the Federal University of Goias/Regional section Goias, and Psychologist of the Surveillance Division of Violence and Health Promotion, Municipal Health Bureau of Goiania. She is a researcher for the Center for Studies of Violence and Gender of UNESP-Assis.


 

[1] Part of this paper was first published as a chapter of the book entitled Olhares- experiências CAPS

labrys, études féministes/ estudos feministas
juillet /décembre / 2014  -julho/dezembro 2014