études féministes/ estudos feministas
Mental health, women and conjugality [*]
Translated by Ana Carolina Ribeiro Romero
Through the example of a clinical case of a woman hospitalized at a psychiatric hospital presenting "unmotivated cry" as a major symptom, we aimed to point out what the seal of psychiatric diagnosis "depression" was hiding. Conversations with the patient revealed that she had been raped for 7 years during her marriage. Two issues stood out on the understanding pointed out by the disqualification of the word "unmotivated". On one hand there were motives concerning the suffering in the private sphere (rape in marriage) that should not be approached by a science that is intended to be impartial. On the other hand, "unmotivated" pointed to aspects of the love life of the patient, indicating how much the loving dispositif (Swain, 2011, 2012) is an important historical construction for the understanding of the constitution of the subjectivities of women in our culture. The article exemplifies and highlights the potentialities of a critical reading of the mental health field through gender relations and a feminist perspective.
Key words: mental health; gender; women
Através do exemplo de um caso clínico de uma mulher internada em um hospital psiquiátrico, cujo sintoma que se destacou foi “choro imotivado”, buscou-se apontar o que a chancela do diagnóstico psiquiátrico “depressão” escondia. Em conversas com a paciente, descobriu-se que a mesma fora estuprada durante 7 anos em seu casamento. Duas questões se destacaram na compreensão que a desqualificação da palavra “imotivado” apontava. De um lado, tratava-se de motivos que tangiam ao sofrimento relacionado ao âmbito privado (estupro no casamento), este que não deveria ser abordado numa ciência que se quer imparcial. Por outro lado, a “imotivação” apontava para aspectos da vida amorosa da paciente, indicando o quanto o dispositivo amoroso (Swain, 2011;2012) é uma construção histórica importante para a compreensão da constituição das subjetividades das mulheres, em nossa cultura. O artigo exemplifica e destaca as potencialidades de uma leitura crítica do campo da saúde mental sob uma perspectiva feminista e das relações de gênero.
Palavras-chave: saúde mental; gênero; mulheres
The study of gender relations as a bias to understand the field of mental health is still incipient. Authors such as Phillips & First (2008), Wisner & Dolan-Sewell (2008), Widiger (2008), among others, indicate that the consideration of this bias will lead to a reinterpretation of the diagnostic classification of various conditions and possibly a change in the epidemiological indices we know.
In this case, it is pointed out the character of the gendered symptoms (how this manifests), that is, that the symptoms are not immediate and motivated signs (as medical symptoms would be), but rather depend on their own semiotics, in which gender relations are fundamental factors that are present in their pathoplastic aspect (Zanello, 2014). In other words, the fact that men and women (in a society marked by binarism) may show different symptomatic expressions is emphasized. An example would be crying, accepted since childhood in the behavior of women but strongly repressed among men as a sign of weakness, which would question them as "real men". This means that crying can be the manifestation of sorrow in a woman, but even if a man did not cry, this does not indicate that he is not sad.
Therefore, through a gender bias it is pointed out the need to fit the description of mental disorders in a gendered way in order to avoid over-diagnosis of certain disorders in women, such as depression, and sub-diagnosis in men (Widiger & First, 2008; Zanello, 2014). A key point for this project is to restore the speech of the individual, not only in their individual suffering, but as gendered speech, marked by the social place from which they speak (Santos, 2009).
In a recent study (Zanello & Silva, 2012) conducted in two large psychiatric hospitals in Brasilia, a statistical survey on the incidence of symptoms and diagnoses in 72 male and 165 female medical records, users and former-users of these hospitals was carried out. Not only the frequency proved quite differentiated (more psychosis -44%; mood disorder -19%; anxiety disorder -8.5%, among men; and among women: more mood disorders -38.3%; psychosis - 23.4%; anxiety disorders -15%; neurotic/histrionic personality disorder -11%; mixed disorders of depression and anxiety -6.3%), but also there was significant appearance, particularly for women, of the "symptoms " specific to them. Among several, such as "detachment from housework", being "manipulative", "hysterical" and related others, we would like to highlight one that has proved quite frequent and is also quite revealing: "unmotivated cry”.
The fact that the word "tearful" appeared in only one of the male records is noteworthy. In the female ones, it not only appeared in 25% of the records but it was almost always present in association with the adjective "unmotivated".
The first question that comes to mind is: what is an unmotivated cry? This happens for two reasons. The first and possibly the most obvious is about who decides whether the reason for a cry is enough or not. Would it be the doctor? The second, less obvious but of a huge symbolic violence is related to the average doctor time when listening to these patients: approximately a minute for each evaluation. Exceptionally it may be extended up to 3 minutes.
Is the cry unmotivated? Or would the doctor not understand the motivation behind it? Or would he be simply not interested? This is what will be discussed from an observed clinical case.
Mayara: the "unmotivated" cry due to rape suffered for 7 years in her marriage
Mayara, 32 years old, was hospitalized for more than two weeks. She was crying every time we went to the hospital. On the rare occasions that she was not already crying, when we greeted her she then burst into tears. Her medical record indicated that her husband had taken her to hospital as he thought she could be depressed. "Unmotivated cry" was present among the symptoms described by the doctor. After a month in the hospital, in one of our visits we found the patient not crying and approached her for a conversation that she apparently showed to be interested and open to have. Mayara then told us that during the seven years of her marriage, she had forced sex with her husband, without feeling any sort of pleasure.
She told us:
"he treated me like a prostitute. How can a husband treat his wife like a prostitute, going to have sex, spreading her legs and doing it ... He raises the neck and closes his eyes slowly... they want to do it easily, oral, anal ... Animalistic... Animalistic. He treated me as a prostitute, I did not accept it, I struggled for seven years, because he is my cousin, it would create an uncomfortable situation in the family, as it did." And she continued: "His point was sex all day and sex of all possible ways, and I, not for a moment in seven years, I did not let him have the sex he wanted". Then we asked: "What did you do?". She answered: "(she gets emotional) this year he swore to me... 'you either change or I'll leave you because you are a gross, ugly, hideous woman and I deserve something better." We asked again: "What did you do when he wanted to have sex and you did not want it?". Mayara: I did nothing, just (gesture of someone who just let the husband do it)... That's all I did. And think of these seven years, which to me were more like seven hundred years."
Mayara then told us that she experienced this relationship as a "softened body", like a "rag doll" (SIC). She described in detail how she was "absent" of that moment when she "let" (in order to be left alone) her husband penetrate her. As shown in the extract above, she felt she was treated as a prostitute. Also, her speech showed bad moral tracts particularly evidenced by her partner’s cursing (and followed by a history marked by bullying related to her overweight), such as: "Ninja turtle", " fatty", "Free Willy". A recent study (Zanello, Bukowitz & Coelho, 2011; Zanello & Bukowitz, 2012) highlighted how bullying related to body, especially the overweight, are considered offensive, by both men and women, when related to them, as they hurt the ideal of beauty, typical of our current lipophobic culture (Novaes, 2006). In other words, the violence was not only sexual but moral... When Mayara decided to separate, she got a job in order to get rid of any economic dependence that her husband could use to subdue her.
When telling about her first hospitalization, the patient reports that she "freaked out" after one of the thousands of times that her husband held her by the arms and had intercourse with her without her consent. Interestingly, Mayara sees this situation as rape, not the other ones though. She reported: "In seven years he raped me twice”. We asked:
"The other times were not even against your will? Did you let him do it?" She answered: "Liberal... no... I let... just had my mind out of the body... do you understand?". Mind outside the body was the dissociation used by the patient to bear the violence to which she was subjected and of which, at least immediately, she saw no escape.
When we asked whether Mayara had shared it with someone, she said she told her mother and father, who advised her not to report anything because time had passed. When we asked if she had told this to the psychiatrist, she answered affirmatively. "And what did they say?" We asked. She said:
"They say nothing, they say nothing...". And she continued: "I know that Dr. Lucia (not her real name) will follow my case now... here in the routine consultation; she said I have to go to a psychologist, for psychological counseling, and there is everything there."
One of the things that the patient reported was that although the family worried about her depressive silence, they (the family) resented her when she talked too much.
She told us:
"I was passive in everything. My family was complaining about me because when I was depressed I became more incommunicable. Depressed people become incommunicable; a person shuts herself, reserves herself, encloses, enters into a... enters into a shell and remains inside. Then my parents do not accept it, but when I talked too much, they said: Stop talking too much, you'll end up with no voice... they miss the time when I was mute."
But what did the patient say? That is what we asked. She said:
It's bothering my family. Anything, anything I say... 'Do not talk too much, you're talking too much, you'll be hoarse, you will lose your voice, you will damage your vocal cords (...) My father's recommendation was: be quiet, do not talk to anyone or you will get hoarse."
And the example given by Mayara was a situation in which she felt very angry and when she expressed it, her father said the sentence above. And she concluded by talking about what her father said:
"‘why do you keep talking about it? You do not need to do this, what for, Mayara? Wait, be patient, be humble'. To my father I have to be humble, talk less, avoid talking to people. He wants me to be the dumb I used to be... depressed... that I have always been."
Depression and silence: The invisibilized female suffering
As pointed out by Garcia , "being a woman in a strongly patriarchal society leads a disproportionate number of them to collapse" (1994,:115). The mental disorder is characterized as
“[...]the exasperation of living conditions of women because in madness she ceases to seek the reason for her unease in their conditions of existence and shows, through the suffering that the situation of an outbreak is, the inner oppression and the loss of any power over herself "(Garcia,1994:119).
According to this author, depression would be a constant condition of women, because "the lack of alternatives for life traps women in a state of whining impotence" (p.117). Phyllis Chesler (2005) points out, also in this sense, that diving into a deep depression is how many women do to react to a situation that they perceive as hardly likely to be changed.
The symptom "unmotivated cry", so constant in female medical records, in the case of Mayara points out, as it can be seen, to a form of violence, approaching a major taboo in our culture: sexual violence within marriage. The name "unmotivated cry" is the invisibility of the suffering of this woman and her conditions. The silence of their symptoms is consistent with the silence of "depression" diagnosis, which provides a psychiatric profile for existential and social issues in which gender relations are found to be fundamental. As pointed out by Porto (2006), there is the coexistence of women with violence and the invisibility of this issue for health workers and health managers who assist them.
In relation to sexual violence within marriage, Saffioti (1994) points out: "Rape is only considered a violent act when committed by persons outside the marriage contract; it is accepted as normal when it occurs within the marriage" (p.443). According to this author, there is a social legitimization of male violence, which creates a belief that it is "marital duty" of women; if she marries, she has to satisfy her husband. Enjoying her body whenever he wants would be his right and her obligation. Mathieu (1985) points out that in these cases women give in much more than just consent.
Dantas-Berger & Giffin & (2005) highlight the ways that marital coercion takes place in the experiences of women. Because it is experienced as marital debt, something within intimacy that should not be opened or shared, they experience it with antagonistic feelings of servitude, disgust and repulsion, constituted as a form of self-violence. According to these authors:
"Sexual violence, especially coercion and/or sexual violence by an intimate partner in the private sphere is little evidenced or nonexistent in the available statistics" (Dantas-Berger & Giffin, 2005: 4).
It is pointed out the absence of a possible vocabulary for this type of violence that, as seen, is legitimized in our culture.
Sexual coercion, naturalized, socially invalidates its nature of violence so that the woman violated and self-violated does not designate this act this way. As observed, Mayara says her husband raped her only twice! As emphasized by Vilhena & Zamora (2004), it is a subjection of gender, to which, in case of rape (even if instituted by marriage) is perverse, as it annuls the desire and subjectivity of women:
"Women are also assimilated as property of men (especially the closest ones) and disregarded as human beings in the (micro) exercise of power" (Vilhena & Zamora, (2004:122).
We believe that there are two fundamental questions to understand the silencing that the word "unmotivated" indicates in allegedly neutral diagnoses, prescribed by psychiatry. The first question is about the reasons concerning the suffering that emerges in these women related to the private sphere; this should not be approached in a science intended to be impartial. But more than that, it is about not to mess with wasps, where leaving without being stung becomes an almost impossible task. It is about to confront the established, with the existing values and what must remain unnamed, invisible. As pointed out by Timm, Pereira & Gontijo (2011), when looking through gender relations, it becomes impossible not to qualify a clinical action as a political action...
"Violence in the private sphere, far from being a purely psychological phenomenon to be kept hidden in the confines of the intimate sphere, is one of the effects of the hierarchy through which genders are organized in the patriarchal culture" (Timm, Pereira & Gontijo 2011: 249). Therefore, it is necessary "to violate" the private secret, as according to Vilhena & Zamora (2004), "home, with its privatizing feelings, can also generate destructive secrets and silences" (Timm, Pereira & Gontijo ,2011:118).
On the other hand, the "unmotivated" points, almost always, to aspects of the love lives of patients, indicating how the loving dispositif is an important historical construction for understanding the constitution of subjectivities of women in our culture.
In a research conducted at the same hospital where the patient was hospitalized (Zanello & Bukowitz 2012), recurring themes were raised in the speeches of male and female psychiatrized patients. We have reached the result that there is a prevalence of relational complaints (77%) among women and a speech marked by virility (71%) among men. Among women, the most recurrent categories in the relational complaints were: amorous (27%), paternal (many cases of physical and sexual violence, 15%), maternal (10%) and affiliates (15%).
If the main suffering brought by women is related to their relationships and particularly to their love lives, it is of paramount importance to understand what is this burden that love occupies in their lives as historical fact and how they came to be validated as women by gendered values based on marriage and motherhood. This is the only way to understand the burden occupied by conjugality as a facto, risk or protection to mental health of women. In this sense, Shear et al (2008) underlines that the marital status, childcare, employment and income contribute to the risk of depression. However, the authors highlight:
"Studies suggest that marriage can affect men and women differently. Specifically, it seems that married men have lower depression rates than unmarried peers, whereas the opposite is true for women" (Bebbington et al,, 1981: 64).
According to these authors, a possible reason would be that disagreements seem to affect women more than men. Likewise, even researches related to physical health show a high correlation between marital satisfaction for women and not for men.
According to our view, this points to the importance of love and conjugality (as well as motherhood) and how these are increasingly becoming "female" values, that is, highly associated with the roles of women and through which they are self-valued. As we have shown in another study (Zanello & Bukowitz 2012), narcissism is gendered and cultural values (of gender) are the ideals by which the individuals accept themselves as objects of judgment and valuation.
In the same sense, Timm, Pereira & Gontijo (2011) point out that universalization and naturalization of gender roles in Western culture assigned to women a symbolic place of resignation, responsibility for the ideal family structures, including filiation and motherhood, and ongoing investment to make themselves perceptible and attractive to be seen by a man.
"In this patriarchal Western culture women have been constituted by the way they are seen by men, feeling deeply helpless when they are not noticed and often settling for a violent family or marital scenario in order 'not to stay alone'" (emphasis added, Timm, Pereira & Gontijo, 2011: 254)
On the other hand, this makes sense of researches that show how the factor "support at work" is correlated with a reduction in mortality or morbidity among men, while it does not present significant correlation among women (Shear et al, 2008: 64).
More than "natural" data, this points to a power dispositif historically constituted that provides women with a privileged place (or exclusionary?) in relation to "love". According to Deleuze (1990), a dispositif must be understood as a kind of hank or skein, a multilinear group. This is how Foucault (1996) defines it:
A definitely heterogeneous group encompassing speeches, institutions, architectural organizations, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral, philanthropic propositions. In short, the said and the unsaid are the elements of the dispositif. The dispositif is the network that can be developed between these elements. (Foucault, 1996: 244)
Foucault distinguishes three dimensions on a dispositif: knowledge, power and subjectivity. In the dimension of knowledge we find the curves of visibility and enunciation. Therefore the dispositifs are configured as machines that make see and that make speak. Regarding the power, the dispositifs require lines of power, distribution and tension forces. And lastly there is a process of subjectivation, a production of subjectivities in a dispositif: "she is to be made, to the extent that the dispositif allows her or makes it possible" (Deleuze, 1990).
According to Marcello (2009), the lines of subjectivation are responsible for the pedagogical production of the individual by himself. It is a positioning of the individuals not as passive objects but as confessing subjects, not of a produced fact about them, but rather a truth about themselves where they themselves must actively contribute to produce. Therefore, the dispositifs are not only normative, but constituents.
In case of women, Swain (2011) highlights the historically constituted and constitutive role of the loving dispositif. According to the author, love is for women what sex is for men:
"In the crevices of the dispositif of sexuality, women are 'different', that is, their social representative and practical constructions suffer interference from another dispositif: the loving dispositif. It would be possible to follow their genealogy in speeches -philosophical, religious, scientific, of traditions, of common sense - that establishes the image of the 'real woman', and tirelessly repeat their duties and qualities: sweet, kind, devoted (unable, futile, unreasonable, all the same!) and, especially, amorous. Amorous of her husband, her children, her family, beyond all limits, of all self-expression"(Swain, 2011, web)
Swain points out that the loving dispositif builds bodies-in-woman that are ready to sacrifice themselves for love to others. The speech of a "real" woman is only understood within this logic of which this dispositif makes enunciable and, mainly, constituent of women in their relation with "to be woman": "It is the reproduction of old formulas that characterize women: sweet, devoted, kind and above all, lovers. Love updates them on the identity expression of 'women': it is their reason for being and living. They are willing the sacrifice and self-forgetfulness for 'love' "(Swain, 2013: 11). In this sense, the "real woman" would be the wife, mother, beautiful, loving and sexually available.
It is not surprising that in this view most female complaints occur in the marriage sphere, demonstrating the importance given to this by the women in their lives. According to Swain (2013), even women who have multiple partners end up living under the aegis of the search for an ideal partner, of finding love and getting married. There is a self-understanding/valuation in this bias, which makes intelligible the submission of many women to suffered relations (paying whatever the price is) and the role that the relation assumes to its narcissistic valuation. Moreover, it is possible to understand the assertion of love and motherhood dispositifs as being related to the private sphere, female identity location and privileged space of women in our culture.
The invisibility of the specificity of female suffering is at a crossroad in which gender issues are presented in its multiple facets: on the one hand, the loving dispositif that constitutes women giving them the possibility of their personal value confirmed by the love of others, which the marriage would be a kind of social order and confirmation of them as "real" women. It is in this perspective that we can understand the wound that a poor conjugal life strikes in the narcissism of a woman and her insistence on remaining and maintaining this type of relationship. On the other hand, invisibility is related to listening to this suffering by a supposed neutral science that does not "get the scoop" on issues of intimacy that challenge power relations. That often challenges the gendered beliefs of the doctor.
Thus, the gender bias causes great discomfort to the area of mental health in various aspects, because it deprives the instituted, undermines the certainties of a supposed neutrality, brings the intimate to the political and questions the power relations in this field as well as their values.
Suffer for love, suffer for loving, silently bear love-related situations, bear in silence to maintain a marriage, children, a family; these are recurring themes in the speech of these women, of whom Mayara was just an example. When heard, under a gender bias, the symptom "unmotivated cry" gains a "motivation" and gave meaning and body to the suffering that needed to be nominated and dismissed. But naming and welcoming it has consequences. As pointed out by Narvaz & Koller (2006), the epistemological, ontological and ethical presuppositions of the research and of the clinics have political implications, and can be of various interests. Then, it is necessary to reflect on the consequences that the adoption of a feminist epistemological assumption can bring to the field of mental health. In our view, this implies deep changes ranging from listening and cares to the diagnosis and treatment.
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Valeska Zanello- Ph.D. in Clinical Psychology by the University de Brasília, with sandwich Ph.D. in the Université Catholique de Louvain (UCL), Belgium. Psychologist and BA in Philosophy by the University of Brasília. Expert in Philosophy and Existence by the Catholic University of Brasília. Associate professor of the Department of Clinical Psychology of the Institute of Psychology of the University of Brasília. Currently working in the interface between mental health, philosophy of language and gender relations.
[*] This paper was presented at the II Colloquium on Gender and Women's Studies held at the University of Brasília in May 2014. The Portuguese version was published in the book of the event.
études féministes/ estudos feministas