Women with mental disorders and motherhood

Abstracts

Considera-se que a capacidade materna para oferecer boas condições de cuidado e acolhimento às necessidades do filho gera ambiente adequado preventivo para o desenvolvimento psicológico da criança. Este estudo buscou descrever o fenômeno da maternidade para usuárias de um ambulatório de saúde mental da cidade de Ribeirão Preto, SP, tendo como referencial teórico o Interacionismo Simbólico. Foram entrevistadas dez mulheres, com, ao menos, um ano de tratamento e no mínimo uma criança de 7 a 12 anos. A Teoria Fundamentada em Dados possibilitou analisar os dados, atingindo uma teoria explicativa para o fenômeno: "tentando se enxergar para permanecer lutando". Conclui-se que essas mulheres necessitam lidar, reconhecer e enxergar-se em sua função materna para permanecer lutando com as limitações impostas pelo transtorno. Trata-se de mais um passo para adequação dos serviços de saúde mental frente a essa demanda, para que essas mulheres sejam vistas para além de seu lugar de portadoras de transtornos mentais.

saúde mental; serviços de saúde; enfermagem psiquiátrica

Se considera que la capacidad materna para ofrecer buenas condiciones de cuidado y reconocimiento de las necesidades del hijo, genera un ambiente adecuado preventivo para el desarrollo psicológico del niño. Este estudio buscó describir el fenómeno de la maternidad para usuarias de un ambulatorio de salud mental de la ciudad de Ribeirao Preto, SP, utilizando como marco teórico el Interaccionismo Simbólico. Fueron entrevistadas diez mujeres, con, al menos, un año de tratamiento y con por lo menos un niño de 7 a 12 años. La Teoría Fundamentada en Datos posibilitó analizar los datos, alcanzando una teoría que explica el fenómeno: "tratando de reconocerse para permanecer luchando". Se concluye que esas mujeres necesitan lidiar, reconocer y reconocerse en su función materna para permanecer luchando con las limitaciones impuestas por el trastorno. Se trata de un paso más para adecuar los servicios de la salud mental frente a esa demanda, para que esas mujeres sean reconocidas no solo como portadoras de trastornos mentales.

salud mental; servicios de salud; enfermería psiquiátrica

ARTIGO ORIGINAL

Women with mental disorders and motherhood

Marisley Vilas Bôas Soares^I; Ana Maria Pimenta Carvalho^II

^IEscola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil: Psychologist, Doctoral Student, e-mail: [e-mail]

^IIEscola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil: Psychologist, Ph.D. in Psychologist, Faculty, e-mail:[e-mail]

ABSTRACT

Mothers' ability to deliver care and tend to the needs of their children is considered to generate an adequate preventive environment for infant psychological development. This study describes the phenomenon of motherhood from the perspective of users of a mental health outpatient clinic in Ribeirão Preto, SP, Brazil, through Symbolic Interactionism theoretical framework. Ten women under treatment for at least one year and with at least one child between 7 and 12 years old were interviewed. Grounded Theory was used for data analysis, which enabled the development of a theory to explain the phenomenon: "of perceiving oneself in such a way as to keep fighting". The conclusion is that these women need to deal with, recognize and perceive themselves in their maternal role so as to keep on fighting limitations imposed by the disease. That these women come and see beyond their condition of mental disorder patients is another step towards the delivery of more adequate mental health services to meet this demand.

Descriptors: mental health; health services; psychiatric nursing

INTRODUCTION

Family members play an important role in the recovery of individuals with mental disorders when the goal is to include them in social life, which is viewed as a possible achievement. Thus, studies have sought to verify how mental disorders impact the family as well as the conceptions family members have about mental disorders' manifestations^(1-2). Even though many studies focus on the impact of mental disorders on family members and caregivers, some studies invert this rationale and give priority to the patients' perspective and on their search to balance social demands and needs arising from the disease.

According to this new focus, studies have evidenced the relation of these disorders to variables and gender differences have provided some evidence to guide preventive actions and treatments taking into account the particularities found in the incidence and manifestation among men and women⁽³⁾. Women's mental health, though, is an emerging issue with few Brazilian studies in the field. nTo address women's mental health and seek understanding of the conditions that determine it, gender, poverty, social position and various forms of violence against women and how these affect their health have to be taken into consideration. Among the disorders that can affect women over life, such as symptoms related to premenstrual syndrome or to menopause, those manifested due to the puerperal period are highlighted, which is when issues related to motherhood also begin. To consider the condition of women one has to refer not only to concepts involving biological particularities, but also to the complex social construction of women's roles and how they act in their social context.

Representations attributed to women concerning their natural responsibility for taking care of the home and raising their children find evidence that institutionalizes this thinking. There are theories about social and historical focus that considered the so-called "maternal instinct" to be a result of ideological conceptions, engendered from the mid 18^th century in Europe⁽⁴⁾. Psychoanalysis ends up reinforcing a difficult aspect for women: guilt for the mishaps and disappointments experienced by their children. It is also in this period that the family becomes a social cell that differentiates experiences lived in the public and private spheres in which the formation of the nuclear family is centered on maternal love through shared affection. Thus, the domestic environment has a strong female connotation.

Women currently face a series of limitations in balancing their multiple functions, related to the job market and also to social behavior and "performing these roles is not an easy and peaceful task because these roles still mean a 'violation' of the old model of individual and family behavior" ⁽⁵⁾. However, the performance of socially expected roles, such as mother and wife, is still part of the female ideal but compete with the desire to achieve professional realization and financial independence.

To deepen reflections about the maternal figure, the concept of parenting⁽⁶⁾ includes several factors that create in the individual abilities to care for his/her offspring: parents' individual psychological resources, children's characteristics and sources of stress and support present in the context in which they are inserted. Holding this concept as a background, among the noted aspects that can influence women's expression, this study addresses women affected by mental diseases - mental diseases affect, among other things, the quality of affective and family relationships. We must consider that these mothers with mental disorders can employ other elements that ensure they exercise motherhood/parenting - in addition to the exclusive quality of the mother-child relationship.

This study examines how women with a diagnosis of mental disorder experience motherhood and perceive themselves as mothers in view of the complex phenomenon of parenting, mental disorders and how these are related to each other.

METHOD

This qualitative study adopted Symbolic Interactionism, whose area of study is the interaction between people. Interaction between people is considered to trigger a dynamic process of individual and social change that permits the transmission of something from one person to another who perceives, interprets, and acts again. Interaction between people is an internal and external event: occurring within oneself and through interaction with another, mediated by meanings attributed by the individual. Meanings are attributed by the individual from the view that defines the world for the individual and interact within the individual (inner interactions) that lead to actions with other individuals (outer interactions). It leads to the concept of perspective, which is inherent in the interaction and shared by it. This perspective is defined through several roles played by the individual and by many other people with whom s/he interacts; it enables many "points of view". In interacting with others, people make themselves understood when they are capable of playing the other's role. When one sees things from the perspective of the other, one is capable of transmitting the meaning of his/her action and sharing common meanings, when such meanings are important to all those involved in the interaction.

Grounded Theory was chosen as the methodological framework because it allows comprehending the individual's experience in relation to the studied phenomenon through human interactions, symbolic exchanges and meanings for the interaction, which enables the construction of theories about the object "based on investigated data, instead of testing an already existing theory"⁽⁸⁾. Grounded theory can generate theoretical concepts capable of interpreting action in its context from the perspective of the participants.

The following inclusion criteria were used: women with any kind of mental disorder for more than one year, who had at least one 7-12 year-old child and who were being cared for in a public mental health outpatient clinic in Ribeirão Preto, SP, Brazil, resident in this city, more specifically in the North district. We considered that the different backgrounds of the different types of mental disorders of this group allowed collecting data capable of depicting the complexity of the studied phenomenon. As for the number of participants, we decided that as data were analyzed, we would obtain the number of participants that corresponded to the richness and valorizations of singular aspects of the study object due to the saturation effect. The final number of participants of this study was ten.

After cases were selected through patients' files, these were telephoned or personally contacted, informed about the study and invited to participate in the study. After individuals' agreement, a time was scheduled, generally on the weekends, according to the interviewee's availability, and the researcher visited them at their homes. This procedure allowed optimizing data collection because only the researcher had to move and it also facilitated scheduling a meeting with the participants and meeting them at their home, many times while they were carrying out household tasks.

Interviews lasted an average of 40 minutes and were recorded and transcribed after free and informed consent was obtained from the interviewees. A semi-structured interview script was developed and improved through a pilot test, in which issues related to mental disorder, motherhood and social support were addressed.

After the transcriptions of interviews, Grounded Theory guided data analysis. Data were divided into smaller units, called incidents, then conceptualized and related among the incidents. In open coding, the first phase of analysis, incidents were coded and compared so they could be categorized using the data's own language. Subcategories formed a larger scope of information from connections made between open codes, which constituted axial coding based on the phenomenon questioning: the causes of the phenomenon occurrence; context in which it happened; what participants did when it happened (strategies); what facilitated or hindered actions related to the phenomenon (intervenient conditions) and the consequences of such actions⁽⁸⁾.

This new grouping permitted the establishment of new relations that formed a set of more abstracted and comprehensive categories, capable of being identified in the codes we sought to represent. Finally, we reached selective coding, which was the base for obtaining the central category with which all the remaining categories are related and it was at that point when a theory concerning the obtained data emerged⁽⁸⁾.

ETHICAL ASPECTS

In order to meet the 4^th item of Resolution No. 196/96 of the National Health Council, authorizations were asked from the institutions where the study, including the pilot test, was going to be carried out and from the City Mental Health Coordination and the City Health Secretary. Afterwards, the study was submitted to the Research Ethics Committee at the University of São Paulo, College of Nursing at Ribeirão Preto (EERP-USP, Protocol No. 554/2005). According to recommendations, all participants signed the free and informed consent agreement.

RESULTS

Participants were on average 34 years old, had completed secondary school, had an average of three children, 70% were in a stable union (including those officially married and cohabitating), 50% had a paid job and the remaining were either housewives or were on sick leave (receiving a government benefit). Participants were under treatment for an average of three and a half years and diagnoses were predominantly for affective and neurotic disorders (F30, F40) in addition to some comorbidities.

Central category: "perceiving oneself in such a way as to keep fighting"

[...] to not go back there (to the initial stage of mental disorder - author's note), you have to hang on, you know? It's like, you have to look in the mirror and be able to see yourself. You have to see yourself regardless of everything else, not only your image, but I guess that it's the whole you so you can keep fighting, on your feet (Mother 1).

Interviewees' accounts reported trajectories of life somewhat similar, among them unexpectedly becoming a mother, resulting in mental suffering. These women generally showed more vulnerability to life events that generate crisis related to human development, which consequently lead to the development of new social roles.

According to the narratives of these women, the phenomenon that guided their experiences was expressed as "perceiving oneself in such a way as to keep fighting" and, while in this state of mind, they had no explanation for the mental disorder they were affected with - and this element was part of the context in which such phenomenon occurred. How they evaluated the bond they had with health services and health professionals also composed part of their disorder's background, because these were sources of information and clarification, or even greater disorientation, in relation to their new life marked by the mental disorder.

The experience they had with help provided by their husbands, who would provide it or not, was also another element present in their experience. Their help, when they provided it, could be a source of stress because these women were highly demanding of themselves and consequently, of others, in relation to household tasks.

The context of this phenomenon was complemented by their perception of family support, which represented a recollection of emotional pain, experienced during childhood, or support according to what family members were able to provide.

Amid this reality, as a causal condition of the central phenomenon, was their own experience of becoming sick, the search for an explanation for the factors that predispose the emergence of a mental disorder, and also, of the factors that trigger such a disorder, which encouraged them to persist in their search to see themselves as continuing to fight.

Strongly associated with this attitude of keeping fighting is the category wishing to be able to do everything, which emerged when they did not accept help or even perceive they needed it.

Another causal element of this phenomenon was conflicts in the marital relationship, since some of them reported experiences that greatly wore down their relationship, culminating in violent breakups (physical and emotional) or, tumultuous experiences amid manifestations of the mental disorder and its consequences.

Experiencing motherhood also emerged as a causal factor, because it assumed a series of representations, which reinforced social expectations and meanings of motherhood, which they were unable to comply with. Consequently such expectations became a burden - the burden of motherhood. With regard to this category, the participants shared the common fact of having experienced at least one unplanned pregnancy, an experience associated with the urgent need to face and exercise motherhood.

These mothers with mental disorders had to use strategies to cope with this phenomenon so they would be able to keep fighting their disease despite the roles they were supposed to play and the need to see themselves in the context in which they were inserted while having to deal with the above causal factors.

Thus, they started coping with their mental disorders and found themselves between adhering to and abandoning treatment, revealing a pattern of accepting and abandoning health services. As they improved their knowledge of themselves, they also developed the capability of knowing the course of their lives, associating personal events with crises or moments when their conditions worsened. At this point, they understood the course of their mental disorders.

Another resource emerged in seeking to deal with the phenomenon, having other sources of support, due to which these women could dedicate a little more time to themselves. They could count on neighbors to babysit their children and so attend medical appointments or have the support of professionals (such as psychologists) who helped them to understand the spectrum of their children's development and also themselves in relation to their disorders.

They also sought to include their occupation in the context of their mental disorders, because they saw it as a resource to which they could hang on and thus feel better. However, their jobs and difficulties remaining in them indicated the severity of the mental disorders.

There were conditions that interfered in the actions employed as strategies to cope with the phenomenon and which were not under the participants' control such as the repercussions of the mental disorder in their daily routines, and they realized how the manifestations of their mental disorder interfered in their daily activities and relationships. In this way, the participants ended up feeling vulnerable to the impact of their mental disorders, fearing new crises and/or living with despair that arose from suicide attempts.

Additionally, as an intervenient factor, and which reflected on actions taken in relation to the phenomenon of trying to find themselves in an individual and daily struggle, was the condition in which they perceived the stigma associated with their mental disorders. From this perspective, they faced the stigma and a lack of comprehension from people close to them, such as their children, partner and neighbors. These conditions greatly affected the phenomenon itself, because these hindered their coping strategies.

Strategies adopted to deal with the phenomenon presented as the central category led to further potential consequences, affecting the condition such that the mental disorder reflected on their children These mothers perceived that their condition interfered with their children' resources when they had to deal with unexpected situations.

A consequence they expected of their actions was simply to be able to lead their lives, and be willing to live with changes caused by the disorder in addition to developing ways to deal with prejudice against those who are affected by a mental disorder.

We observed that the phenomenon was permeated by the presented elements in the mothers' movement of trying to see themselves (amid external and internal demands) so they could keep fighting - as the identified central phenomenon, which reflected motherhood experienced as mental disorder patients.

DISCUSSION

Data analysis enables reaching the conclusion that motherhood for women with mental disorders demands that they mobilize the internal resources they have so as to reconstruct their identity in the context of their lives. Motherhood as a phenomenon of life gathers meanings and values that are subordinate to the acquisition and attribution of functions and expectations that fall on women and which exert an important impact on the dynamics of personal and family life.

In this regard, motherhood, as a women's ideal, is a social construction based on biological aspects^(4,9) and which, even in these times, find echoes to reinforce the role of women as caregivers and responsible for taking care of home. These ideas are also identified in the reports of mothers with mental disorders, who point to motherhood as a "standard" of adult life, that is, it ensures them the realization of a social expectation related to the female gender^(10-11).

We verified that the participants most emphatically verbalized the difficulties they experienced in a broad sense (in their relationships with family, with their partners, with daily routines permeated mental disorder). When they addressed motherhood they tended to reproduce stereotyped views as can be perceived by the "wishing to be able to do everything", though they also added the "burden of motherhood". Due to the stigma associated with mental disorder, motherhood for these women led them to question themselves and society regarding their ability to perform the roles they were supposed to play⁽¹⁰⁾, seeking to understand to what extent they dealt with stress caused by the symptoms of their disorder or the difficulties of the mother-child relationship.

According to the concept of parenting⁽⁶⁾, the ability to exert the maternal role is also based on sources of stress and support present in the genitor's context of life, which include: marriage, social network and occupation.

These women included their partners in their reports in the context in which the phenomenon occurred, with the factor "type of help provided by the husband", which assumed a binary possibility: occur or not occur. When the partner actively assumed care, he would perform house tasks no longer performed by the mental disorder patient and also provide what was necessary to maintain the house and family members.

There were cases in which the mental disorder precipitated the end of an already fragile marital union, and the disease was the excuse needed to consummate its rupture. In this context, the family of origin became more supportive, delivering care and giving support which these mothers counted on to have a minimum level of organization in their routine and home. The family and the informal support network such as neighbors represent an important instrument for strengthening and delivering care in these conditions given the restrictions presented by health services and, in a larger sphere, by the limited capacity of public policies to adequately meet these demands^(12-13).

As one of the elements that constitute parenting, in relation to the remaining factors mentioned earlier, internal resources and the mother's life history provide data about how maternal roles will be developed.

The participants' reports revealed that the experience of an unplanned pregnancy was concomitant with the disease manifestations or even aggravated them, indicating that an unplanned pregnancy and its recurrence are notable as destabilizing situations in the interviewed mothers' individual and family dynamics. Additionally, women become more susceptible to the development of mental disorders during the puerperal period due to the effects of hormonal actions triggered by pregnancy^(14-15).

The conclusion is that the mothers who participated in this study, their reports about their trajectories and how they have tried to rescue themselves amid these events, denote the need they have to recognize and see themselves in their maternal role so they can keep fighting the limitations imposed by the mental disorder.

This is a specific reality and at the same time common to so many other women. Specific because it addressees a subject little explored in Brazilian scientific articles, but not less important - given its preventive potential for care related to mental health.

The study also points to the need to adapt mental health services in the face of this demand, so these women see themselves beyond their condition as mental disorder patients.

FINAL CONSIDERATIONS

We can assert that the inclusion of gender issues in the mental health field will enable more adequate care delivery given that the sick individual - here generically speaking - primarily is a man or a woman, on whom rest expectations and social attributions that are part of the elements affecting the health-disease process. In this way, addressing these issues for women's mental health and motherhood under the methodological framework used in this study contributes to other studies published in this periodical toward the enlargement of knowledge, whether in the mental health field or in terms of strategies of scientific research, which can be used in qualitative studies^(8,15).

Recebido em: 16.7.2008

Aprovado em: 28.7.2009

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Publication Dates

• Publication in this collection
  30 Nov 2009
• Date of issue
  Oct 2009

History

• Accepted
  28 July 2009
• Received
  16 July 2008