Foreword

This important book goes to the heart of much post-modern psychiatry, and the scholarly chapters expose the ambiguities of terms used by policy makers to characterize women’s mental health services. What is mental health promotion, and how is it distinguished from mental disorder prevention? They each have overlapping properties but are derived from ‘different conceptual principles and frame works of understanding’, as the WHO (2005) has aptly summarized. What ‘mainstreaming’ means—and how such attempts to integrate and routinize such services cope with rapid changes in culture and gender roles in a multi-faith world? Are women-only services delivered by women-only health workers basic needs, or are they wants, preferences, and desires? We pay lip service to ‘personalized’ health care, but is ‘individualized’ care the same thing? Not according to the relationship-based Medicine of the Person concept developed by Paul Tournier.

How can revised classifications of mental disorder, whether in DSM-5 or ICD-11, capture these gender-specific relationship-based facets? The Royal College of Psychiatrists’ Perinatal Specialist Section has recommended that the familiar diagnostic terms ‘puerperal psychosis’ and ‘post-natal depression’ should no longer be separately delineated, and that a mandatory pre- and post-partum onset specifier be introduced for all mental disorders. Such nosological scientific mainstreaming paradoxically could disadvantage women and the development of the women-only services currently advocated by policy makers if the established link of mood disorder to childbirth, symbolized by the ‘puerperal’ or ‘post-natal’ nosological specifier, is lost.

The reader will be stimulated to reflect on the answers to these questions within a local National Health Service (NHS) context. Thus a culturally sensitive psychiatry and a women’s mental health service does ‘begin at home’; and most chapters reflect the structures of the NHS in the UK, with its systems of commissioning and competition for resources.

Society is indeed changing in its core structures, with more serial marriages, lone parenting, same-sex relationships, and the way in which transmission of knowledge occurs between generations. Britain has one of the highest divorce rates in Europe. The roles of women and men, and the circumstances for the development of children are changing—and changing fast. Some women regard childbearing and optimal parenthood as a threat to autonomy, economic viability, and to individualized choice. Yet Layard and Dunn (2007) have concluded, as does this author, that parenthood is an awesome responsibility and that parents should therefore plan for ‘long-term commitment’ to each other as well as to the welfare of their child. Yet the proposal that ‘relationship disorders’ should be coded in hospital statistics rarely gains popular credence, despite the evidence that bonding problems adversely effect child development and that relationship difficulties can be ameliorated with psychological assistance.

The insight of continental philosophers (Buber, Levinas, Merleau-Ponty, and Kirkegaard) to the understanding that personhood is achieved in relationship to others has been neglected; British medicine has also been impoverished by the lack of a developmental dynamic and humanistic perspective which is more prominent on the continent. Thus mental health and psychiatry training in reproductive health and in women’s health programmes is surprisingly weak. Obstetricians and gynaecologists may for example have had no postgraduate training in these subjects and yet failure to provide accessible specialist perinatal liaison mental health services can have tragic consequences.

This book shows clearly that mental disorder in women, including perinatal disorder is still, alas, judged harshly by society; women are expected to remain strong and to multi-task with impunity. Furthermore in-depth discussion about the health promoting benefits of consensual sexual activity, strategies to maintain a creative and loving relationship, and the relevance of religious and spiritual beliefs are overlooked.

An understanding of women’s mental health requires therefore a conceptual framework that exceeds the conventions of a narrow bio-medical scientific approach (the medical model), is sensitive to the dynamics of relationship-driven mental disorders, and recognizes that most women most of the time are in relationships with men, and many with their own or others’ children. To encompass this broad public and personal health agenda requires a breadth of training and personal maturity in the health professional; or a team that, in its entirety, is able to understand the bio-social and psycho-spiritual facets of the woman’s disorder.

There are two current theoretical approaches, which assist this multi-professional process, and which provide the theoretical framework, without which the consideration of women’s mental health becomes a personal lottery of loosely formed ideas and prejudices. The first is derived from philosophical ideas of linguistic analysis which recognized that the understanding of diverse values (such as gender and sex roles, or autonomy, and patriarchy) as well as the contribution of scientific facts are both vital for any comprehensive care programme that is shared with the service user.

The second is the integrative diagnostic assessment developed by the World Psychiatric Association which combines the descriptive with the ideographic approach and emphasizes the need to contextualize the individual’s symptoms and to engage the user in the management process. This socio-cultural envelope draws less on the intricacies of philosophy than on the track record of sociology (of gender, sex roles, and feminism) and the socio-anthropological studies of women’s health, which were pioneered by Margaret Mead, Scheper Hughes, and Carol MacCormack.

Professor Kohen has commendably succeeded in encouraging her authors to highlight how a consideration of women’s mental health may challenge the personal assumptions of professionals, whose hidden prejudices and values become exposed. Readers will be urged to reflect on the endemic nature of domestic violence; the cultural confusion of changing gender roles; the lower status and threat to autonomy of motherhood in high income countries; the doubling of rates of depression and anxiety in divorced women compared with those who are married; and the adverse effect of all these factors on child development. In low and middle income countries, the link between adverse mental health in women, poverty and low school attainment, and a 1 in 16 life time risk of maternal mortality in parts of Africa should override any reluctance to consider reproductive health as a specific priority in a post-modern feminist society.

Of the eight UN Millennium Development Goals, three are specifically related to women’s mental health: gender equality, reduction of child mortality by two-thirds by 2015, and reduction of maternal mortality by three-quarters. At the conclusion of the International Consensus Statement of Women’s Mental Health, the 139 WPA member societies were each urged to implement its recommendations and to distribute them to their members. The WPA now needs to determine the impact of this consensus statement, and the extent to which psychiatrists, and their professional organizations, are effectively advocating the scaling up of maternal, newborn, and child health (MNCH) services and greater gender equality—and, when necessary, challenging religious assumptions that may disadvantage women.

The Royal College of Psychiatrists has recently mainstreamed its international outreach and should work with the College of Obstetricians and Gynaecologists to encourage NHS collaborative links with maternity services in low and middle income countries and so support an infrastructure at community level. Silo thinking in world organizations, including WHO and WPA and national colleges, has increased the likelihood that the well-being of the newborn and gender-specific women’s mental health can be overlooked.

The triple jeopardy of old age, femininity, and dementia can similarly be overlooked; at least a third of women suffer from mental disorder in their old age and may not have children or other family members to care for them.

Pastoral work, lunch clubs, drop-in centres, practice choirs, and charitable agencies, such as Methodist Homes for the Aged (MHA), Help the Aged, and Age Concern, will relieve, not just the burden of mental disorder on the elderly person, but also reduce the frequency of depression in carers (mostly women) and younger family members.

In the UK greater thought should now be given to sustaining marriage (through, for example, tax incentives) and supporting parenthood—but not at all costs. The churches and other voluntary organizations should consider modernizing and secularizing their naming ceremonies (baptism) and provide greater support to families and children at risk.

I have spent over 30 years conducting studies on post-natal and antenatal mental disorder, and have been a strong advocate for improved services for women, but these activities were driven by the clinical priorities that confronted me first in Uganda, and then subsequently in Scotland and Stoke-on-Trent. I have never regarded these studies, or their conceptual framework, as confined to women’s health to the exclusion of men and their families. The renowned Charles Street Day Hospital, ‘opposite the bus station in Hanley’, was deliberately named a ‘parent and baby’ and not a ‘mother and baby’ unit. Likewise the Edinburgh Postnatal Depression Scale (EPDS), now translated into over 25 languages, has not only withstood the test of time but is used to highlight the impact of mental disorder on the father and the impact of depression on the development of the infant. The most complex clinical managements, in my experience, were when both parents had mental disorder; when the grandparents, though healthy, were unhelpful, and if absent or themselves unwell, were unsupportive.

Women’s and men’s health are partially interlocked; what is required of clinicians is a relationship-based personalized biosocial/psychospiritual assessment, which considers ‘meaning and purpose’ (spiritual/existential needs) and, when relevant, the world-views and beliefs of the family.

Greater attention to women’s mental health is thus a political, economic, humanitarian, and human rights priority. It is scandalous that we accept a 1 in 16 lifetime risk of dying in childbirth in sub-Saharan Africa; that governments do not speak out against all forms of domestic violence; and that the availability of cost-effective treatments for common mental disorders (which disrupt family life and threaten the well-being of the children) are so often lost between competing priorities.

Globalization, and the influx of migrants with different world-views and religious beliefs, make it essential that those advocating improved mental health for women demonstrate not only that there is ‘no health without mental health’, but that there is also ‘no reproductive health without mental health.’

Taking these slogans seriously will raise profound questions about the future directions for psychiatry. Psychiatry is at a crossroad; the issues raised by the contributors to this scholarly volume will ensure that this debate continues, and any new routes are more clearly sign-posted. Psychiatry, psychiatrists, and other mental health workers are bio-psycho-social scientists, who accept the limitations for research of a ‘patchy reductionism’, and yet also make available skills as healers of the body, mind, and spirit. Such a complex vocation requires thorough training, a personal sense of meaning and purpose as well as an inherent curiosity about women as well as men—and especially about those factors that make for harmonious relationships.

This excellent book about women and mental health provides pointers to the direction ahead, and to the need to make yet more explicit the evidence base and the diverse values, which will underpin these public health priorities.

John Cox

Secretary General World Psychiatric Association (2002–2008) Cheltenham, January 2010

This book is dedicated to the memory of Dora Kohen who died in 2009 and had worked so tirelessly to improve the well-being of families throughout the world.