Interview: Women and their vulnerabilities to mental health issues

Mental health issues in women arise from a combination of factors.
Interview: Women and their vulnerabilities to mental health issues

In this interview, White Swan Foundation's chairman, Subroto Bagchi talks to Dr Prabha S Chandra about women, depression and societal factors that contribute to their being more vulnerable to mental health issues.

Edited excerpts for the video interview that can be viewed here

Subroto Bagchi: Welcome to A New Dimension. I am Subroto Bagchi, and with me in the studio today, we have Dr Prabha Chandra. Doctor, welcome. Dr Prabha Chandra is the head of department of psychiatry at the National Institute of Mental Health and Neurosciences. She is also secretary to the International Association for Women's Mental Health.

Thank you so much for coming as my guest to A New Dimension.

Dr Prabha Chandra: It's my pleasure.

SB: It's a privilege for us to have you come here and talk about women and mental health as a subject. But just tell me, how's the day been so far?

PC: The day has been busy. It's my outpatient day, and I've seen four women with different varieties of problems. There was one young woman with intellectual disability, whom the family is thinking of getting married; one software engineer who has sexual problems and physical health problems which are probably of psychological origin; and then another woman who wants to get pregnant but has had depression in the past. She and her husband came and discussed that with me. So it's been a full day so far.

SB: And what about the fourth woman?

PC : The fourth lady actually had an eating disorder.

SB: Okay, what age range, for example, do these four women fall (into)?

PC: Well all these women were below the age of 35, really. Quite young women.

SB: And is this largely an urban phenomenon or do you think this could be the case in the rural sector too?

PC: No absolutely not. For example, one woman with intellectual disability came from rural Davangere. And another woman came from Nellore - so it's definitely not an urban phenomena. It's there in every corner of India.

SB: So it's not an urban-rural issue, neither is it a rich-poor issue. (P: No, not at all.) I'm keen to hear your views on it. Here's a country of 1.2 billion people, and we are told that we have less than 4,000 psychiatrists and probably about 10,000 trained medical personnel. That makes it really a drop in the ocean. And in that, 50% of 1.2 billion people are women. But I'm told that 50% does not make 50% of the problem. And some people say that women's mental health is probably a far bigger issue, not only for the individual suffering, sometimes silently, but for the caregivers. And also, being the central part of the idea of a family, it has much bigger ramifications. So tell us what do you think about women in mental health - should we be specifically drawing attention to mental health.

PC: I think it's a very good point and I have often pondered over this issue. Why is women's mental health given so much importance than, say, men's mental health? In fact, there are societies for women's mental health - there are books on women's mental health. For example, the Indian Psychiatric Society has a taskforce on women's mental health but not a taskforce on men's mental health. So, obviously there is an issue here.

Gender can modify manifestations of mental health problems in so many ways. So I'm sure there are men who have mental health problems as well, and they have unique mental health problems; they have problems of their own. But I think the reason why women's mental health has become such an important issue is - women outnumber men in terms of the number of women in depression, say, which is the commonest condition in the world in terms of mental health problems.

SB: So are you telling me that women are more prone to certain categories of issues and is there a biological basis for that, or is it both biological and social?

PC: That's correct. And I try to look at it as a triangle, really. You have the social, cultural and the third is psychological. So women are made differently from men, psychologically. And this is not just about the biology and the social construction of gender. But there are ways in which women cope with their problems and issues - the way they communicate; the way they internalize their problems, which are unquely women. So I think it's like a triangle with a woman in the middle and all of these contribute to her strength and her vulnerabilities.

SB: We use the word woman, but we are really talking about an entire lifetime - from the time the girl child comes to the world to the time she is pre-teens, puberty, adolescent, young adult and then she is a young woman. And of course the later stages. So, are health issues potentially different when it comes to women?

PC: Absolutely. I think probably that may be one of the reasons why women's mental health becomes that much more unique. Because life stages, including her reproductive life stages in some way determine the path that women's mental health may take. Even physcial health is quite determined by life stages. For example, puberty seems to be the key turning point for young girls. And before puberty, boys and girls have the same traits for most disorders – particularly depression, anxiety. And suddenly at puberty there is a peak and suddenly girls will have four times more chances of developing depression as compared to boys.

SB: Let's talk about womanhood - which begins from the time the girl child is born to puberty and to the time she grows up to the stages of her reproductive cycle and the time thereafter. Depending on the different phases, do you see different kinds of challenges and issues as far as mental health for women is concerned?

PC: I think that's a very key issue. So let's start from birth and then up to puberty. I think that's one phase that is very important but not given as much attention as it should. In a lot of families, the girl child is born - there's not necessarily a jubilation, particularly in some situations. And quite often a girl may not be given the importance she should be given or the kind of expectations that are there from her are very different compared to the boy child. So i think a lot of girls, even when they are very young, grow up with a sense that they are second grade citizens in the family. And also the roles given to them are kind of not very empowering – they are expected to be quiet, seen-not-heard kind and that's true for many families. I think that's one area that creates that vulnerability – as she enters the family, she is not very sure what she...

SB : So you kind of set her up to be an unsure individual, irrespective of any mental health issues. 

PC: That's right. That sort of creates the vulnerability- not being valued and validated in some way in the family set-up. And after that, we also know that the chances of abuse, sexual abuse are much much more among young girls compared to young boys. And if it happens, and that creates a vulnerability - specially if she tries to disclose or she is not given the kind of protection she needs; or if she tells someone and she is not believed - that again creates a trauma, which is a second vulnerability. And in case the family is not very well-knit, it has its own issues. Parents are not there for the children - then that's a third vulnerability, which of course may be common to both boys and girls. But if the girl has come in with a set of vulnerabilities, then that adds on to it. And then comes puberty. Now puberty by itself is a very positive change for the girl – all the good things are happening, she is growing in the right direction. But hormonally, and for the brain, it creates a certain kind of problem, which increases her vulnerability to develop some specific problems - specifically depression is four times more common among girls in puberty. So that's something which is like a tip...

SB: Okay, and how much of that is likely to be a passing phase and how much of that needs serious attention?

PC : That's a little difficult to say...

S: But as a practicing doctor, you'll have a feel you know, is it like 50% of the cases will get into full blown depression...?

PC : No, it's not like that. It's not that puberty will cause a girl to develop depression and after that she either continues or doesn't continue. But what has been said is that at the age of 13-14 till she is 80, women have four times higher rate of depression. So puberty in some ways makes that difference. So it's probably the hormones which are actually increasing the vulnerability in somebody who is already in some ways vulnerable.

SB: So basically you are saying that all things remaining equal, the girl child or woman has significantly higher risk of developing depression and anxiety also.

PC: And then, of course, your question about the reproductive life stages. So, you know, a lot of women, they are brought up in this environment. They have studied and then they get married. And apart from urban, educated women, most of them are uprooted from all that is familiar and put into an environment and a milieu where everything is unfamiliar.

SB: So they have to start all over again.

PC: They have to start all over again. So all the connections that they’ve made are actually broken, and she is expected to simply, within a day, within a week, completely adjust to this new environment.

SB: You are kind of being continuously forced to be a stranger in life.

PC: That’s right and I think that creates again a huge amount of vulnerability. So while many girls might - because they think it’s their lot, that it’s culturally acceptable, you know, you’re supposed to do this - may somehow manage. But if you’re somebody who has had a vulnerability previously, then this particular woman finds it very very difficult. And sometimes you move, you know, far away. And especially in India, the culture is that once you’re in your husband’s place, that family becomes your primary family and you’re not supposed to be so dependent on your parents; parents also tell her that now you have to adjust to your new family. So what does this person do? You know, I often ask men that, if you had to do this - if you had to take yourself away from everything that’s familiar and go to a new environment, how would you ever adjust?

SB: Are Western women any better for that matter?

PC: Maybe this kind of vulnerability doesn’t happen to them, you know. This particular vulnerability is very unique to our Indian situation. In the West, I guess, it’s the husband and wife getting used to each other at a very equal level.

SB: The sense of equality is far more.

PC: And that’s challenging in itself. But this is - the woman has to adjust to a whole range of people, and to be with the husband who’s also unfamiliar. He’s not her ally or anything like that. He’s unfamiliar.

SB: So doctor, tell me, during a normal day’s work, in the course of your everyday engagements at NIMHANS, in these different phases, when do you see people coming in for mental health assistance peak, really?

PC: I think that for me, it comes in soon after marriage. That’s the time when a lot of young women come. Or, to be more specific, women between the ages of 20 to say, 30 and 35. That seems to be the time, and soon after marriage. And that’s the time when two-three years after marriage, the husband’s family starts thinking she has a problem, she cannot adjust, and this term ‘she doesn’t listen to us’, she’s not able to work...Yesterday, a man told me, she doesn’t wash my shirt collars properly. And that’s the reason why they thought she had a problem. So the expectations are so enormous.

SB: Sounds like the man had a problem.

PC: Well, you know, sometimes expectations are so enormous that the labeling happens - she is slow, she is unable to do the day-to-day activities, so the emphasis is more on her performance rather than on companionship, or listening to her voice and trying to understand what’s happening to her. So I think in that sense it’s a fairly vulnerable stage. And before you know it, she’s pregnant. So she’s coming in with all these vulnerabilities, and invariably she has no control over her childbearing. So this woman who came in today told me that it’s been three months of marriage. She’s a pharmacist. She has a mental health problem, and she says, we’ve come here to get advice about having a child. And I said, are you ready to become a mother? She says no, I’m not ready to become a mother. But my husband wants it and my mother-in-law wants it. So I’m going to listen to what they’re saying. So I think in those circumstances this is a woman who is obviously going to suffer. Because she’s not ready to be a mother and all the pressure that’s put on her in addition to her having a mental health problem. So I think these are the kind of vulnerabilities.

SB: Let me ask you this - how should I put it - pointed question. A person with a mental health issue - like this lady we talk about here - should she, or can she, or is it desirable at all, that that person should have a child? Is the child at very high risk because one of the parents or both of the parents have a mental health problem?  

PC: Okay, so the first issue is about marriage. And then the second issue is about having a child. Now, it’s every human being’s right to have a partner; and it’s every human being’s right to have a child. So, I think, in terms of a rights approach, everybody has a right. The reason why somebody gets married is to provide companionship, to be an equal partner, to have somebody to look after you, to have somebody you can look after. The reason for marriage is, at one level, that. But at a social level, it’s something else. It’s about having a respectful name in society- that you’re married. So a lot of parents actually hide things about women with mental health problems. And it’s much more for women than for men. And one they think that maybe marriage will...

SB: Fix it.

PC: Yes, fix things, which is completely untrue. And the second thing is, they think that...

SB: It might actually aggravate that.

PC: Yes, because of the kind of stress the woman is going through. And also, they think it’s alright to not tell the potential husband about the problem. Because, you know, nobody will get married to her and invariably use words like depression, stress - and not really talk about the problem.

SB: So you basically palm her off.

PC: I mean, in their minds, they are doing the right thing for their girl. They are concerned, and they feel that after them, who will look after this person. So in their minds, they’re doing the right thing.

SB: So doctor,  I know we have a time constraint here - I would like you to tell us, what should the society do in order to better provide for the female child and then the woman, as far as mental health challenges or problems are concerned. And within that, what are the kind of things the medical community should do so that we’re able to deal with the issues far better than what we’re doing today?

PC: Okay the first thing I think is to provide a secure environment for the child at home, soon after she is born.

SB: So recognize that the female child is at a higher risk, particularly what you talked about - pre-puberty. She is more exposed to people making her feel inhibited. So as she’s growing up, being an easy prey for sexual predatory behaviour.

PC: I think valuing her, validating her, making sure she’s protected, making sure that if she has a problem, she has a space where she can talk about it and she’s heard, providing her with the educational resources and background that will make her flower, really. That’s the first thing. Second thing is kind of preparing her later for what she’s going to go through. Hormonal changes, also equipping her with skills. Girls are very often not equipped with conflict resolution skills - I mean, neither are boys really - but girls have to do this because, like you mentioned, they are the center, pivotal part of the family. So negotiations, managing her emotions better, learning to soothe herself, because she is going to go through many challenges. Preparing her for motherhood: I think that’s very key. Even a mentally ill woman can be a mother. And we have had many situations where they can be good mothers. And I think the key thing is to prepare them and to make sure that she is ready to become a mother. With all these vulnerabilities, if she’s not ready, if she’s doing it for society or for her husband or in-laws, then that child is again going to be at risk. I think it’s very important that the mother is seen as great potential. That while she has the baby in her womb and later, she has great potential in preventing this child from having a problem and to enable another good citizen to grow. So I think it’s key that that phase of a woman’s life is really paid attention to. And here I would say that the spouse has a major role. The partner has a major role.

SB: So doctor, thank you so much for giving us all the information. One thing I would request is that - is there a message you would like to share on the subject of women and mental health with the larger audience out there? Or within that larger audience, any specific group that you think could help?  

PC: Well, I think everybody’s responsibility is to ensure that a woman has good mental health. But if I had to choose one group, I would say it’s the men. Because I think women are a part of men’s lives in so many ways and I think they’re also part of the risk. So a lot of the vulnerability happens because of the men. Men are the partners who women can communicate to. I would say that fathers, brothers, partners, husbands, sons are my target group most of the time. If they understand a woman’s vulnerabilities, try to look beyond just the anger or the anguish or the anxiety, or the inevitability to do things, and try and understand what’s going on behind that, you know, where is this woman coming from, what has she been subject to, (what are) her strengths and her inner resources and tries to energize that, rather than focusing on her weaknesses, protecting her yet strengthening her... and recognizing that a woman is actually very strong, very resilient and make sure that resilience comes through despite the fact that she has a mental illness or depression or whatever, she’s just trying to survive. She’s somebody who’s trying to fight with the system. So I think if men could do that, that would be wonderful.

SB: So basically, enlist the support of the 50 per cent of the 1.3 billion people and that’s kind of counter-intuitive because we tend to think of women’s problems as women’s problems. But you’re saying, bring the men into the picture. And that certainly brings a new dimension to the new dimension. Thank you so much doctor, it’s a pleasure to have you.

PC: Thank you, my pleasure.

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