" European Strategies to Combat Violence Against Women"

 Violence against women and mental health

E. Reale, V. Sardelli

            The maternal role, with its unlimited burden of work and responsibility , is the first factor risk of mental illness for women

            The  second risk factor is the violent pressures exerted by the social and family environment.

            There are various kinds of family contexts and in most of them women are judged, diminished and subjected to all sorts of pressures, included violence.

            Violence is the most typical  instrument of pressure on women; it can assume various form such as:

-           sexual violence in the form of  rape;

-           physical violence, threats and bowls;

-           verbal and psychological violence (insults, depreciation and denial of autonomy).

            Rape takes place more  frequently outside the family environment, in connection with external relationships. 

            Verbal and psychological violence take place more frequently within family environment.

            We shall now consider family violence performed by male figures in order to point out its link with mental health.

            In the family, the woman is subjected to verbal and psychological violence consisting in abuses and critical judgments which tend to reduce her autonomy and self-confidence, making her more available to others at the same time.

            It is not by chance that insults always refer to what she hasn't done - or to what she hasn't done well - in order to be considered and physical violence make her question her possible faults; she is therefore induced to suffer and accept anything and to wonder: "maybe i have deserved it, it is my fault if this has happened, maybe i should have behaved better".

            Violence combined with a sense of guilt and a feeling of being responsible, at first prevents her from considering it as an unfair action and behaviour, as a serious violation of her right, as an assault to her liberty and dignity.

            Violence, denigration and insults form a powerful and specific risk factor for depression: a depressed woman is a woman who has lost her self-confidence, who no more trusts her capacity of being autonomous, who continuously questions herself and her actions, who feels responsible for everything even when she is the abused and beaten victim.

            If the burden of work is - as we have seen - a powerful element of stress for the woman's general health, the lack of positive criticism, the erosion of her self-esteem, the use of violence as a form of pressure in everyday life are specific risk factors for depression.

            Women do not take into consideration that their tiredness depends on their being overburdened. Moreover, they can find no support nor understanding in the social and family context; in fact, their tiredness will easily be dismissed with comments such as: "You do not work, you do nothing; then, why do you feel tired?"

            When they are tired, women tend to reduce their work, to give up the tasks connected to their female role, and sometimes to ask for help, support and understanding.

            This behaviour creates a conflict between the woman and her partner and context, and it often produces violence as a form to force her back into her role and into the burden of work she is required to cope with by other people's needs.

            The insults, the physical and verbal violence are present as caused by inadequacy of women to female model. When the woman  identifies herself with that point of view ("I am inadequate"), she cannot react to violence, she cannot even recognize it as such, she hides it to others because she feels guilty. When woman is involved in violence and believes that she has provoked it, she feels ashamed and hides herself to others. Many times the  so-called 'domestic accidents' tend to hide an experience of violence. 70 per cent of women who need to go to hospital as a consequence of "domestic accidents" do not declare the real cause, that is that they have suffered violence from their partner.

            Women are often advised by relatives to hide violence because the punishment of a violent partner could have serious consequences for the children (a financial and affective loss).

            Let's now have a closer look on the effects that a denied and hidden violence can have on women and their life.

            Most times the woman continues her relationship with the violent man and submit herself to his requests and behaviours; as a consequence:  

-           she feels despised and worthless;

-           she is forced to increase her tasks or to cope with unpleasant tasks, conforming herself to her partner's desires and orders;

-           she tends to limit, even to cancel her own needs.

            Depression is therefore the result of the powerful combination of all these risk factors:  

1.         an increase of the burden of family duties;

2.         a reduction or total loss of personal interests and spaces;

3.         a reduction or total loss of external relationships (the woman has less time to spend outside the family and, above all, she would feel ashamed in telling other people what she is forced to suffer at home);

4.         the failure of her personal project concerning particularly the sentimental side of her life (an aspect which is of great importance to women) and the painful disillusion of all her expectations in love, support, trust and understanding from her partner;

5.            reduction or total loss of her self-esteem; at the same time she tends to feel responsible and guilty to the way she is treated and judged: "nobody appreciates and acknowledges what I do, I am unable to make myself respected... it is all my fault, I am a total failure, I am hopeless";

6.         negative judgments and strong pressures coming from the family context;

7.         an increase of feelings such as tiredness, lack of motivation, anxiety, uncertainty and fear for the future.

            All these seven factors

(excess burden of work, restriction on personal interests and activities, restriction of external relationships, failure of personal plan, subjective perception of inadequacy, negatives judgments of the familial context, the increase of physical ailments)

determine the perception of being unable to cope which that kind of situation, the feeling of being unable to put up with it, combined with the awareness of being unable to  modify that situation (in those cases in which the woman has already made an unsuccessful attempt to change), all these perceptions lead the woman towards mental illness and depression.

            The feelings of tiredness fear and anxiety eventually lose their connection with the unbearable condition of life that the woman considers unchangeable and against which she has given up any attempt to fight; those feelings, then, become symptoms, that is signs of an illness and a discomfort totally disconnected from the woman's life with her burdens and sufferings.

            Most cases of female depression refer to women who feel guilty for having been insulted or assaulted.

            Medicine and Psychiatry constitute an additional risk factor for women's mental health because often doctors cannot understand  the reasons behind tiredness, fear, lack of motivation, sadness, lack of self-confidence, and they can only confirm or certify to the woman that she suffers from depression and anxiety, thus hiding and silencing the real reasons of malaise and distress. These are linked to the female daily life and to the oppression of the female role. The suffering is then converted into pathology which prevents the recognition of its real nature and makes the change of the woman's life-style impossible.

            Medicine and Psychiatry as they still are today are obviously inadequate and cannot support women properly. The requests of women using mental health services have no priority whatsoever; moreover, the services provided are inadequate to the women's needs and their private lives is taken in no consideration. Women with mental health problems more often turn to General Practitioners; they are more frequently admitted to psychiatric hospitals, are twice as liable to get a diagnosis of depression and anxiety, and are three times more likely to be prescribed tranquillizers"

            Our experience, as psychologists and clinical researchers, suggests that:

it is then necessary to plan of health precautions (sanitary preventive intervention) aiming to reveal the real problems hidden behind the symptoms, the true nature of those sufferings diagnosed as psychic troubles.

            This preventive intervention must  to take in proper consideration:

            the overload connected with domestic work;

-           the violence which is often hidden behind the woman's sense of guilt;

-           the negative criticism from the social and family context which tends to overwhelm women's self-confidence in their own capacities;

-           the condition of isolation in which women live depriving them of any support from other kinds of relationships.

            Our clinical work with an individual woman suggests the necessity of utilizing a specific protocol of intervention which:

-           analizes the woman's everyday life and her personal history, in order to find out the presence of external impositions in her choices;

-            discovers how much external requests and pressures have been exercised on her in order to obtain certain behaviours and services;

-           finds out those capacities and resources that the woman is no more aware of;

-           helps and supports her in the difficult task of changing her life-style, by planning with her a new kind of life of which she is the centre and where she can therefore re-affirm her rights to her own spaces, interests and personal relationships and to new life goals.

            This period of clinic and psychological support to the woman considers, when necessary, the possibility of her departure from the place where she usually lives.

            In these cases it is necessary to bring to the surface the sense of guilt - which can be rooted in previous cases of mothers who were also victims - and gradually lead the woman to the recognition not only of the external violence but also of her own image as a beaten, humbled woman and as a loser.

            In the cases of depressed women, their tale of violence comes out after some time and it is as if they saw it for the first time; this is very painful and they refuse to accept it, considering it their own fault and failure and thus becoming, unintentionally, accomplices of (collusive with) the violent man.

            This unintentional complicity between the woman and her torturer, caused by a mistaken concept of the female role as it is generally affirmed in the social context, provokes an increase in violence itself. The violent man experiences in person (in addition to what the traditional models have taught him) that there is no opposition nor rebellion and that violence "pays".

            The other kind of situation this intervention has to consider is that of women traumatized by one single episode or act of violence.

            The intervention has to be adequate to face situations of women who, after an act of violence acknowledged as much and publicly declared, worsen their usual life- style and show anxiety and depression symptoms which tend to last for some time.

            Our experience in these cases is that one single violence, apart from its traumatic effect , can often be related to previous situations characterized by unacknowledged violence (criticism, oppression, etc.).

            The exposure to violence of one or more members of the family is a strong risk factor of psychological destabilization not only for the woman, but also for the children, especially the daughters.

            From our work  with adolescents results that, in contexts which are coercive and violent, daughters (usually the eldest ones) are led to help and support their mother, both psychologically and materially, and/or to play the role of  moderators in conflicts between their parents.

            Thus they assume an early adult attitude by taking, a burden of responsibility too heavy for their age and very dangerous for the psychological development of their ego.

            In fact, this alliance creates a sort of identification with their mother and of  adaptation to the patterns of submission and passivity which are, then, transmitted from generation to generation.

            Beyond these psychological interventions on individual woman or groups of women who have been subjected to violence, it is necessary to plan wider interventions of a preventive kind.

            These interventions must have an informative and a formative character and may be addressed to two main categories: women who risk violence and its psychological consequences, and health operators working in those services open to requests of help from women.

            The contents of these interventions are:

-           the modification of domestic work models in the sense of a reduction of women's overload and a sharing of those tasks and responsibilities normally attributed to women;

-           the modification of the female image as an individual dependent on other people's needs and the affirmation of a positive model of a woman who can develop her capacities freely, without those limits imposed and referred to gender;

-           the training to identify the risk factors of psychic illness present in woman's everyday life; special attention must be given to the ability to face requests and violent behaviours from the context;

-           the training to develop situations of social and psychological self-protection, such as keeping a net of relationships outside the family which can be the major opponent to the condition of isolation that favours the woman's dependence on violent relatives.

Information and training

            We should develop training interventions on the daily life style addressed to women

and health workers.

            At  first  we should inform about certain aspects of "the crisis" surrounding the female role. Inadequate solutions to this problem would increase the risk of mental illness. The goal of informative approach is to arouse women awareness of:

-           how to combat stress and other pathological problems linked  to female role; 

-           how to change the  pattern of subordination  and dependence ;

-           how the absence of reaction to violence is linked to illness and others psychological troubles.

            Then we should  develop the formation addressed to  medical and social workers  who come into contact with  women's  disturbances,  in order to:

-            reduce/eliminate the use of psyco-pharmacological drugs;

-            stimulate a medical and psychological approach which explains the connection   between illness- disturbances and everyday life  (homely work and violent pressure  from the family context)

            In order to reach these two goals the member states should organize:

a.            information programs for  the prevention addressed to housewife and female workers exposed  to the risks of violence or mental and physical disorders (female adolescents, women under excessive burdens, with external work as well as housework  , women with small children, etc). 

            This information can be done by seminars, follow-up courses, and other courses addressed to women who have responsibility  in the  educational, political and work institutions; 

b.            Seminars and training courses  for public health workers which should be interested in the public expense budget and in the refresh tasks scheduling.

Services

            Some women suffer from unsustainable life conditions: insulation, separation,  widowhood ,  unemployment, lack of economical supports , small children, etc .

            Some others are ill  anxious,  depressed:   they  no more speak about their difficulties linked to everyday life,  nor are able to recognize  oppression, violence,  fatigue and tiredness. 

            We are proposing two types of service for these women:

1.         The first type of service is addressed to women who have not yet developed an illness.

             They are preventive services which do not aim to cure an illness, but which attend  to prevent specific situations of distress. The goals of these consultation   services of  should be the reduction of the damage brought by the subordination and violence in everyday life. 

            They should listen to  listen women's life problems and  make  awareness, abilities, skills  oriented to problem solving arouse in women.

            These services could organize:

a.            listening-centres,  training-courses, social and psychological support-groups, etc.  Each  initiative is addressed to women with specifical problem: women who have given up working  during   maternity and/or few years after,  women having difficulties in social relationships, in organizing both housework and  external work;  ill-treated, abused, alcoholic women, etc.

b.            Programs for health education with a view to :

 -          increasing  women ability   to communicate and express themselves emotionally; 

  -            increasing the ability of analyzing their life-style;

-            improving their image and their  self-esteem;

-           reducing the risks of symptoms of mental pathologies.

2.         The second type of service is addressed to women who have already begun to develop an illness and manifest symptoms, and who have already had psychiatric treatment.

            They  should encourage women to understand the way in which their daily lives have led them to illness by using a method  which must be necessarily different from that traditionally adopted in psychiatry.

            The specialised services   should  offer practical help and necessary support  by creating a concrete  alternative to  hospitals and to psychiatric cures.  

            These services have the following   goals:

-           to reduce or eliminate the use of specific therapheutical means, such as hospitalization,  drugs, or any other strategy that tends to impede or delay the comprehension of the concrete and tangible causes of their illness;

-           to  consider the symptoms of mental illness as signs of   unbearable life conditions;

 -            to create a new life-style for women's benefits in keeping with their interests,  aptitudes and emotions