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Mental health problems in women attending district-level services in South Africa
ARTICLE IN PRESS
Social Science & Medicine 63 (2006) 587–592 www.elsevier.com/locate/socscimed
Mental health problems in women attending district-level services in South Africa Anthony L. Pillay, Anita J. Kriel Department of Behavioural Medicine, Midlands Hospital and University of Kwazulu-Natal, Pietermaritzburg, Kwazulu-Natal, South Africa Available online 14 March 2006
Abstract Various sociodemographic and clinical variables pertaining to women using district-level clinical psychology services in Pietermaritzburg, South Africa were examined. During the year 2004, a total of 422 women accessed this service. Over one-third had relationship problems, 21% depression, and 14% suicidal behaviour. Nearly half the women reported significant financial problems. Of the 174 married (or cohabiting) women, 94.8% experienced relationship problems, 56.9% reported substanceabusing partners, and 48.3% reported violent partners, and 51.1% perceived their partners as disengaged while 37% viewed them as oppressive. Clinician estimates revealed notably low self-esteem in 65% of the women. We conclude that mental health services and training programmes need to become more cognisant of gender issues to develop gender-sensitive interventions. r 2006 Elsevier Ltd. All rights reserved. Keywords: Women’s mental health; Mental health services; Domestic violence; Marital problems; Depression; South Africa; Gender
Introduction Psychological services around the world are accessed more by women than men, a phenomenon that is probably more related to gender differences in help-seeking behaviour, than psychopathology prevalence (World Health Organisation, 2001). Recent South African research at a semi-rural primary health care facility showed that women over the age of 30 years constituted 86.1% of patients attending psychological consultations (Petersen, 2004). Another South African investigation at an urban psychological service revealed that almost 70% of attenders over the age of 18 years were women (Seedat, Kruger, & Bode, 2003). Corresponding author. Tel.: +27 33 3454221; fax: +27 33 3455730. E-mail address: [email protected] (A.L. Pillay).
0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.01.031
Reports from elsewhere in the world show a similar trend in the gender distribution of individuals seeking psychological care (World Health Organisation, 2001). With this type of patient profile at mental health facilities, it is critical that service providers and planners examine whether they are positioning themselves to meet the needs of the women seeking help. Although historically mental health services have not had a reputation for gender-sensitive practices, this must be urgently addressed, through firstly an examination of the needs of women presenting at the community or district-level mental health services. Domestic and intimate partner violence is an example of a very serious problem affecting women in South Africa, and reliable statistics are difficult to obtain due to the under-reporting that characterises this phenomenon. Dissel and Ngubeni (2003) point out that there are many actions that constitute
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domestic violence, but which are not defined as domestic violence in the South African legal system, and as a result are not counted in the final tally. Also, recent research has confirmed that women with violent or controlling male partners are at increased risk of HIV infection, related of course to the lifestyles of their aggressive male partners (Dunkle et al., 2004). The under-reporting of sexual violence and coercive sex against women has been emphasised as well in the local context, with research implicating the gender power inequality in society as a major contributing factor (Jewkes, 2000). Previous research in the Msunduzi area found violence and substance abuse by partners as precipitants to women’s nonfatal suicidal behaviours (Pillay, Van der Veen, & Wassenaar, 2001). It is therefore important to assess the need for mental health services targeting this issue (Kimerling & Baumrind, 2005b). Another issue of note is the race distribution of women accessing mental health services, considering South Africa’s socio-political history, which comprised discriminate and disparate services by race. Following a decade of democracy it is important to determine whether service provision and utilisation patterns are more equitable. A recent study in the United States found that African-American, Hispanic, and Asian women were significantly less likely to use mental health services than white women (Kimerling & Baumrind, 2005a). To this end the authors sought to investigate the socio-demographic and clinical variables relating to women using district-level clinical psychology services. The rationale for the study was to identify the needs of women attending these centres. The major research questions were as follows: (a) what is the socio-demographic profile of women attending district-level clinical psychology services, and (b) what is the mental health profile of these women, especially in terms of violence and substance abusing partners. While there are numerous important areas of questioning that could be included in this study, the modest nature and size of this investigation limited the number of variables that could be examined. Background to the investigation The investigation was conducted within the Msunduzi (Pietermaritzburg) municipality, 80 km off the east coast of South Africa. The city has a population of 553 223 of whom 176 379 (31.9%) are
women over the age of 21 years (Statistics South Africa, 2005a). The area has a history of government clinical psychology service provision of around 30 years, most of which was a racially based service during the apartheid era. In the early years the service was located in a psychiatric hospital, with clinical psychologists increasingly providing care at community mental health clinics, general hospitals, and primary health care centres since the mid-1980s. The municipality has two large tertiary psychiatric hospitals and a tertiary level general hospital, all of which provide specialised levels of care, in keeping with the national health policy. District-level clinical psychology services are provided at six community mental health clinics, two district general hospitals and one primary health care centre. Although socio-economic status is not specifically assessed in this study, attenders at these government mental health facilities are generally of low socio-economic status. Method Subjects The subjects included all women over the age of 21 years attending district-level clinical psychology services within the Msunduzi municipality over the year ending 31 December 2004. A minimum age of 21 years was used as an inclusion criterion since that is the age of majority in South Africa. The nine service points detailed above constituted the study sites. Women accessing private practitioners and tertiary level government clinical psychology services were excluded from this study. The rationale for this was to examine the socio-demographic and clinical variables surrounding the use of basic level government clinical psychology services by women from low socio-economic backgrounds. Instrument The instrument was designed as a brief checklist to be completed by the patient’s attending clinical psychologist following the intake interview. This data collection sheet did not require the subject’s name, but recorded the following details for each female patient: age, referral source, race1, educa1 Race was recorded solely to understand how communities differentially affected by apartheid are accessing the mental health services, considering the previous inequity in service
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tion, employment status, marital status, number of children, presenting problem, the presence of marital/relational problems, financial problems, substance abuse by patient or partner, violence by partner, partner’s response to patient (i.e. oppressive, disengaged, supportive, or enmeshed), and patient’s self-esteem (low or adequate). The latter two variables were based on the clinician’s assessment, following the intake interview. ‘‘Partner’s response’’ meant the patient’s perception of the way the partner related to her. In other words, was the partner perceived as oppressive (authoritarian or controlling), disengaged (uninvolved), supportive (caring or concerned) or enmeshed (over-involved)? Regarding patient’s self-esteem, the attending clinical psychologist was requested to give her/his clinical impression, using a simple distinction between ‘‘low’’ and ‘‘adequate’’ self-esteem, based on how the patient presented in the first session. While this is a rather crude assessment, the clinical assessment of self-esteem (particularly the dichotomy between ‘‘low’’ and ‘‘adequate’’) is a simple process for a trained clinical psychologist. Nevertheless, it represents a meaningful mental health status indicator. Clinicians were requested to make these judgements purely on the clinical impression gained from the standard first interviews, which usually address all the variables covered in the present study. They were not requested to ask any questions specifically for the research or to deviate from their standard interview structure for the purpose of the research. In this study, marital problems, financial problems, substance abuse by patient or partner and violence by partner were deemed problems when patients specifically reported these as sources of distress during the standard initial interview. Of course, these are subjective reports, and it is expected that self-reports of substance abuse are likely to be minimised. However, patients’ reports of marital problems, and substance abusing and violent partners as a source of distress do need to be taken seriously. The patient’s presenting problem is usually obtained in one of two ways during the standard interview: it is stated in the referral letter, and it is asked in the initial part of the interview by the attending clinical psychologist. The data collection sheet provided no prescribed options for this (footnote continued) provision. The authors oppose race classification and the divisions they create.
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variable, allowing the psychologist to note exactly what was reported. The researchers performed a post hoc grouping of the presenting problems into the broad categories reflected in the results section. Procedure All clinical psychologists staffing the study sites were informed of the investigation, and given instructions regarding the completion of data collection sheets for each patient meeting the inclusion criteria. The instrument was anonymous and only the data of patients agreeable to providing information were entered into the study. Extremely few (i.e. less than 20) patients withheld consent to participate. No individual other than the attending psychologist could link the data collection sheet to the specific patient. Results During the study period, 422 women accessed the district-level clinical psychology service. The mean age was 36.1 years, with a range between 21 and 65 years. The race distribution was as follows, with the Msunduzi population distribution for women over 21 years given in parentheses: 38.6% Black African (74.1%), 31.8% Indian (12.6%), 16.4% White (9.9%), and 11.8% Coloured (3.4%). (The terminology1 employed by Statistics South Africa (2005a) is used). One-fifth of the women (20.2%) had either no formal education or only primary schooling. Married/cohabiting women constituted 41.2% of the subjects, while 35.5% of the women were single. The educational and marital proportions are consistent with national statistics (Statistics South Africa, 2002). Three-quarters of the women had children (75.5%), with 9.3% having more than three children. Women seen at the two district general hospitals constituted 58.1% of the sample, while all but 2.8% of the rest were seen at the community mental health clinics. Medical practitioners referred 49.5%, while 27.3% were self-referred, and nurses referred 11.6%. Table 1 shows the presenting or referral problems. Only 29.6% of the women were employed, and 45% reported experiencing significant financial problems. Of the 174 married/cohabiting women 165 (94.8%) reported relationship problems. Almost half (48.3%) the married/cohabiting women disclosed experiencing violent abuse from their
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Table 1 Presenting problems as reported by women or referral agents
Relationship problems Depression Suicidal Bereavement Anxiety Financial problems/unemployed Parenting difficulties Sexual abuse Terminal illness Somatoform disorder Mental retardation Assault
n
%
146 91 73 55 40 25 20 18 17 14 10 5
34.6 21.6 17.3 13.0 9.5 5.9 4.7 4.3 4.0 3.3 2.4 1.2
Some patients were referred with more than one presenting problem.
partners, and 56.9% reported high levels of substance use by their partners. Substance abuse by the women was noted in 8.8% of the total sample. Over half (51.1%) of the married/cohabiting women viewed their partners as disengaged, while 37.4% perceived their partners as oppressive. Clinician estimates of self-esteem indicated that 65% (223) of the women had significantly low selfesteem. There were no significant differences between self-referred and health professional-referred women on the following variables: marital status (w2 ¼ 0:93); relationship problems as a presenting problem (w2 ¼ 0:37); spousal substance abuse (w2 ¼ 0:03), patient’s substance abuse (w2 ¼ 3:11), violent spouse (w2 ¼ 0:23) and patients self-esteem (w2 ¼ 0:66). Discussion While the sample may appear relatively small, it must be remembered that it excludes the women consulting the three tertiary level clinical psychology services and over 65 psychologists in private practice in the area. Considering very few patients declined to participate in the study, the race distribution of the sample reflects the service utilisation trend in the area. The under-representation of Black African women attending district clinical psychology services may be explained in several ways. Firstly, women in this community have historically had little or no access to clinical psychology services, and as a result may still be unaware of their role and
means of access. Secondly, Black African women’s awareness of mental health problems may be less than those of other women, given the considerable educational and social disadvantages they experienced in South Africa’s apartheid history. Thirdly, the preference to consult indigenous healers is also a factor, considering communities with limited access to modern health care rely more on traditional healing practices (Mkhize, 2004). The finding that just over half the women were seen at the two district hospitals may be due to (i) the stigma-related preference to seek mental health care at a general hospital rather than a specialised mental health clinic, and (ii) the fact that almost half the women were referred by medical practitioners. It is noteworthy that over one-third of the women presented due to relationship problems, which had obviously been severe enough to warrant professional attention. Of course, ‘relationship problems’ include a wide range of interpersonal issues ranging from verbal disagreements to violence (see below) between intimate partners. Women in these situations need psychosocial intervention, especially considering the gendered power dynamics in relationships (De la Rey, 2001). Considering the serious consequences of relational conflict for women, for example the high rate of suicidal behaviour (Pillay et al., 2001), it is important that health facilities are able to offer appropriate intervention. The relatively high rates of depressive and suicidal presentations in the sample are consistent with international data (Patel, Araya, de Lima, Ludermir, & Todd, 1999). The American Psychiatric Association (2000) cited a lifetime risk of up to 25% for major depressive disorder in women. Considering the treatability of depressive illness, early identification is important since treatment can prevent suicidal behaviour (Rutz, Knorring, & Walinder, 1995). The finding in the present sample that one in six women (17. 3%) presented with suicidal behaviour is of concern. While considerable work has been done on interventions and compliance with treatment in the Msunduzi area (Pillay, Wassenaar, & Kramers, 2004) the prevention of suicidal behaviour remains a priority (World Health Organisation, 2001). The finding that 13% of women in the sample presented with bereavement issues should be viewed within the context of the HIV/AIDS pandemic sweeping the country, even though the present investigation did not establish the cause of death of the women’s significant other.
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Almost one in ten women accessing the district clinical psychology services presented with anxiety spectrum disorders. This must be viewed in the context of the World Health Report 2001, which noted that anxiety and depressive disorders are more commonly diagnosed in women than men, with the trend being evident in both high- and low-income countries (World Health Organisation, 2001). The findings relating to the high rate of women not employed and experiencing significant financial problems should be understood in the context of the high unemployment rate prevalent in South Africa, where the rate for Back women is more than seven times that for White males (Statistics South Africa, 2005b). Cross-national research also confirms that mental health problems are more common in poorer communities than in wealthier ones (Patel et al., 1999). That almost 95% of the women who were married (or living with a partner) reported having relational conflict is of concern. Of course, the fact that affected women are seeking professional help is encouraging. The further finding that almost half the married/cohabiting women reported suffering violent abuse from their partners is worrying, and must be viewed against the high incidence of intimate-partner violence in many parts of the world. The fact that the women sought professional assistance raises the issue of the extent to which mental health personnel are equipped to render appropriate assistance, considering traditional training models offer little input in this area (Lawson 2003; Wilson & Strebel, 2004). In this context calls are being made for a review of curricula and content in training programmes (Ahmed & Pillay, 2004). Women attending district-level clinical psychology services need crisis intervention, support and empowerment (including knowledge about their rights, the legal and socialwelfare systems, and access to related help agencies) more than any form of traditional psychotherapy. Over half the married/cohabiting women reported that their partners abused substances. Although this reflects subjective reports, it indicates the extent to which the women are distressed by their partners’ substance use, which is also a serious public health problem (World Health Organisation, 2004). Substance abuse in men has also been shown to feature strongly as a risk factor for suicidal behaviour in their partners (Pillay et al., 2001). Again, the role that clinical psychologists need to play in these consultations needs careful consideration, since affected women need specific types of
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interventions and information on how to deal with their partners’ behaviours. The finding that less than 10% of the women reported a substance abuse problem must be viewed cautiously given the subjective reporting, but should also be seen within the context of generally lower rates among women compared to men (World Health Organisation, 2004). That over half the married/cohabiting) women had viewed their partners as disengaged and over one-third as oppressive are indicative of the way they viewed their positions in the relationships. Almost 90% of the women in intimate relationships felt unsupported by their partners, with many feeling they were treated as less than equal in the relationships. Such situations are destructive to women’s mental health, and must be challenged at a societal level, since social change can only be achieved when women are able to question the societal structures that sustain oppression (Kiguwa, 2004). Clinician estimates revealed that almost twothirds of the women had notably low self-esteem. This is not surprising considering the association between mental health problems and low selfesteem, as well as the contexts of abuse, relational problems, unemployment and financial problems affecting many of the women. Of course, self-esteem issues in women seeking mental health attention must also be understood against the backdrop of broader societal issues such as power and control, which are central in the social construction of gender relations (Boonzaier & de la Rey, 2004). Conclusion The findings of this investigation are somewhat encouraging in the sense that women of all cultural groups were using the district-level clinical psychology services, especially considering that access was historically more difficult for Black African women. However, the extent of women abuse among those seeking mental health care is of concern. The development of gender-sensitive interventions is essential if we are to appropriately assist those seeking mental health care. It is also critical that mental health services and training programmes become more cognisant of gender issues, and reorientate themselves to meet the current mental health demands (Ahmed & Pillay, 2004). Specific training, for example, on dealing with intimate partner violence and empowering women would go
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a long way in equipping students of mental health to respond more confidently to the common problems they are likely to face. Acknowledgement The authors are grateful to their clinical psychologist colleagues in the Midlands Hospital Complex for their assistance in the data collection. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.—text revision). Washington, DC: Author. Ahmed, R., & Pillay, A. L. (2004). Reviewing clinical psychology training in the post-apartheid period: Have we made any progress? South African Journal of Psychology, 34, 630–656. Boonzaier, F., & de la Rey, C. (2004). Woman abuse: The construction of gender in women and men’s narratives of violence. South African Journal of Psychology, 34, 443–463. De la Rey, C. (2001). Consciousness-raising groups as an intervention strategy against gender oppression. In M. Seedat, N. Duncan, & S. Lazarus (Eds.), Community psychology: Theory, method and practice (pp. 309–323). Cape Town: Oxford University Press. Dissel, A., & Ngubeni, K. (2003). Giving women their voice: Domestic violence and restorative justice in South Africa. In Paper presented at the XIth international symposium on victimology, Stellenbosch, South Africa, July 2003. www.csvr.org.za/papers/papadk3.htm (accessed 16 January 2006). Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D. (2004). Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet, 363, 1415–1421. Jewkes, R. (2000). MRC News, October 2000: Report on rape. www.mrc.ac.za/mrcnews/oct2000/rapereport.htm; Accessed 16 January 2006. Kiguwa, P. (2004). Feminist critical psychology in South Africa. In D. Hook (Ed.), Critical psychology (pp. 278–315). Cape Town: University of Cape Town Press. Kimerling, R., & Baumrind, N. (2005a). Access to specialty mental health services among women in California. Psychiatric Services, 56, 729–734.
Kimerling, R., & Baumrind, N. (2005b). Intimate partner violence and welfare utilization among California women. www.dhs.ca.gov/director/owh/owh_main/cwhs/ cwhs%20symp/research_papers/a_kimerling.pdf; Accessed 07 November 2005. Lawson, D. M. (2003). Incidence, explanations, and treatment of partner violence. Journal of Counseling and Development, 81, 19–32. Mkhize, N. (2004). Psychology: An African perspective. In D. Hook (Ed.), Critical psychology (pp. 24–52). Cape Town: University of Cape Town Press. Patel, V., Araya, R., de Lima, M., Ludermir, A., & Todd, C. (1999). Women, poverty and common mental disorders in four restructuring societies. Social Science & Medicine, 49, 1461–1471. Petersen, I. (2004). Primary level psychological services in South Africa. Health Policy and Planning, 19, 33–40. Pillay, A. L., Van der Veen, M. B. W., & Wassenaar, D. R. (2001). Non-fatal suicidal behaviour in women: The role of spousal substance abuse and marital violence. South African Medical Journal, 91, 429–432. Pillay, A. L., Wassenaar, D. R., & Kramers, A. L. (2004). Attendance at psychological consultations following non-fatal suicidal behaviour: An ethical dilemma. South African Journal of Psychology, 34(3), 350–363. Rutz, W., Knorring, L., & Walinder, J. (1995). Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatrica Scandinavica, 85, 83–88. Seedat, M., Kruger, P., & Bode, B. (2003). Analysis of records from an urban African psychological service: Suggestions for mental health systems research. South African Journal of Psychology, 33(1), 44–51. Statistics South Africa (2005a). Census 2001 by municipality: KZ225 Msunduzi. www.statssa.gov.za/census01/Census/Dialog/Saveshow.asp; Accessed 29 March 2005. Statistics South Africa (2005b) Unemployment: Labour force survey key findings. www.statssa.gov.za/keyindicators/lfs.asp; accessed 6 May 2005. Statistics South Africa (2002). Women and men in South Africa: Five years on. Pretoria: Author. World Health Organisation (2001). The world health report 2001. Geneva: Author. World Health Organisation (2004). Gender in mental health research. Geneva: Author. Wilson, T., & Strebel, A. (2004). Psychiatric discourses of woman abuse. South African Journal of Psychology, 34, 421–442.
Social Science & Medicine 63 (2006) 587–592 www.elsevier.com/locate/socscimed
Mental health problems in women attending district-level services in South Africa Anthony L. Pillay, Anita J. Kriel Department of Behavioural Medicine, Midlands Hospital and University of Kwazulu-Natal, Pietermaritzburg, Kwazulu-Natal, South Africa Available online 14 March 2006
Abstract Various sociodemographic and clinical variables pertaining to women using district-level clinical psychology services in Pietermaritzburg, South Africa were examined. During the year 2004, a total of 422 women accessed this service. Over one-third had relationship problems, 21% depression, and 14% suicidal behaviour. Nearly half the women reported significant financial problems. Of the 174 married (or cohabiting) women, 94.8% experienced relationship problems, 56.9% reported substanceabusing partners, and 48.3% reported violent partners, and 51.1% perceived their partners as disengaged while 37% viewed them as oppressive. Clinician estimates revealed notably low self-esteem in 65% of the women. We conclude that mental health services and training programmes need to become more cognisant of gender issues to develop gender-sensitive interventions. r 2006 Elsevier Ltd. All rights reserved. Keywords: Women’s mental health; Mental health services; Domestic violence; Marital problems; Depression; South Africa; Gender
Introduction Psychological services around the world are accessed more by women than men, a phenomenon that is probably more related to gender differences in help-seeking behaviour, than psychopathology prevalence (World Health Organisation, 2001). Recent South African research at a semi-rural primary health care facility showed that women over the age of 30 years constituted 86.1% of patients attending psychological consultations (Petersen, 2004). Another South African investigation at an urban psychological service revealed that almost 70% of attenders over the age of 18 years were women (Seedat, Kruger, & Bode, 2003). Corresponding author. Tel.: +27 33 3454221; fax: +27 33 3455730. E-mail address: [email protected] (A.L. Pillay).
0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.01.031
Reports from elsewhere in the world show a similar trend in the gender distribution of individuals seeking psychological care (World Health Organisation, 2001). With this type of patient profile at mental health facilities, it is critical that service providers and planners examine whether they are positioning themselves to meet the needs of the women seeking help. Although historically mental health services have not had a reputation for gender-sensitive practices, this must be urgently addressed, through firstly an examination of the needs of women presenting at the community or district-level mental health services. Domestic and intimate partner violence is an example of a very serious problem affecting women in South Africa, and reliable statistics are difficult to obtain due to the under-reporting that characterises this phenomenon. Dissel and Ngubeni (2003) point out that there are many actions that constitute
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domestic violence, but which are not defined as domestic violence in the South African legal system, and as a result are not counted in the final tally. Also, recent research has confirmed that women with violent or controlling male partners are at increased risk of HIV infection, related of course to the lifestyles of their aggressive male partners (Dunkle et al., 2004). The under-reporting of sexual violence and coercive sex against women has been emphasised as well in the local context, with research implicating the gender power inequality in society as a major contributing factor (Jewkes, 2000). Previous research in the Msunduzi area found violence and substance abuse by partners as precipitants to women’s nonfatal suicidal behaviours (Pillay, Van der Veen, & Wassenaar, 2001). It is therefore important to assess the need for mental health services targeting this issue (Kimerling & Baumrind, 2005b). Another issue of note is the race distribution of women accessing mental health services, considering South Africa’s socio-political history, which comprised discriminate and disparate services by race. Following a decade of democracy it is important to determine whether service provision and utilisation patterns are more equitable. A recent study in the United States found that African-American, Hispanic, and Asian women were significantly less likely to use mental health services than white women (Kimerling & Baumrind, 2005a). To this end the authors sought to investigate the socio-demographic and clinical variables relating to women using district-level clinical psychology services. The rationale for the study was to identify the needs of women attending these centres. The major research questions were as follows: (a) what is the socio-demographic profile of women attending district-level clinical psychology services, and (b) what is the mental health profile of these women, especially in terms of violence and substance abusing partners. While there are numerous important areas of questioning that could be included in this study, the modest nature and size of this investigation limited the number of variables that could be examined. Background to the investigation The investigation was conducted within the Msunduzi (Pietermaritzburg) municipality, 80 km off the east coast of South Africa. The city has a population of 553 223 of whom 176 379 (31.9%) are
women over the age of 21 years (Statistics South Africa, 2005a). The area has a history of government clinical psychology service provision of around 30 years, most of which was a racially based service during the apartheid era. In the early years the service was located in a psychiatric hospital, with clinical psychologists increasingly providing care at community mental health clinics, general hospitals, and primary health care centres since the mid-1980s. The municipality has two large tertiary psychiatric hospitals and a tertiary level general hospital, all of which provide specialised levels of care, in keeping with the national health policy. District-level clinical psychology services are provided at six community mental health clinics, two district general hospitals and one primary health care centre. Although socio-economic status is not specifically assessed in this study, attenders at these government mental health facilities are generally of low socio-economic status. Method Subjects The subjects included all women over the age of 21 years attending district-level clinical psychology services within the Msunduzi municipality over the year ending 31 December 2004. A minimum age of 21 years was used as an inclusion criterion since that is the age of majority in South Africa. The nine service points detailed above constituted the study sites. Women accessing private practitioners and tertiary level government clinical psychology services were excluded from this study. The rationale for this was to examine the socio-demographic and clinical variables surrounding the use of basic level government clinical psychology services by women from low socio-economic backgrounds. Instrument The instrument was designed as a brief checklist to be completed by the patient’s attending clinical psychologist following the intake interview. This data collection sheet did not require the subject’s name, but recorded the following details for each female patient: age, referral source, race1, educa1 Race was recorded solely to understand how communities differentially affected by apartheid are accessing the mental health services, considering the previous inequity in service
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tion, employment status, marital status, number of children, presenting problem, the presence of marital/relational problems, financial problems, substance abuse by patient or partner, violence by partner, partner’s response to patient (i.e. oppressive, disengaged, supportive, or enmeshed), and patient’s self-esteem (low or adequate). The latter two variables were based on the clinician’s assessment, following the intake interview. ‘‘Partner’s response’’ meant the patient’s perception of the way the partner related to her. In other words, was the partner perceived as oppressive (authoritarian or controlling), disengaged (uninvolved), supportive (caring or concerned) or enmeshed (over-involved)? Regarding patient’s self-esteem, the attending clinical psychologist was requested to give her/his clinical impression, using a simple distinction between ‘‘low’’ and ‘‘adequate’’ self-esteem, based on how the patient presented in the first session. While this is a rather crude assessment, the clinical assessment of self-esteem (particularly the dichotomy between ‘‘low’’ and ‘‘adequate’’) is a simple process for a trained clinical psychologist. Nevertheless, it represents a meaningful mental health status indicator. Clinicians were requested to make these judgements purely on the clinical impression gained from the standard first interviews, which usually address all the variables covered in the present study. They were not requested to ask any questions specifically for the research or to deviate from their standard interview structure for the purpose of the research. In this study, marital problems, financial problems, substance abuse by patient or partner and violence by partner were deemed problems when patients specifically reported these as sources of distress during the standard initial interview. Of course, these are subjective reports, and it is expected that self-reports of substance abuse are likely to be minimised. However, patients’ reports of marital problems, and substance abusing and violent partners as a source of distress do need to be taken seriously. The patient’s presenting problem is usually obtained in one of two ways during the standard interview: it is stated in the referral letter, and it is asked in the initial part of the interview by the attending clinical psychologist. The data collection sheet provided no prescribed options for this (footnote continued) provision. The authors oppose race classification and the divisions they create.
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variable, allowing the psychologist to note exactly what was reported. The researchers performed a post hoc grouping of the presenting problems into the broad categories reflected in the results section. Procedure All clinical psychologists staffing the study sites were informed of the investigation, and given instructions regarding the completion of data collection sheets for each patient meeting the inclusion criteria. The instrument was anonymous and only the data of patients agreeable to providing information were entered into the study. Extremely few (i.e. less than 20) patients withheld consent to participate. No individual other than the attending psychologist could link the data collection sheet to the specific patient. Results During the study period, 422 women accessed the district-level clinical psychology service. The mean age was 36.1 years, with a range between 21 and 65 years. The race distribution was as follows, with the Msunduzi population distribution for women over 21 years given in parentheses: 38.6% Black African (74.1%), 31.8% Indian (12.6%), 16.4% White (9.9%), and 11.8% Coloured (3.4%). (The terminology1 employed by Statistics South Africa (2005a) is used). One-fifth of the women (20.2%) had either no formal education or only primary schooling. Married/cohabiting women constituted 41.2% of the subjects, while 35.5% of the women were single. The educational and marital proportions are consistent with national statistics (Statistics South Africa, 2002). Three-quarters of the women had children (75.5%), with 9.3% having more than three children. Women seen at the two district general hospitals constituted 58.1% of the sample, while all but 2.8% of the rest were seen at the community mental health clinics. Medical practitioners referred 49.5%, while 27.3% were self-referred, and nurses referred 11.6%. Table 1 shows the presenting or referral problems. Only 29.6% of the women were employed, and 45% reported experiencing significant financial problems. Of the 174 married/cohabiting women 165 (94.8%) reported relationship problems. Almost half (48.3%) the married/cohabiting women disclosed experiencing violent abuse from their
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Table 1 Presenting problems as reported by women or referral agents
Relationship problems Depression Suicidal Bereavement Anxiety Financial problems/unemployed Parenting difficulties Sexual abuse Terminal illness Somatoform disorder Mental retardation Assault
n
%
146 91 73 55 40 25 20 18 17 14 10 5
34.6 21.6 17.3 13.0 9.5 5.9 4.7 4.3 4.0 3.3 2.4 1.2
Some patients were referred with more than one presenting problem.
partners, and 56.9% reported high levels of substance use by their partners. Substance abuse by the women was noted in 8.8% of the total sample. Over half (51.1%) of the married/cohabiting women viewed their partners as disengaged, while 37.4% perceived their partners as oppressive. Clinician estimates of self-esteem indicated that 65% (223) of the women had significantly low selfesteem. There were no significant differences between self-referred and health professional-referred women on the following variables: marital status (w2 ¼ 0:93); relationship problems as a presenting problem (w2 ¼ 0:37); spousal substance abuse (w2 ¼ 0:03), patient’s substance abuse (w2 ¼ 3:11), violent spouse (w2 ¼ 0:23) and patients self-esteem (w2 ¼ 0:66). Discussion While the sample may appear relatively small, it must be remembered that it excludes the women consulting the three tertiary level clinical psychology services and over 65 psychologists in private practice in the area. Considering very few patients declined to participate in the study, the race distribution of the sample reflects the service utilisation trend in the area. The under-representation of Black African women attending district clinical psychology services may be explained in several ways. Firstly, women in this community have historically had little or no access to clinical psychology services, and as a result may still be unaware of their role and
means of access. Secondly, Black African women’s awareness of mental health problems may be less than those of other women, given the considerable educational and social disadvantages they experienced in South Africa’s apartheid history. Thirdly, the preference to consult indigenous healers is also a factor, considering communities with limited access to modern health care rely more on traditional healing practices (Mkhize, 2004). The finding that just over half the women were seen at the two district hospitals may be due to (i) the stigma-related preference to seek mental health care at a general hospital rather than a specialised mental health clinic, and (ii) the fact that almost half the women were referred by medical practitioners. It is noteworthy that over one-third of the women presented due to relationship problems, which had obviously been severe enough to warrant professional attention. Of course, ‘relationship problems’ include a wide range of interpersonal issues ranging from verbal disagreements to violence (see below) between intimate partners. Women in these situations need psychosocial intervention, especially considering the gendered power dynamics in relationships (De la Rey, 2001). Considering the serious consequences of relational conflict for women, for example the high rate of suicidal behaviour (Pillay et al., 2001), it is important that health facilities are able to offer appropriate intervention. The relatively high rates of depressive and suicidal presentations in the sample are consistent with international data (Patel, Araya, de Lima, Ludermir, & Todd, 1999). The American Psychiatric Association (2000) cited a lifetime risk of up to 25% for major depressive disorder in women. Considering the treatability of depressive illness, early identification is important since treatment can prevent suicidal behaviour (Rutz, Knorring, & Walinder, 1995). The finding in the present sample that one in six women (17. 3%) presented with suicidal behaviour is of concern. While considerable work has been done on interventions and compliance with treatment in the Msunduzi area (Pillay, Wassenaar, & Kramers, 2004) the prevention of suicidal behaviour remains a priority (World Health Organisation, 2001). The finding that 13% of women in the sample presented with bereavement issues should be viewed within the context of the HIV/AIDS pandemic sweeping the country, even though the present investigation did not establish the cause of death of the women’s significant other.
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Almost one in ten women accessing the district clinical psychology services presented with anxiety spectrum disorders. This must be viewed in the context of the World Health Report 2001, which noted that anxiety and depressive disorders are more commonly diagnosed in women than men, with the trend being evident in both high- and low-income countries (World Health Organisation, 2001). The findings relating to the high rate of women not employed and experiencing significant financial problems should be understood in the context of the high unemployment rate prevalent in South Africa, where the rate for Back women is more than seven times that for White males (Statistics South Africa, 2005b). Cross-national research also confirms that mental health problems are more common in poorer communities than in wealthier ones (Patel et al., 1999). That almost 95% of the women who were married (or living with a partner) reported having relational conflict is of concern. Of course, the fact that affected women are seeking professional help is encouraging. The further finding that almost half the married/cohabiting women reported suffering violent abuse from their partners is worrying, and must be viewed against the high incidence of intimate-partner violence in many parts of the world. The fact that the women sought professional assistance raises the issue of the extent to which mental health personnel are equipped to render appropriate assistance, considering traditional training models offer little input in this area (Lawson 2003; Wilson & Strebel, 2004). In this context calls are being made for a review of curricula and content in training programmes (Ahmed & Pillay, 2004). Women attending district-level clinical psychology services need crisis intervention, support and empowerment (including knowledge about their rights, the legal and socialwelfare systems, and access to related help agencies) more than any form of traditional psychotherapy. Over half the married/cohabiting women reported that their partners abused substances. Although this reflects subjective reports, it indicates the extent to which the women are distressed by their partners’ substance use, which is also a serious public health problem (World Health Organisation, 2004). Substance abuse in men has also been shown to feature strongly as a risk factor for suicidal behaviour in their partners (Pillay et al., 2001). Again, the role that clinical psychologists need to play in these consultations needs careful consideration, since affected women need specific types of
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interventions and information on how to deal with their partners’ behaviours. The finding that less than 10% of the women reported a substance abuse problem must be viewed cautiously given the subjective reporting, but should also be seen within the context of generally lower rates among women compared to men (World Health Organisation, 2004). That over half the married/cohabiting) women had viewed their partners as disengaged and over one-third as oppressive are indicative of the way they viewed their positions in the relationships. Almost 90% of the women in intimate relationships felt unsupported by their partners, with many feeling they were treated as less than equal in the relationships. Such situations are destructive to women’s mental health, and must be challenged at a societal level, since social change can only be achieved when women are able to question the societal structures that sustain oppression (Kiguwa, 2004). Clinician estimates revealed that almost twothirds of the women had notably low self-esteem. This is not surprising considering the association between mental health problems and low selfesteem, as well as the contexts of abuse, relational problems, unemployment and financial problems affecting many of the women. Of course, self-esteem issues in women seeking mental health attention must also be understood against the backdrop of broader societal issues such as power and control, which are central in the social construction of gender relations (Boonzaier & de la Rey, 2004). Conclusion The findings of this investigation are somewhat encouraging in the sense that women of all cultural groups were using the district-level clinical psychology services, especially considering that access was historically more difficult for Black African women. However, the extent of women abuse among those seeking mental health care is of concern. The development of gender-sensitive interventions is essential if we are to appropriately assist those seeking mental health care. It is also critical that mental health services and training programmes become more cognisant of gender issues, and reorientate themselves to meet the current mental health demands (Ahmed & Pillay, 2004). Specific training, for example, on dealing with intimate partner violence and empowering women would go
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a long way in equipping students of mental health to respond more confidently to the common problems they are likely to face. Acknowledgement The authors are grateful to their clinical psychologist colleagues in the Midlands Hospital Complex for their assistance in the data collection. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.—text revision). Washington, DC: Author. Ahmed, R., & Pillay, A. L. (2004). Reviewing clinical psychology training in the post-apartheid period: Have we made any progress? South African Journal of Psychology, 34, 630–656. Boonzaier, F., & de la Rey, C. (2004). Woman abuse: The construction of gender in women and men’s narratives of violence. South African Journal of Psychology, 34, 443–463. De la Rey, C. (2001). Consciousness-raising groups as an intervention strategy against gender oppression. In M. Seedat, N. Duncan, & S. Lazarus (Eds.), Community psychology: Theory, method and practice (pp. 309–323). Cape Town: Oxford University Press. Dissel, A., & Ngubeni, K. (2003). Giving women their voice: Domestic violence and restorative justice in South Africa. In Paper presented at the XIth international symposium on victimology, Stellenbosch, South Africa, July 2003. www.csvr.org.za/papers/papadk3.htm (accessed 16 January 2006). Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D. (2004). Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet, 363, 1415–1421. Jewkes, R. (2000). MRC News, October 2000: Report on rape. www.mrc.ac.za/mrcnews/oct2000/rapereport.htm; Accessed 16 January 2006. Kiguwa, P. (2004). Feminist critical psychology in South Africa. In D. Hook (Ed.), Critical psychology (pp. 278–315). Cape Town: University of Cape Town Press. Kimerling, R., & Baumrind, N. (2005a). Access to specialty mental health services among women in California. Psychiatric Services, 56, 729–734.
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