Research as a basis of innovative practiceResearch as a basis of innovative practice

The case of reproductive healthThe case of reproductive health

Professor Jane M Ussher,

Centre for Health Research

University of Western Sydney

Gender Differences in DepressionGender Differences in Depression

Epidemiological research –

life time occurrence of depression in community samples women outnumber men at a ratio of 2:1 - 4:1

prevalence depression in previous 1-12 months women between 1.2 and 2.7 times more likely to have

experienced depression than men

Ussher (2011) Women’s Madness: Myth and experience, London, Routledge/New York

Biology to Blame:Biology to Blame:Raging hormones and reproductive Raging hormones and reproductive

debilitationdebilitation

Pre-post adolescent gender difference:

“the female prevalence in depression is linked to women’s reproductive years” (Cyranowski, Frank, Young, & Shear, 2000, p25)

“in later life (after age 55), the female excess of depressions diminishes; mostly because of falling rates in women at a time when their oestrogen levels are again low” (Angold et al 1999, p1044)

Body to Blame: Body to Blame: Menarche, PMS, PND, MenopauseMenarche, PMS, PND, Menopause

“The excess of depression in women compared with men occurs at times of great hormonal fluctuations–at the time of puberty, in the postnatal period, and premenstrually–and it is worst in the few years before menstrual cycles end (Studd, 1997, p.977).

Evaluating raging hormone theoriesEvaluating raging hormone theories

Examination of adolescent onset: ‘turning on’ of the endocrine system in girls pre to post-puberty

But: only 4% of variance accounted for by oestrogen levels

life events, and the interaction of oestrogen levels and life events, 17% variance (Brooks-Gunn & Warren, 1989).

Ussher, JM. (2010) Are we medicalizing women’s misery? A critical review of women’s higher rates of reported depression. Feminism and Psychology 20(1) 9-35

Psycho-social risk factors for womenPsycho-social risk factors for women’’s s depressiondepression

MaterialityPhysical and Social Environment

poverty caring roles (inc. motherhood) employment status absence of social support social powerlessness and

discrimination current relationship context multiple role strain and conflict sexual violence or abuse, in

adulthood or childhood

Ussher (2011) Women’s Madness: Myth and experience, London, Routledge/New York

IntrapsychicPsychological factors

female gender socialisation depressogenic attributional styles:

Internal, global stable Rumination

emphasis on affiliation = increased vulnerability when relationships under threat;

Internalisation of devalued traditional feminine roles;

network events – events affecting significant others

Myth of Premenstrual MadnessMyth of Premenstrual Madness

Systematic review of the research literature on menstrual cycle mood change (Romans et al 2012) 14.9% found an association of negative mood and the

premenstrual phase 38.3% found no association of mood with any MC

Rates of severe premenstrual distress (PMDD) 1.3% women – random community sample (Gehlert et al

2009)

Post-natal depression – 10-15% Post-natal depression – 10-15% womenwomen

Risk factors Younger age, partner violence, previous history of depression.

Preventative factors Realistic expectations of motherhood Rejection of Discourse of “perfect wife and mother”

Support from partner and others Ability to communicate needs and concerns Ability to control some aspects of environment Physical rest and healthy diet

Myth of Menopausal DepressionMyth of Menopausal Depression

Longitudinal study of 2,565 US women aged 45-55 – majority who entered menopause did not become depressed; Women who did exhibit depression more likely to have

been depressed earlier in life (Avis, Brambilla, McKinlay, & Vass, 1994)

Study of 2000 Australian women aged 45-55:

“most of the time” felt clear-headed (72%), good natured (71%), useful (68%), satisfied (61%), confident (58%), loving (55%) and optimistic (51%) (Dennerstein, 1996).

Social constructionist analysisSocial constructionist analysis

PMS, PND, Menopausal Syndrome as discursive labels - pathologising deviations from idealised femininity

Gendered illness

Continues the historical connection between the womb and the brain: ‘wandering womb’

Ussher, JM (1989) The Psychology of the Female Body. London, Routledge.

Historical legacy of monstrous Historical legacy of monstrous femininefeminine

Menstrual MadnessMenstrual Madness

Menstruation is 'the moral and physical barometer of the female constitution' (Burrows, 1828, p.147)

A cause of 'moral and physical derangement' (Maudsley, 1873, p.88).

Post-natal maniaPost-natal mania

‘Every medical man has observed the extraordinary amount of obscenity, in thought and language, which breaks forth from the most modest and well-nurtured woman under the influence of puerperal mania… Religious and moral principles alone give strength to the female mind; and when these are weakened or removed by disease, the subterranean fires become active; and the crater gives forth smoke and flame’ 1858, A Manual of Psychological Medicine

Dr. L.V. Marce: post-natal symptoms caused by unknown ‘connexions’ between the womb and the brain 1858

Menopausal DisturbanceMenopausal Disturbance

menopause ‘universally admitted to be a critical and dangerous time for (women)’ (Tilt, 1882, p15).

During the change of life the nervous system is so unhinged that the management of the mental and moral fibres often taxes the ingenuity of the medical confident…the disturbance can cause normally moral women to act without principle…be untruthful…be peevish…even have fits of temper…steal…leave their families…brood in melancholy self absorption (Tilt, 1882, p101)

2020thth C. Premenstrual change as a C. Premenstrual change as a Psychiatric IllnessPsychiatric Illness

Premenstrual Tension (PMT): accumulations of ‘the female sex hormone’, oestrogen (Frank, 1931),

Premenstrual syndrome (PMS): (Greene and Dalton in 1953) – 40% women

‘Late Luteal phase Dysphoric disorder' (LLPDD) DSM-IIIR (American psychiatric association, 1994),

Premenstrual Dysphoric Disorder (PMDD): DSMIV (2000) 8-10% women

Perinatal depression: Body to BlamePerinatal depression: Body to Blame

It is very likely that the essential cause of post-natal depression is the sudden decrease in hormones, particularly oestradiol that occurs after delivery. In this way it is similar to the depression of pre-menstrual syndrome & the menopause which is also related to decreases in ovarian hormones, particularly oestrogen… (John Studd, 2004)

Menopausal Atrophy & DepressionMenopausal Atrophy & Depression

Oestrogen deficiency is as much a disease as thyroid, pancreatic or adrenal deficiency. No attempt will be made to detail all of the unwholesome effects of this deficiency disease; a few will suffice, e.g. thinning of bones, dowager’s hump, ugly body contours, flaccidity of the breast, atrophy of the genitals.. & depressionFeminine Forever, Robert Wilson, 1966

Low levels of hormones in your body will lead to mood changes in about 50% of women, making you irritable, depressed, weepy and nervous. The Menopause Health Guide, 1995

Impact on Women: SubjectificationImpact on Women: Subjectification

Regimes of Truth in Science and Popular Culture:Regimes of Truth in Science and Popular Culture:

Western women positioned, or take up subject position, of monstrous feminine – mad, bad, and dangerous

Blaming the body for distress self-castigation

Construction of distress as an embodied pathology - ‘PMS’, ‘PND’, or Menopause medical and psychological regulation

Ussher, J.M. (2003c). The role of premenstrual dysphoric disorder in the subjectification of women. Journal of Medical Humanities, 24(1/ 2), 131-146.

Ussher, JM (2006) Managing the Monstrous Feminine: Regulating the Reproductive Body. London, Routledge.

Premenstrual Experiences ResearchPremenstrual Experiences Research

70 women interviewed about subjective experience of PMS (36 UK and 34 Australia). 30% increase in symptoms premenstrually Intervention studies – mixed method, pre-intervention interviews:

psychological therapy vs SSRI (Ussher, Hunter et al 2002) self-help PMS therapy (Ussher, Perz, Weisberg, 2006)

Qualitative analysis: Thematic decomposition: subject positions taken up by women (as ‘PMS sufferer’).

Premenstrual madnessPremenstrual madness

My reactions to certain situations would be extreme, with a lot of anger, you know, total depression and just too extreme, like a nut case.

I just completely lost the plot (sigh).

I’d need to completely isolate, because I didn’t think that anyone else would understand or if they touched me I might burst into tears and think I’m a complete loony.

Because you’re not sane. (laugh) You’re not really rational (laugh).

Menstrual monsterMenstrual monsterDr. Jekyll to Mr. Hyde. Horrible, bitchy, vicious, violent & depressed.

I’m like something out of the exorcist – my head spins around! I get cranky & nasty

we have sort of like a catchword in the house (devil mummy), it's like 'you be careful because devil mummy isn't too far away & just don't do anything or don't say anything’, I try to explain it to them you know & say ' I'm really sorry, I'm not really in control, I'm trying, but it's two people

Ussher, J.M. (2008). Managing the Monstrous Feminine: The Role of Premenstrual Syndrome in the Subjectification of Women. In P. Moss and K. Teghtsoonian (Eds.), Contesting Illness: Authority, Bodies and Context (pp. 181-200). Toronto, Buffalo, London: University of Toronto Press.

PMS self vs. Non-PMS self - SplittingPMS self vs. Non-PMS self - Splitting

Mad – sane Bad – good Inertia – energy Introversion – sociability Out of control – control Irresponsible/ responsible Giving up – soldiering on Failing – coping Angry – calm

Depressed – happy Irrational – rational Intolerant – tolerant Vulnerable – strong Passive – active Body – mind Irritable – even tempered Fat/ugly – OK Frustrated – not frustrated

Ussher, J.M. (2004). Premenstrual syndrome and self-policing: Ruptures in self-silencing leading to increased self-surveillance and blaming of the body. Social Theory and Health, 2(3), 49-62.

Premenstrual change in non-Premenstrual change in non-Western CulturesWestern Cultures

Hong Kong, China, or India – menstruation positioned as a natural event

Women report premenstrual water retention, pain, fatigue, and increased sensitivity to cold

Rarely report negative premenstrual moods; don’t position them as ‘PMS’.

Premenstrual change in non-Premenstrual change in non-Western CulturesWestern Cultures

In Australia, some women experience what they call pre-menstrual syndrome or PMS, have you heard of this?

I Never heard of that. [Laughs] What this is, some women say before their periods they feel, they feel

different in themselves in their moods, so they can feel tense or angry or depressed//

I Yeah, we experience this. I1 You have that? I2 Do, do you have a word or a way of describing that to other

people? [Interpreter and participants talking in first language – 6 secs] I So, yeah, no name for that. [Laughs] Ussher, J.M., M. Rhyder-Obid, J. Perz, M. Rae, W.K.T. Wong, and P. Newman (2012). "Purity, Privacy and Procreation:

Constructions and Experiences of Sexual and Reproductive Health in Assyrian and Karen Women Living in Australia." Sexuality

and Culture 16 (4): 467-485.

How can we explain the emergence and course of premenstrual distress?

Can we reframe it without reinforcing the notion of the reproductive body, and therefore the woman, as monstrous ?

PMS as a material-discursive-PMS as a material-discursive-intrapsychic experienceintrapsychic experience

Materiality of premenstrual change – sensitivity, arousal, mood; materiality of life stress/relational context

Discursive construction of PMS, femininity

Women’s intra-psychic negotiation and coping – within a relational context

All 3 levels irrevocably interconnected

A Material-Discursive-Intrapsychic A Material-Discursive-Intrapsychic approach to PMSapproach to PMS

Relational Context of PMSRelational Context of PMS

PM Reactivity = loss of controlPM Reactivity = loss of controlA relational issueA relational issue

Expression of emotion in relationships = PMS

But you haven't got any control over, you can't control how you feel. Or sometimes if it's really bad I get stroppy, you know? And it must be really (hurtful) for my husband. I mean he's great, but that's not fair on him. You can't go on like that forever

Ussher, J.M. (2003a). The ongoing silencing of women in families: an analysis and rethinking of premenstrual syndrome and therapy. Journal of Family Therapy, 25, 387-404.

Coping with ‘PMS’ by avoiding relationshipsCoping with ‘PMS’ by avoiding relationships

I: And then how did you feel when you stayed up there on your own?

J: Better. Because I just want to be on my own. I don't want people around me. I don't want to have to talk to anybody. I just want to be alone. Without any demands on me or anything. …. so I can have some peace to make myself feel better. To calm myself down.

Research on Relationships and PMSResearch on Relationships and PMSFundingFunding: : ARC Discovery 2006-2009ARC Discovery 2006-2009

Sample N = 327 Questionnaires(N= 60 Interviews)

Age 18 – 48 years

Relationship status: Currently partnered Not currently partnered

63%37%

Sexual orientation: Heterosexual Lesbian

63%37%

Examine construction and experience of PMS across relationship type and context (Ussher, Perz)

Self-Silencing and PMSSelf-Silencing and PMS

Self-silencing: focus on others at the expense of the self, accompanied by repression of one’s own needs and concerns, (Jack 1991) Tied to idealised constructions of “perfect wife and mother” Linked to women’s depression (Jack 1991; 2007)

327 Australian women self-positioned as PMS sufferers: Significantly higher self-silencing than population norms (STSS)

Perz, J., & Ussher, J.M. (2006). Women’s experience of premenstrual syndrome: A case of silencing the self. Journal of Reproductive and Infant Psychology, 24(4), 289-303.

Ussher, J.M. & Perz, J. (2010). Disruption of the Silenced-Self: The Case of Pre-Menstrual Syndrome. In D.C. Jack & A. Ali (Eds.), The depression epidemic: International perspectives on women’s self-silencing and psychological distress . Oxford: Oxford University Press (pp. 435-456)

Self-Silencing and PMSSelf-Silencing and PMS

Higher Self-Silencing higher premenstrual distress

But: self-silencing not significantly related to depression – contrast previous research

Why? Accounts of self-silencing being ruptured premenstrually

Perz & Ussher, 2006; Ussher & Perz 2010

Short fuse metaphorShort fuse metaphor

They were fighting over my son’s Bob the Builder spoon and I just said ‘right’ and I snapped it in half and said ‘no-one’s having it’ and that was it. I regretted it later on, of course”.

I have less patience with my husband & child & my expectations of them increase (premenstrually).

Ussher & Perz 2010

Pressure cooker metaphorPressure cooker metaphor

There's a few days of the month where I feel I'm not myself, or there's you know, anger or tension that builds up and then I release it at that point. And others around me suffer the consequences!

The issues that I suppress during my ‘normal’ time come up when premenstrual. I get angry that I am the only one who cares about the housework. I get angry on behalf of all women everywhere who have to pick up after everyone else.

Ussher & Perz 2010

Positioning of emotionsPositioning of emotions

Anger, irritability, depression positioned as PMS

Negates issues which may precipitate emotion

Women experience guilt and self-blame

Exonerates partner from responsibility

Inter-subjective context of PMSInter-subjective context of PMS Response of partner impacts on women’s construction

and experience of premenstrual distress

Supportive partners: recognition, understanding, support, share responsibility, facilitate self-care

Unsupportive: disbelieving, rejecting, argumentative, no support, no sharing responsibilities

Ussher, J.M., Perz, J., & Mooney-Somers, J. (2007). The experience and positioning of affect in the context of intersubjectivity: The case of premenstrual syndrome. International Journal of Critical Psychology, 21, 145-165.

Ussher, J.M. & Perz, J. (2013) PMS as a Gendered Illness Linked to the Construction and Relational Experience of Hetero-Femininity. Sex Roles 68, 1-2, 132-150

Pathologizing vs understandingPathologizing vs understanding

You know, on the one day, probably 3 months ago or so and he came in and said ‘who am I talking today?’ is it schizo Elaine, nice Elaine, sexy Elaine or cranky Elaine’? And I just, and I was really pre-menstrual and I thought ‘that’s just so unnecessary. I’m not that bad’.

he's very understanding he never used to be but he is now he sort of he knows to leave me alone or he knows when to come up and give me a cuddle

Over-responsibility vs supportOver-responsibility vs support

On a Sunday night if I’ve got the ironing to do and I’m cooking dinner and I’ve got to make the lunches for the kids tomorrow and they’re in the bath and he’s out in the garden, just that week of the month I can’t cope with doing all that at once. I shouldn’t have to tell him that the kids need a bath, or they need to be read to. I get really frustrated that I have to ask.

It’s about… someone just…recognising that you’re actually feeling really out of sorts and taking some of the responsibility off you to actually manage it: “Well, now you’re feeling crap. And I know there’s nothing that much that can fix that, and you don’t have to worry about, where the food’s coming from”, or, I mightn’t even think about a bath, and then she’ll say, “How about you go and have a bath? And I’ll run it for you,” and I’ll be like, “Oh, that would be really nice!” It’s about just being able to just be.

Lesbian-Heterosexual differencesLesbian-Heterosexual differences

No differences in accounts of premenstrual change: intolerance, irritation, emotional sensitivity, negativity towards

others, overwhelmed in the face of life’s demands.

But, women in lesbian relationships report significantly: Higher levels of premenstrual coping Lower levels of self-silencing Lower relationship tension More supportive partners

Ussher & Perz, 2008; Perz & Ussher 2009

Accounting for lesbian experiences of PMSAccounting for lesbian experiences of PMS

Gender role: Mutuality, reciprocity, egalitarianism Higher level of expressiveness

Empathy understanding and confidence in conflict resolution

Presence of Children Fewer lesbian couples had children

Perz & Ussher, 2009

Implications for Innovative Implications for Innovative PracticePractice

Women Centred Psychological Therapy for PMSWomen Centred Psychological Therapy for PMSDrawing on narrative and cognitive behavioural therapy strategiesDrawing on narrative and cognitive behavioural therapy strategies

8 weekly sessions (Ussher, Hunter & Cariss, 2002)

Self-help package (Ussher & Perz, 2006)

Reformulate ‘PMS’ in context of woman’s life: Re-author premenstrual change – not pathology Self-care:

• doing things you enjoy; diet and exercise; time out

Positive thinking (CBT) Anger management; assertiveness Relationships and PMS

Ussher, J.M., Hunter, M., & Cariss, M (2002). A women centred cognitive behavioural treatment

package for premenstrual symptoms. Clinical Psychology and Psychotherapy, 9, 3319-3331.

Evaluation of interventionsEvaluation of interventions

RCT: Comparison of psychological vs medical (SSRI) intervention vs combination

All interventions significantly reduce symptoms over 6 month period

Psychological intervention more effective at follow-up plus improved self-efficacy/coping

Hunter, M., Ussher J.M., Browne, S., Cariss, M., Jelly, R., & Katz, M. (2002). Journal of Psychosomatic Obstetrics and Gynaecology, 23, 193-199.

RCT: Comparison of self-help pack and pack plus minimal intervention

PM ‘symptoms’ still present

Both resulted in reduction of distress, improvement in coping

Pack plus minimal intervention more effective

Ussher, J.M., & Perz, J. (2006). Evaluating the relative efficacy of a self-help and minimal psycho-educational intervention for moderate premenstrual distress conducted from a critical realist standpoint. Journal of Reproductive and Infant Psychology, 24(4) 347-362.

PMS Couple InterventionsPMS Couple Interventions Comparison of individual and couple intervention for

moderate-severe premenstrual distress – with wait list control

Randomised controlled trial; mixed methods

90 women and their male partners; 30 couples each condition

ARC Discovery Grant, Ussher & Perz, 2008-2012

Premenstrual emotions as Premenstrual emotions as understandableunderstandable

Oh! It… it’s a weight off my mind. ’Cause at first I used to think I was just, you know, going a little crazy, and I was so angry, and, um... and it’s kind of helped with my emotions, helped me deal with, “those are PMS feelings.” (Olivia)

I know now, you’re not actually the wicked witch (Danni)

It does allow me to not blame myself so much (Nicki)

Resisting critical self-surveillanceResisting critical self-surveillance

I just don’t care. Don’t cook dinner and things like that (Jackie)

a little easier on myself…being a little kinder (Olivia) ,

cutting myself a little bit of slack (Merrin),

being gentler on myself (Celia),

a little bit nicer to myself (Danni),

self indulgent and precious (Nancy)Ussher, J.M. (2008). Challenging the Positioning of Premenstrual Change as PMS: The Impact of a psychological intervention on women’s self-policing. Qualitative Research in Psychology, 5(1), 33-44.

Avoidance of conflictAvoidance of conflictTo protect others: It was in the kitchen and… I can remember just getting

so cranky I just went in and sat down in um our formal lounge room just to stay away from everyone because I was just so angry (Katie)

To protect the self: I just wanted to really minimise anything that would

impact on me ’cause I knew I was really sensitive” (Kathryn)

Care of the selfCare of the self

Solitude is wonderful, being by yourself, doing your own thing (Jill)

I just need half an hour in front of the TV and not to talk too much (Melanie)

I don’t really want to go out. I’d rather curl up with a book and have a quiet time (Marylin)

I need flannelette sheets (laugh). You know, just that comfort. Comfort and, um, you know, comfort food and comfort environment and a bath (Tracy)

ConclusionConclusion

Women’s distress needs to be taken seriously - as a social construction and lived experience

Can’t be seen as biological, psychological or discursive:

a material-discursive-intrapsychic phenomenon

Supportive interventions and health education needs to take all three levels on board