Exploring Psychosis and Bipolar Disorder in Women
Exploring Psychosis and Bipolar Disorder in Women
This is the first attempt to systematically explore the qualitative literature on the experiences of women with psychosis. Three overarching themes emerged and a model was developed to explain their experiences.
Women appear to construct idiosyncratic illness models of their experience, which did not necessarily incorporate information from dominant biomedical paradigms of mental illness. This is concordant with data suggesting that individuals' understanding of their problems, rather than labels/diagnoses, have a strong mediating influence on how they view themselves in relation to mental illness.
Women were critical of health care professionals ignoring contextual factors in their lives. This is reminiscent of the feminist critique: labelling women as mentally ill hides injustices including social inequalities. Gender interacts with other relevant variables, such as race, ethnicity and socioeconomic status. Women from minority groups (e.g., immigrants) are more likely than British born white women to experience mental ill health. While racism, access to resources and social isolation might be important factors, there is evidence that their experience of the mental health system is different for these groups of women. For example, African-Caribbean women are more likely to be hospitalized on an involuntary basis and they are more likely to receive medication for mental distress. The importance of the relationship between sociocultural factors with illness models has already been highlighted: marginalized groups may be more likely to reject white, middle-class professionally conceived psychiatric explanations.
The way that mental health is conceptualised in western societies reflects underlying societal structures and relationships. The mental health system reflects this bias and it has been argued that psychiatric care and treatment does not take account of spiritual belief systems and their role in coping with mental distress, as discussed by women in the current study. Religious beliefs might conflict with illness paradigms used by health professionals and could discourage engagement. However, religion and spirituality might provide positive coping to people with bipolar disorder and schizophrenia.
The role of self-determination in influencing health and wellbeing is well established. The failure to provide services, which preserve the self-determination of people with mental illness, has been reported elsewhere, but this problem is particularly pertinent for women. Although a focus on self-determination is an important component of recovery-oriented services, it has been argued that these concepts have not yet been established in the mental health system. Reducing women's view that service involvement will inevitably lead to a loss of self-determination is likely to enhance engagement with services. Several recommendations have been made in the literature to help health professionals support the self-determination of people with mental illness, including a focus on individual preferences to inform decision-making and paying attention to women's beliefs about their illness rather than dismissing them in favour of dominant biomedical models.
Women reported that they believed an understanding of contextual factors to be imperative to understanding their mental illness and that professionals' minimising of these factors discouraged engagement. The role of stress in precipitating psychosis has been established; however, the link between contextual factors and psychosis might be particularly important for women because severe physical or sexual abuse was associated with psychosis in women but not men.
Although stigma is common to all mental illnesses, it is greater for people with SMI. Stigma is not unique to women, but there is some evidence that the effect of stigma might be greater for women, having a greater impact on their willingness to disclose problems and seek support. Goffman realised that stigmatized people reveal or hide certain parts of themselves in order to influence the reactions of others, demonstrated by women in the current study using the strategy of appearing "normal". This strategy was driven by their beliefs about how others react to people with a mental illness in line with modified labelling theory. Consistent with this approach, women who felt more threatened by the potential reactions of others were more motivated to hide their illness. Stigma and discrimination related to mental illness interact with additional inequalities related to gender and ethnicity to render some women doubly disadvantaged.
Changes in relationships were related to the restrictions imposed on social support networks caused by illness. However, the strategies people use to manage the reactions of others, such as social withdrawal and non-disclosure, can have negative consequences for social support networks. Furthermore, individuals with psychosis may have a poor understanding of the feelings and intentions of others. Thus, family members are not always equipped to provide the level of care needed by individuals with SMI.
As the process of metasynthesis is inherently interpretative, introducing subjectivity and potential bias, transparency in the development of themes was emphasised. In addition, the systematic identification of studies and critical appraisal by two independent raters enhanced the rigour of the metasynthesis. Finally, comprehensive details of the included studies were provided to enable the reader to consider the findings within the various contexts. However, information about ethnicity, class, level of education, religion, marital and parenting status and SES were often not provided, but future research should routinely provide comprehensive information about male and female participants, including their parenting status. Notably, the majority of the participants in the 13 reviewed studies were described as poor.
As this metasynthesis focused solely on women's views, it would be important for future research to synthesise the views of men so that similarities and differences between experiences could be evaluated. Some of the themes identified in this review may apply to men.
The findings outlined here have several implications for ways in which services can optimise women's use of strategies for coping with mental illness. Given the importance of informal social support networks and the difficult changes in relationships that can occur as a result of illness, a family-centred approach should be taken to women's care, by educating and supporting family members and involving them in decision-making. Professionals should be provided with regular training around how to enhance women's engagement with services. Strategies might include ensuring continuity of care when possible, a more holisitic assessment of women's difficulties which encompasses contextual factors and spiritual beliefs and inclusion of women in decision-making. Reflection on the assumptions of healthcare professionals about male and female behaviours and how this influences practice should be encouraged in supervision. If women believe they are listened to by culturally sensitive services, women will be able to seek more support, optimising their coping.
As some women are also mothers and parents, their wellbeing, their child(ren)'s wellbeing and that of the family should be enquired about, if possible assessed and, where necessary, appropriate and effective parenting interventions should be offered.
Discussion
This is the first attempt to systematically explore the qualitative literature on the experiences of women with psychosis. Three overarching themes emerged and a model was developed to explain their experiences.
Women appear to construct idiosyncratic illness models of their experience, which did not necessarily incorporate information from dominant biomedical paradigms of mental illness. This is concordant with data suggesting that individuals' understanding of their problems, rather than labels/diagnoses, have a strong mediating influence on how they view themselves in relation to mental illness.
Women were critical of health care professionals ignoring contextual factors in their lives. This is reminiscent of the feminist critique: labelling women as mentally ill hides injustices including social inequalities. Gender interacts with other relevant variables, such as race, ethnicity and socioeconomic status. Women from minority groups (e.g., immigrants) are more likely than British born white women to experience mental ill health. While racism, access to resources and social isolation might be important factors, there is evidence that their experience of the mental health system is different for these groups of women. For example, African-Caribbean women are more likely to be hospitalized on an involuntary basis and they are more likely to receive medication for mental distress. The importance of the relationship between sociocultural factors with illness models has already been highlighted: marginalized groups may be more likely to reject white, middle-class professionally conceived psychiatric explanations.
The way that mental health is conceptualised in western societies reflects underlying societal structures and relationships. The mental health system reflects this bias and it has been argued that psychiatric care and treatment does not take account of spiritual belief systems and their role in coping with mental distress, as discussed by women in the current study. Religious beliefs might conflict with illness paradigms used by health professionals and could discourage engagement. However, religion and spirituality might provide positive coping to people with bipolar disorder and schizophrenia.
The role of self-determination in influencing health and wellbeing is well established. The failure to provide services, which preserve the self-determination of people with mental illness, has been reported elsewhere, but this problem is particularly pertinent for women. Although a focus on self-determination is an important component of recovery-oriented services, it has been argued that these concepts have not yet been established in the mental health system. Reducing women's view that service involvement will inevitably lead to a loss of self-determination is likely to enhance engagement with services. Several recommendations have been made in the literature to help health professionals support the self-determination of people with mental illness, including a focus on individual preferences to inform decision-making and paying attention to women's beliefs about their illness rather than dismissing them in favour of dominant biomedical models.
Women reported that they believed an understanding of contextual factors to be imperative to understanding their mental illness and that professionals' minimising of these factors discouraged engagement. The role of stress in precipitating psychosis has been established; however, the link between contextual factors and psychosis might be particularly important for women because severe physical or sexual abuse was associated with psychosis in women but not men.
Although stigma is common to all mental illnesses, it is greater for people with SMI. Stigma is not unique to women, but there is some evidence that the effect of stigma might be greater for women, having a greater impact on their willingness to disclose problems and seek support. Goffman realised that stigmatized people reveal or hide certain parts of themselves in order to influence the reactions of others, demonstrated by women in the current study using the strategy of appearing "normal". This strategy was driven by their beliefs about how others react to people with a mental illness in line with modified labelling theory. Consistent with this approach, women who felt more threatened by the potential reactions of others were more motivated to hide their illness. Stigma and discrimination related to mental illness interact with additional inequalities related to gender and ethnicity to render some women doubly disadvantaged.
Changes in relationships were related to the restrictions imposed on social support networks caused by illness. However, the strategies people use to manage the reactions of others, such as social withdrawal and non-disclosure, can have negative consequences for social support networks. Furthermore, individuals with psychosis may have a poor understanding of the feelings and intentions of others. Thus, family members are not always equipped to provide the level of care needed by individuals with SMI.
As the process of metasynthesis is inherently interpretative, introducing subjectivity and potential bias, transparency in the development of themes was emphasised. In addition, the systematic identification of studies and critical appraisal by two independent raters enhanced the rigour of the metasynthesis. Finally, comprehensive details of the included studies were provided to enable the reader to consider the findings within the various contexts. However, information about ethnicity, class, level of education, religion, marital and parenting status and SES were often not provided, but future research should routinely provide comprehensive information about male and female participants, including their parenting status. Notably, the majority of the participants in the 13 reviewed studies were described as poor.
As this metasynthesis focused solely on women's views, it would be important for future research to synthesise the views of men so that similarities and differences between experiences could be evaluated. Some of the themes identified in this review may apply to men.
The findings outlined here have several implications for ways in which services can optimise women's use of strategies for coping with mental illness. Given the importance of informal social support networks and the difficult changes in relationships that can occur as a result of illness, a family-centred approach should be taken to women's care, by educating and supporting family members and involving them in decision-making. Professionals should be provided with regular training around how to enhance women's engagement with services. Strategies might include ensuring continuity of care when possible, a more holisitic assessment of women's difficulties which encompasses contextual factors and spiritual beliefs and inclusion of women in decision-making. Reflection on the assumptions of healthcare professionals about male and female behaviours and how this influences practice should be encouraged in supervision. If women believe they are listened to by culturally sensitive services, women will be able to seek more support, optimising their coping.
As some women are also mothers and parents, their wellbeing, their child(ren)'s wellbeing and that of the family should be enquired about, if possible assessed and, where necessary, appropriate and effective parenting interventions should be offered.
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