“You know how air works?” asks Sadaf, a counselling psychologist based in Mumbai, when I request her to explain how psychosocial factors affect our mental health. “It’s always around us and the pollutants we breathe affect our body. In the same way, social factors exist around us in all forms, all the time, and when they influence our behaviour, we call them psychosocial factors. In India, patriarchy is the biggest inducer of them, affecting women’s mental health at different stages.”
A report on psychosocial factors and women’s mental health, published by the WHO in 1993, talked in-depth about the link between the increased prevalence of mental health issues in women and their vulnerable location in a patriarchal society.
In April 2017, The Mental Health Care Act was passed and brought in some revolutionary changes. Noting additions like decriminalization of suicide and access to discrimination-free healthcare, it is safe to assume that the law considers women’s mental health to be a pivotal concern. But in a society like ours where male-centrism has dominated the foundations of healthcare and psychology, is just being concerned enough?
Childhood and the beginning of imposition
In 1981, Sandra Bem came up with the Gender Schema Theory that reflects upon children learning to adapt roles assigned to their gender, starting from birth.
Kartiki Keshkamat, a clinical psychologist who works with children and caregivers, says, “How girls look, how much they have started to weigh, what they wear -- I see parents being worried about all these things when the children are as young as 10. In schools, little girls are literally taught how to sit, keeping their legs closed. Kids do not usually rebel about this being imposed on them at this age. This is how socialization works and the impact of it becomes visible in future.”
Passive observing of events, mostly occurring within homes, too, has an effect on girls. Girls growing up witnessing violence towards their mother, internalise the pain and find it difficult to cope with it when they find themselves in a similar situation, says Sadaf.
While the childhood years, starting from birth to teenage, are defined and restricted by a certain set of social expectations, the demands for the emotional availability of women start to show up during adolescence. They have a larger impact on their general mental well-being and adversely affect a person who already has an illness.
Adolescence, expectations and the family
“There is a positive side and a negative side to living in a family. The positive side is that you are never lonely, there is always someone around, but the negative is that there are always very high expectations, and as a woman, to a very large extent, you are ‘performing’ a lot of the times,” says Jasveen, who spent her adolescence in a patriarchal joint family, which she believes contributed to her depression and anxiety.
The symptoms of anxiety became clearer to Jasveen when she entered late adolescence. When she opened up to her family about her symptoms, they thought what most Indian parents think about women.
“It became a part of ‘this is what girls do’. Be it combusting into tears, inability to control emotions, feeling overwhelmed, getting short of breath -- all the symptoms that we assign to anxiety disorders were just being applied to me for being a woman,” she says.
Among anxiety disorders, when the symptoms are not normally visible and the person seems to be in control of them but isn’t, the condition is termed as high-functioning anxiety. When Jasveen couldn’t convince her family members about what was going on with her, she learned to suppress her symptoms -- which made things worse.
“I figured since I wasn’t being treated well for my actual emotional turmoil, I sort of learned to suppress it within me and appear in a proper “ideal feminine” way as demanded. All emotions are normal but when you’re only supposed to show the ones that society deems respectful, it becomes unhealthy. On the outside, I’m all respectful, smiling and not lashing out, but on the inside, I would push it so much that every once in a while, there would be a massive outburst,” says Jasveen.
If it wasn’t for her gender and the accommodations people demand from it, Jasveen would not have to force her anxiety into becoming high-functioning: “I have become an ‘expert’ at making it look like I have everything under control when I don’t because of the stigmas attached to me as a woman. I’m still trying to find the balance between the two states.”
The frequency of emotional labour -- when you’re constantly required to express emotions for the fulfilment of other people -- is more talked about in professional settings and intimate relationships. However, in India where families play a huge role in upbringing, it takes a higher toll on women’s mental health and research has always been supportive of this effect.
Early adulthood and the abuse that never comes out
Vaishnavi moved to a relative’s place when she got into college because it was a close commute from there. However, little did she realise that a male relative who lived in the same house was secretly molesting her.
“When the time came and I fully knew this was happening, I realised it has happened to me before, when I was at an age where I didn’t know what it was. He used to be noticeably touchy throughout the day, when he needed something that was kept near me or just generally. And when I slept, I remember his hands crawling up on me or behind my back,” she recalls.
Vaishnavi did not open up to anyone about this except her brother. She returned home but that wasn’t the end of it.
“The trauma began when I started getting dreams about being chased by men in mobs and the triggers while being in the house would also act upon me…because during family gatherings, he would sit in the same room as me and I couldn’t take that,” she says.
All types of sexual abuse can lead to mental health issues, but when it is perpetrated by someone from the family, the consequences cage the victim with problems that become extremely hard to battle.
“Moving on does not work. I still get dreams every other day and have a general hatred towards men. I knew even if I had told someone about this, the family would have taken all steps to protect him. Someone I know has even tried (because it has happened with more women than me in the family) but they were shunned by the elders because he is one of the ‘reputed’ family members,” shares Vaishnavi.
Such issues, which mostly go unresolved because they happen within the family setting, are followed by mental health issues like Post Traumatic Stress Disorder (PTSD), excessive shame, guilt and episodes of anger.
The construction of marriage and domestic violence
A man was recently granted divorce by the Supreme Court on the mere ground of his wife refusing to live with his parents. “A wife is expected to live with the groom’s family,” said the ruling.
The construction of marriage in India attempts to take away most of women’s rights as an individual and in return give them a plethora of conditions that either lead them to a particular mental illness or add to the ongoing issues.
“There is a whole lot of stigma attached to women who do not choose to marry, and when you do, there is a certain criteria of eligibility you have to meet, be it physical like beauty standards, personality-wise like you’re supposed to be submissive, demure, be traditional against your will. All these things can be very distressing for women and specially for the ones who do not easily conform to these gender roles,” says Jagruti Wandrekar, a consultant psychologist who works with women and victims of domestic violence.
Depression is one of the most common disorders that are strongly associated with gender roles and expectations. For men, marriage is perceived as a preventive measure for depression while for women, it’s the other way round.
Last year, close to 30% of married Indian women, aged between 15 to 49 years, experienced violence in marriage according to the official numbers of the National Family Health Survey.
Mental disorders that are linked to domestic violence and intimate partner violence include clinical depression, PTSD, anxiety disorders and psychosis. An existing illness often becomes a reason for a woman to become a victim of domestic violence, too – either from the partner or family members.
“There are times when we never get to know if the woman was already going through some stress or if there is a history of illness because it is kept hidden by the family until she is married. When it comes out, both the families indulge in a blame game,” says Advaita, a Mumbai-based psychologist.
Emotional abuse is one of the types of domestic violence that often goes unaddressed in the Indian context.
Advaita points out that emotional violence is equally and sometimes more debilitating than physical violence. “The biggest impact of emotional violence I have observed is when I actually started working with women using emotion-focused techniques and other modes of treatment -- a lot of insights are based on altering thought-process or irrational beliefs that they’re are conditioned to have which makes them take the blame of a broken marriage,” she says.
Learned helplessness is a mental state that was first assigned to animals as observed during experiments by the infamous Martin Seligman in the 1960s. The specimens were continuously subjected to an aversive stimulus to an extent that they stopped thinking about escaping it. This made the animals attain helplessness and compliance to whatever they were put against.
Researchers assimilated this finding to women who could not escape abusive interpersonal relationships.
“The first question people ask when they hear about a case is “why didn’t she just leave?” even when she had the financial resources to leave and the support. This is where learned helplessness comes in. The repeated cycles of trauma make them habituated of it. The families do not help either…instead, the mother and sisters of the victim often tell her to stay on and that this is how it is,” says Advaita.
A major flaw pointed out in the current Mental Health Act deals with mental illness being used as a ground for divorce proceedings. Researchers in psychology and law have also objected to the ambiguous manner in which it has been framed.
“We have had many cases where husbands and in-laws approach psychiatrists in the hopes of getting any mental health diagnosis (or even a prescription for sleeping pills) that they could then use to label women as an unfit partner/parent. It goes without saying that there is no disclosure of any abuse,” says Swetha Shankar, a psychosocial manager working with The International Foundation for Crime Prevention and Victim Care (PCVC) in Chennai.
Talking about the general idea that some mental health service providers have about victims of domestic violence she further added, “Often, when women seek help from law enforcement or health care institutions for domestic violence, they are labeled as overly emotional, angry, hysterical, paranoid, suspicious etc. Families very often term them as 'mad', 'crazy' 'psycho' etc. It's a short step from there to a misdiagnosis, forcefully being medicated, denial of access to legal or counseling support, losing custody of children etc.”
Motherhood and mental health
Women, during pregnancy, are at the receiving end of a flood of ‘advice’ from family and friends. Recently, the Government also joined the bandwagon when the AYUSH ministry issued a statement advising women to give up meat during pregnancy.
“I believe for every mother who is consensually having the baby, the time of the birth is overwhelming, with mixed emotions. The amount of love you can give the child kind of correlates with what is going on around you,” says Kuppulakshmi, talking about postpartum and how it affects women’s mental health.
Kuppulakshmi with her child.
“The interference of people used to stress me a lot, from naming the child to tying an ‘arana kayiru’ all of which I found very absurd and patriarchal and nobody would ask me what I think about anything or what the child wants. As soon as a woman becomes a mother, society takes ownership of both the child and the mother,” points out Kuppulakshmi.
Postpartum depression (PPD) can be attributed to the lack of comprehensive care and support.
“I was desperate to go back to work and thought about hiring a nanny because everything was becoming very hectic for me. That too was met with discriminatory remarks about how dare I put my priorities before the child’s. I wish there was more discussion about postpartum depression in general. I wish someone had told me that it is okay to think about yourself too,” shares Kuppulakshmi.
Middle aged, elderly women and ageism.
When Usha joined a prestigious not-for-profit to extensively work for environmental activism, her depression was at a moderate stage. She was in her mid 40s.
But soon, she had to confront ageism at the workplace.
“Firstly, this is a vulnerable stage because we are amidst competition with young coworkers and that is okay… what is not okay is the type of discrimination middle aged and older women go through. Many times, my fellow colleagues and I have been called “mummy” or “aunty ji”. We are professionals and none of us want to be called that at such a setting,” says Usha.
When she raised her voice against ageism, she was labeled ‘crazy’.
Usha also spoke about dealing with menopause, one of the most undermining biological changes women go through in this period.
Studies have repeatedly linked negative mental health outcomes with this phase and for someone like Usha who had been a feminist activist throughout her life and had stood up for numerous issues including sexual harassment of female employees, such deliberate circumstances posed a serious additional stress.
Vaidehi Chilwarwar, a psychotherapist working with elderly (65+) people talked about the issues that are inflicted upon elderly women’s mental health: “Conflicts arise mostly due to lack of agency, and the diminishing ability to make decisions over things that concern themselves. There is a major lack of awareness in terms of sexual health as well, because the insecurity of male partners and husbands is still present.”
Group therapy session of elderly women. Image: Vaidehi
When Usha’s depression was at its peak, she went to a counsellor who along with showing blatant impatience towards her, also told her to adjust with issues that were going on with her and her relationships which caused her illness in the first place.
Workplace and the illness that stands in its corner
While workplace sexual harassment continues to correlate itself with major mental health issues in victims, women employees already struggling with a mental illness go through a doubled battle as soon as they step into the office.
“Since the nature of the condition had me waiting for a trigger to go down an obsessive spiral about any remote insecurity, it prevented me from focusing on work,” says Soumya*, a Chennai-based graphic designer who was diagnosed with obsessive compulsive disorder (OCD) and body dysmorphic disorder.
Body dysmorphic disorder, found equally in both men and women, makes one obsess over a flaw in their appearance that may or may not be visible to others, creating extreme distress. Despite no gender differences in occurrence, cultural norms do have an impact on women suffering from it.
“My brain would pick on any trigger, even on something that wasn’t addressed to me. The office had a fair amount of desperate men objectifying women in general. Such things make you uncomfortable even if they're not directed at you. The constant male gaze oriented remarks were hard to ignore in a small office set up, especially since these remarks were made so unapologetically. There were also a fair amount of mansplaining moments. These stopped only when they had reason to believe I was good at my work. There was this general perception of women: stupid until you prove yourself to be smart,” Soumya adds.
Soumya never talked about her condition because she did not feel comfortable doing it in an environment she did not trust, fearing how much worse things could get if she did.
Betrayal from healthcare
Not only is access to non-judgmental healthcare challenging for women, therapists’ bigoted nature has made it difficult for them to push their willingness to seek it in the first place.
The story of Bengaluru’s Aishwarya* gives a chilling perspective on this.
“I had depression arising out of my conflicts with my now estranged husband. He took me to a psychiatrist for counselling and later had his friend, who is a psychologist, collude with the psychiatrist I was seeing, behind my back. The second therapist I informally met told me that I am playing the ‘victim’ card but all I was doing was not letting my husband gaslight me,” says Aishwarya.
Both the psychologists Aishwarya met were mutually connected with her husband and allegedly attempted to create a false notion of illness in her. They established that she had bipolar and borderline personality disorder.
“It’s beyond my understanding how a medical professional can make a person’s life hell by making them believe they are mentally ill, just because they have been told to do so,” she fumes.
Both the professionals mentioned by Aishwarya are well established in their fraternity.
There has been little discussion about reports on mental health professionals turning a blind eye towards women who refuse to be affected by patriarchal constraints. They are met with sexist remarks directed towards their lifestyle choices as well as ‘advices’ to conform to those gender roles.
The current Mental Health Bill gives a ray of hope by condemning discrimination of people seeking help on the basis of gender, caste, sexual orientation etc but the problem exists in the monitoring of such instances and overlaps with the genuine lack of mental health professionals in India.
The kind of therapy that works
A range of researches contributed by Dr. Thara R of Schizophrenia Research Foundation (SCARF), Chennai stress upon the psychosocial rehabilitation of women which can only be possible by promoting gender-sensitive mental healthcare services in India.
Therapy works efficiently if provided in the right manner and it’s time therapists start recognising the significance of a non-judgmental approach while doing therapy. Jagruti, who has been working with women for 6 years now, spoke about how feminist approaches work better with women.
“When women narrate their experiences about what happened with them, the first thing that is important for any therapist to do is to validate them and to convey that they know where they are coming from,” says Jagruti.
Techniques like Cognitive Behavioural Therapy (CBT) and Rational Emotive Behavioural Therapy (REBT) focus on replacing thoughts that are irrational in nature and somehow harm the person’s well-being, but Jagruti suggests that they need a feminist modification: “We incorporate discussions on patriarchy and sexism during group therapy sessions and women welcome that. There is a demand for a feminist approach to therapy because the awareness is increasing, too. Sometimes it takes 2 to 3 sessions with a client just to ensure that they are in no way to be blamed for anything.”
Soumya noticed how things improved for her at her workplace after she underwent therapy that was inclusive of feminist approaches: “I've done more in this one year towards my growth and goals than I have deliberately in the last 2-3 years. Therapy helped me ignore the triggers my brain used to feed on, helped me use rational thought to fight most of my irrational obsessions, and be more vocal in general about what wasn't okay to me. The volume of sexist remarks reduced, don't know if I got better at turning a deaf ear or if they actually realised it wasn't something I was okay with and weren't so unapologetic about it.”
Therapy for lesbian and bisexual women
In the case of lesbian and bisexual women, gay affirmative therapy has proven to be effective for women. Sadaf explains the base of it and what it means to be affirmative.
“Gay affirmative therapy is principled on being non-judgemental and affirming the choices that people make which may be beyond what's considered ‘normal’. In many ways, this therapy is client-centered and narrative in nature. But the added element is the awareness of the marginalization of the community. This awareness helps the therapist more acutely to not put the blame on the woman in question,” she explains.
Feminist therapy has a close connection with the lives of marginalised women in the West and it applies the same assumption of taking into account societal oppression.
Kartiki, who has worked with LGBTQ+ clients, says that lesbian and bisexual women also face systemic and institutional violence.
“This could be exacerbated because of them not complying with heteronormative expectations of marriage with men. Due to these difficulties, lesbian and bisexual women in therapy might require additional support which primarily should stem from legal and social agencies. However, due to the criminalization of homosexuality, such persons often find themselves completely alone in India,” says Kartiki.
Often times, women do not recognise their mental health issues in the first place.
“They are inherently suspicious of mental health personnel due to first hand negative experiences at the hands of a few professionals who are misinformed about human sexuality and gender, who might also perpetrate violence against such vulnerable individuals. They may thereby create an impression that the larger mental health community is working against their best interest and is therefore unapproachable,” she says.