Reconceptualising Reproductive Disorders:
The Development of a
Material-Discursive-Intrapsychic Approach
J.M. Ussher
PsyHealth: Research in Gender, Culture and Health, School of Psychology,
University of Western Sydney, Australia
Summary
This paper critically examines the positivist-realist paradigm that
dominates medicine and psychology, arguing that it leads to the
pathologisation of distress associated with women’s reproductive health.
Taking the case of post-natal depression, an alternative material-discursive-intrapsychic model is proposed, which acknowledges the myriad
causes of women’s distress, and avoids either biological or psychological reductionism.
Introduction
Within medicine and psychology, disciplines dominated by a positivist-realist epistemological perspective, the desire for valid and reliable comparison across epidemiological and treatment studies, and the
need to facilitate research into etiological mechanisms, has precipitated
the desire to establish consensus definitions of problems associated with
women’s reproductive health – such as premenstrual syndrome (PMS),
postnatal depression (PND), and menopausal distress. The diagnostic
categories reified in DSMIV are the archetypal case. The desire for a
scientific approach and uniform definitions of reproductive health problems may appear on the surface to be a necessary first step for both
research and clinical intervention. However, the very notion of categorization of experience into psychiatric syndromes, within a positivistrealist model, has been criticised from many different avenues.
For example, take the case of Post Natal Depression. The focus on
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diagnostic categories reifies the notion of PND as a clinical entity that
occurs in a consistent and homogeneous way, that has an identifiable
etiology, and is perceived to have caused the symptoms women report.
This acts to deny the social and discursive context of women’s lives, as
well as the gendered nature of science, which defines how women’s
bodies and lives are studied. In contrast, as many critics have argued,
PND can be conceptualised as a social category created by a process of
expert definition (1), similar to other mental health problems (2). In this
view, PND is a socially constructed label, based on value-laden definitions of normality. Parallel arguments have been made about many
other ‘disorders’, both physical and psychological (3), leading to a
deconstruction of expert diagnosis, and to a questioning of the existence
of many “syndromes”.
Within mainstream psychology and medicine, if a phenomenon cannot be objectively observed and measured using reliable, standardised
techniques, then it cannot be ‘known’. This has resulted in a methodology driven, rather than a theory driven, analysis of PND and its possible aetiology. For example, the role of unconscious factors, cannot be
easily assessed within a hypothetico-deductive frame, and so they are
not included in the majority of mainstream analyses. Equally, as historical, political, and wider societal factors are not easily operationalized
and assessed, they are only addressed within social constructionist or
feminist critiques. According to a positivist paradigm, PND is construed
as an individual problem - a disorder affecting an individual woman, on
whom bio-medical or psycho-social factors impact and produce symptoms.
The woman who presents with problems is implicitly positioned as
passive and devoid of social context in traditional analyses of PND,
since agency is not easy (if at all possible) to observe. So it is inevitable
that it is her body, or her symptoms, that are the entire focus of attention. Yet women are not passive objects in relation to either interpretation of physical or psychological symptoms, or in relation to the discursive construction of PND. Recognition of or self referral for treatment
is a process of active negotiation of symptomatology, current life events
and lifestyle, and cultural, medical or psychological discourse about
PND. Many women make sense of their experiences through positioning themselves as suffering from depression, anxiety or problems such
as PND; others may experience symptoms but not make ascriptions of
any of these problems. In one study of new mothers (4), one third of
those who met the criteria for post-natal depression didn’t want it labelled as such. They said that they weren’t experiencing an illness, but
dealing to the best they could with overwhelming tiredness, isolation,
lack of support and physical strain. To position these women as ‘false
negatives’, as they are in the case of PMS research (5) is to misinterpret
the active negotiation and resistance of dominant discourse associated
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with mental health problems in which many women engage. It is to
reinforce the notion of women as passive dupes, rather than active
agents who continuously make sense of and interpret the social sphere,
and their own psychological or bodily experiences (6).
As psychological symptoms are not visibly apparent, they have to be
observed through the interface of subjective accounts. As these may
easily fall outside the required standards of objectivity and replicability,
in empirical research they are collected through the use of standardised
instruments. This is why there has been an inordinate amount of attention given over to developing reliable and valid standardised questionnaire measures for assessing the incidence of specific reproductive health
problems, such as PMS, PND, or the menopause. In mainstream research in this area there is almost total reliance on quantitative methods
of data collection and statistical analysis of results. Thus, the complexity and contradictions evident within women’s subjective accounts is
negated, and a potentially rich source of data is left uncollected and
unexamined.
Equally, within mainstream psychology and medicine, women are
made to fit the researcher’s model of PND, in contrast to grounded
methods of data collection and analysis, where the constraints of apriori
assumptions are not imposed upon participants accounts, which are collected
in a more open, qualitative manner. The use of questionnaires also
assumes that ‘symptoms’ can be categorised and classified in a dichotomous manner as existing or not, with the only added complexity being
the notion of a degree of symptomatology. That a woman might reply
that she sometimes has a symptom and sometimes does not; that it
depends on what is happening in her life, whether she has recently
eaten, what she is thinking, or how recently she has had sex, amongst
other factors, is not acknowledged at all; neither is her assessment of
the meaning of her symptoms (7).
A Material-Discursive-Intrapsychic analysis of Postnatal
Depression
Many women do experience extreme distress in the postnatal period.
Is this a specific illness? Or simply a depression that occurs postnatally?
If psychological, social and physical factors have been found to be
associated with symptoms, which one is the most important? What I
would suggest is a move towards a material-discursive-intrapsychic analysis,
where both material, discursive and intrapsychic aspects of experience
can be examined without privileging one level of analysis above the
other. ‘Material-discursive’ approaches have recently been developed in
a number of areas of psychology, such as sexuality, PMS, and mental
or physical health (8, 9). This is as a result of both a frustration with
traditional medicine and psychology which has tended to adopt a solely
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materialist standpoint, thus serving to negate discursive aspects of experience, and a dissatisfaction with the negation of the material aspects
of life in many discursive accounts. This integrationist material-discursive approach is to be welcomed, yet arguably does not always go far
enough, as the intrapsychic is often still left out, for the reason that it
is seen as individualistic or reductionist, or not easily accessible to
empirical investigation. Equally, when intrapsychic factors are considered (for example in psychoanalytic or cognitive theorising) they are
invariably conceptualised separately from either material or discursive
factors. It is time that all three levels together are incorporated into
academic theory and practice, in order to provide a multidimensional
analysis of women’s lives, of postnatal depression as a discursive category, and of the mental health symptoms many women experience(10).
So what is a material-discursive-intrapsychic approach?
The level of materiality To talk of materiality is to talk of factors
which exist at a corporeal, a societal or an institutional level: factors
which are traditionally at the centre of bio-medical or sociological accounts. This would include biological factors associated with psychological symptomatology; the physiological changes that take place during pregnancy, childbirth and in the post-natal period; the physical presence
of a baby; difficulties the child may experience; lack of sleep and other
physical consequences of pregnancy and motherhood material factors
which institutionalise the diagnosis and treatment of PND; gender inequalities and inequalities in heterosexual relationships, legitimating
masculine power and control. The latter would encapsulate economic
factors which make women dependant on men; presence or absence of
accommodation which allows women in destructive relationships to
leave; support for women of a legal, emotional and structural kind,
which allows protection from further harassment or abuse. The fact of
how many children are present (or are in custody battles withheld), and
the material consequences of being married (or not) are also part of this
level of analysis. Equally, previous history of abuse, or of bereavement
is partly a material event; as is family history - the number of siblings,
parental relationships and factors such as parental divorce or separation
from parents in childhood. There are also many material consequences
of experiencing or being treated for PND, in terms of physical or psychological vulnerability, as well as powerlessness at an economic or
societal level. The social isolation which can be a consequence of mental
health problems, or which can act to exacerbate it’s effects is also partly
a material issue. Sex, ethnicity and sexuality are also associated with
materiality - with the reproductive body, with gendered or sexual behaviour, and with physical appearance.
The level of the discursive To focus on the ‘discursive’ is to look to
social and linguistic domains - to talk, to visual representation, to ideology, culture, and power. What is arguably of most relevance in analy-
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ses of PND is the discursive construction of depression, of medical or
psychological expertise (3), as well as the analysis of the relationship
between representations of ‘motherhood’, ‘fatherhood’, ‘woman’ and
‘man’ and the social roles adopted by individual women and men.
Hegemonic discursive representations of femininity position motherhood as easy, as natural, and women who are distressed or not coping
after childbirth as ‘ill’, rather than distress being an understandable
response. Equally, the discursive positioning of ‘raging hormones’ as
the root of women’s reproductive distress locates ‘PND’ in the body.
Discursive representations of woman as fulfilled through love and romance, ideally with a man, are one of the explanations put forward for
why women stay in unhappy, neglectful or violent relationships with
men, and arguably one of the explanations for why women internalise
marital or family difficulties as depression. Women are taught to gain
happiness through relationships, and taught that it is their fault if it fails.
The level of the intrapsychic Intrapsychic factors are those which
operate at the level of the individual and the psychological: factors
which are traditionally the central focus of psychological analyses of
PND. This would include analyses of the way in which women blame
themselves for problems in relationships, and psychological explanations for why this is so, incorporating factors such as low self esteem,
depression, the impact of previous neglect or abuse, guilt, shame, fear
of loss or separation, and the idealisation of both heterosexuality and of
men. It would include an analysis of psychological defences, such as
repression, denial, projection or splitting, as mechanisms for dealing
with difficulty or psychological pain. For example, we see evidence of
splitting in the way women see themselves, or their man, as all good or
all bad, with no acknowledgement that everyone can exhibit both positive and negative characteristics at the same time; or in the way women
blame themselves, or their bodies, for problems which they experience.
It would also include women’s internalisation of the idealised fantasy of
motherhood, and of the expectations of being ‘woman’ in a heterosexual social sphere.
Thus depression during the post-natal period cannot be simply attributed to one factor. A complex interaction of material, discursive and
intrpsychic factors determines whether a particular women will experience depression or not. It is the combination of these factors that leads
to depression – no one single factor is the ‘cause’, and thus no one
single factor can be the ‘cure’. This approach acknowledges, and takes
seriously, women’s pain and despair; it takes the myriad causes of this
despair on board; it does not blame the woman, or her body; it does not
position her as ‘mad’ or ‘abnormal’; and it is strongly critical of a
society in which women are expected to be perfect, to be super-mothers, meaning that women feel a failure when the reality does not match
the fantasy.
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Conclusion
This paper has argued that mainstream medical and psychological
accounts are based on a positivist-realist paradigm, which provides a
narrow and limited understanding of women’s reproductive health. Taking
the case of PND, a material-discursive-intrapsychic approach has been
suggested. This leads to the conclusion that depression following childbirth is not a pathological condition. Rather, it is an understandable
response to the difficulties of motherhood. It results from a complex
interaction of material, discursive and intrapsychic factors, which differ
across women, and thus need to be assessed on an individual basis.
Many women who experience depression in the early years of their
child’s life can be helped by social support, having realistic expectations of themselves and of the difficulties of the mothering role, and
practical help with childcare. For other women, where the depression
may be more severe or long lasting, medical treatment (of a traditional
or complementary nature) or psychological therapy, can be beneficial.
For clinicians, the most important thing is to validate the woman’s
feelings, to be empathic and understanding, to reassure her that she is
not unusual or abnormal, and to avoid any notion of blame. This means
being sensitive to the strong influence of idealised expectations of
motherhood, which position women who are unhappy post-natally as
failures. Whilst avoiding a pathological framework where a woman is
positioned as ‘ill’, it is also important to offer support and help of a
psychological, medical and practical nature, as is appropriate for a woman’s
individual circumstances and desires.
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