A hidden assumption in various diagnostic criteria of psychological disorders is the view of the normal self as individualised, autonomous, discrete, and consistent over time. In other words, the self is seen as something separate from the rest of the world, and as being the same over time and place. This is no surprise as the psychiatric dictionary globally continues to be oriented to the Western cultures and ‘developed’ civilizations. This concept of self makes women, especially in collectivistic and non-Western societies, more vulnerable to the overdiagnosis of psychopathology as they appear more unsure, dependent, emotionally unstable and relationally preoccupied. Years of scholarly works by Phylis Chesler, Elaine Showalter, Sarah Pinto and closer to home by Bhargavi Davar, Renu Addlakha and U. Vindhya point to these connections between femininity, culture, and psychopathology.
I use the concept of relational self to understand normal and non-normative experiences of women patients. The relational self can be defined as a dialogical process through which the woman makes sense of herself as an individual using the lens of her connections and interactions in the larger social systems. In other words, a relational self is one where a person understands and experiences themselves with others, through others, and within one’s relation to the world. The concept of relational self is not limited to understanding women’s experiences but is used across contexts that appreciate psychic, personal, and interpersonal interconnectedness of experience.
During my doctoral field work in a leading mental health hospital based in New Delhi, I interacted with several women patients over the period of a year to understand their idea of normalcy and illness. The participants of the study were on medications and were either part of the day care or admitted to a room in the hospital for their treatment. Focus of the data collection and analysis was to highlight the lived experience of their illness and the manner in which they described them. Over the course of the year, they shared stories about their homes and families, their desires, understanding of their illness and their identity as a ‘patient’.
Following are some insights gathered from the fieldwork that speak about the ways in which women relationally understood their symptoms, nature of illness, markers of normalcy, and pathways to recovery. In other words, their experience of symptoms, recovery etc. was through a relational self – a self that is built through connections with the world. To retain confidentiality, their names have been changed and markers of their social identity are not disclosed.
#1 Difficulty in Household Work as Early Signs of Pathology
Women subah uthne ki prerna deti hain, gents kabhi nahi uthte. Problem tab hui jab mein subah ki chai nahi bana payi..Ladies ko gas-stove ke connection jaldi milte hain than gents
(Women wake up early and inspire others in the household to wake up too. Men, rarely are able to get up early. Issue began when I could no longer make the morning tea… Women find it easier to gas stove connection too !!!)Manmeet, diagnosed with schizophrenia
Manmeet gave the above response when asked to describe the life of a woman. In her art work, she drew a kitchen and a big mug of morning tea which she missed. They felt that this part of their life defined their womanliness to a great extent. Even though the hospital organised regular cooking therapy sessions, women patients rarely participated in them enthusiastically as they missed being in ‘their kitchen’, a space that was sacred to them and loss of which was felt intensely. In traditional middle-class households, kitchen is often the space for creative expression and establishment of status for the woman. It is easy to view the importance of the kitchen as a symbol of oppression of women, but it can also be understood a space of privacy, autonomy, self-expression, and power. Hence, the loss of this space brings a feeling of insufficiency, inadequacy, and lack of womanliness.
#2 Moralization of Women’s symptoms
Alcoholism is not a moral issue. It’s a medical issue… You need to accept your condition as a disorder not habit. See it medically. Chemical imbalances have a role to play. People are not aware about this. Pehle humesha lagta tha ki yeh mere galti hai and others are in pain because of me (Earlier I used to feel that it’s all my fault and others are in pain because of me).– Parineeta, diagnosed with alcohol use disorder
Psychiatric diagnosis locates pathology within the person and rarely acknowledges the complex individual-social matrix that often contains the roots of the symptom. The location of cause within the person in both biomedical and psychological approaches, makes the relational self of women prone to guilt. Additionally, their institutionalisation in a psychiatric hospital further adds to the stigma and guilt for bringing shame to one’s clan. The women patients reported feeling ashamed and “a sense of burden” to their family. Chhavi, diagnosed with depression, felt that she has been “a parasite” to her family and hoped that one day she will redeem them of all the pain she had caused. Psychiatric women patients are often perceived as immoral due to their socially deviant behaviour. Lastly, it is not uncommon in India to hear attributions around mental illness as a way of punishment for the wrong acts of the individual or the family.
#3: Caregiving is accompanied by Self Neglect
Mein bahut jaldi attached ho jato thi shayad abhi bhi ho jaon. Sensitive type ho mein thodi. Ek cousin ki becchi rehti thi humaare saath. Mein usse kuch zyaada hi attach ho gayi, uske bare mein over emotional ho gayi… meine Bura time nikaale hai doosre ke saath. Aur isliye meine bahut suffer kiya hai. Mere grandfather ko dementia ki problem thi. Raat ko so nahi paate the ki kahin nikal na jaye. Is liye meine apni raat ki medicine band kardi. Uske baad jo effects aate the woh bahut burre hote the.
(I used to get very attached too soon and might still behave similarly now. I am the sensitive kinds. Once, a cousin’s daughter stayed with us for a few days and I got very, almost over attached to her and would get emotional about her. …I have spent difficult time with people and for that reason I have suffered. My grandfather has dementia and I had to wake up all night fearing that he might leave the house. I started skipping my night medicines for depression in order to not sleep. Because of that my depression increased as I had terrible side effects)Rajinder, diagnosed with depression
Caregiving through emotional and physical investment is often considered typical of the culturally expected feminine behaviour. The Indian woman is a respected mother irrespective of her biological age and psychological level. Rajinder thinks this depression is caused by the caregiving roles she had to perform for the family and in the process self-neglect was considered inevitable. This neglect can also be culturally respected as “women as martyrs” for family is valued highly in our psyche. Another important feature of the relational self is the process of self-silencing. It is a psychological mechanism through which the woman both consciously and unconsciously neglects, rejects, or even represses her instincts and thoughts in order to maintain an outer harmony. Self-silencing by women is both an act of maintaining structural balance (family dynamics, societal norms etc.) and an internalised regulatory mechanism which is also linked to problems like depression, eating disorders etc. when performed extensively.
#4: Symptom Serving to Maintain Family Balance
I know why I am on depression. It is because I have chosen to bury away parts of my memory that cause a lot of pain. In therapy, I understood the connection between my father’s affair, my silence on it and my depression. But then I stopped therapy soon, what will I do with all this knowledge? I want my father you be my hero always. Even now he is so supportive of me, even when I cannot take care of my job, my husband and my son. He is and will always be there for me…Preeti, diagnosed with moderate depression and generalised anxiety disorder
Systems-oriented perspectives in Psychology sees individual symptoms in light of family dynamics and hence any problem with the individual can be interpreted as a balancing act for a larger group. For instance, a child develops behavioural problems to distract his parents from their couple issues. In line with this, Preeti’s self-silencing ensures the togetherness of her parents and her desire for her father to be revered. In a society like India, where elders of the family are placed on a pedestal and are considered embodiment of values, principles, and social order, to consider them human would also seem a sign of disrespect and disregard for their moral authority. Hence, to suppress memories that cause difficulties in order to maintain peace with family values and dignity is a common pattern amongst Indian patients.
The above themes allow us to critique to the assessment and treatment procedures of psychiatry which focus on the individual solely and not on the larger matrix in which the symptom is located. For me, it points to the limitations of insight-oriented work as a method of healing. Insight is a common goal of popular psychotherapies which assume that more awareness of childhood events and their impact will lead to a healthier personality. As opposed to that, with a relational self, one sees the functional nature of the symptom in maintaining structural balance or status quo. In other words, the symptoms have a function depends on the context and situation. The family being seen “as together” becomes more important than exploring “what is wrong with me”. From a Western view point, upon which diagnostic criteria are made, this will look problematic or hypocritical or dishonest, but it simply reflects the Indian way of thinking which is context-dependent, practical, and at home in contradictions. It thus becomes important to listen to women’s symptoms, their stories, and the context in which the symptom first appeared and was later maintained. Looking at the signs of pathology through a relational self also gives an insight into the lived world of the woman patient; it not simply considers the experience as oppressive or valorizes it, but appreciate its fluid nature as a symbolic of our collective psyche.
Dr. Annie Baxi
Annie is an academic, practitioner and researcher in the area of Critical Clinical and Health psychology. Her doctoral work is titled - Exploring Discourses around Normalcy and Madness in Women’s lives: A study of contemporary Indian society. In this research, she has studied a range of women groups and highlights the ways in which macro social processes shape and are shaped by individual subjectivities in the quest for normalcy and how madness can also be a manner of recovery and authentic living. She is also a practicing psychotherapist and used a blend of psychodynamic and phenomenology. Her work is published in journals, books (Sage and Speaking Tiger publishers) and magazines (Outlook). Besides this, she is a handloom connoisseur, a lover of short stories and a proud homemaker.