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 ©2004 by MEDIMOND S.r.l. E516R9005 99 100 14th International Conference of Psychosomatic Obstetrics and Gynaecology 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 Edinburgh, Scotland, May 16-19, 2004 101 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 102 14th International Conference of Psychosomatic Obstetrics and Gynaecology 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- Edinburgh, Scotland, May 16-19, 2004 103 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. 104 14th International Conference of Psychosomatic Obstetrics and Gynaecology 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. References 1. NICOLSON P. Post-natal Depression: Psychology, science and the transition to motherhood. London: Routledge; 1998. 2. USSHER JM. Women’s madness: Misogyny or mental illness? Amherst, MA, US: University of Massachusetts Press; 1991. 3. FOUCAULT M. Madness and Civilisation: A history of insanity in the age of reason. London: Tavistock; 1967. 4. SMALL R, BROWN S, LUMLEY J, ASTBURY J. Missing voices: What women say and do about depression after childbirth. Journal of Reproductive and Infant Psychology ;12(2):89-103.1994 5. HAMILTON S. Problematic aspects of diagnosing premenstrual phase dysphoria: recommendations for psychological research and practice. Prof. psych. research and practice. 21(1):60-68. 1990 6. USSHER JM. Fantasies of Femininity: Reframing the Boundaries of Sex. London: Penguin; 1997a. 7. USSHER JM. Postnatal depression: A critical feminist perspective. In: Stewart M, editor. Pregnancy, Birth and Maternity Care - a feminist perspective. London: Butterworth Heinemann.; 2003d. Edinburgh, Scotland, May 16-19, 2004 105 8. USSHER JM. Body talk: The material and discursive regulation of sexuality, madness and reproduction. London: Routledge; 1997b. 9. YARDLEY L, ed.. Material discourses of health and illness. Florence, KY, US: Taylor and Francis/Routledge; 1997. 10. USSHER JM. Women’s Madness: A Material-Discursive-Intra psychic Approach. In: Fee D, editor. Psychology and the Postmodern: Mental Illness as Discourse and Experience. London: Sage;. p. 207-230. 2000.