¨ Good mental health is just as important as good physical health.
Just as a woman's body can be healthy or unhealthy, so can her mind and spirit. When her mind and spirit are healthy, she has the emotional strength to take care of her physical needs and those of her family, to identify her problems and attempt to solve them, to plan for the future, and to form satisfying relationships with others.
Almost everyone has difficulty doing these things at times. But if the difficulty continues and keeps a woman from carrying out her daily activities - for example, if she becomes so tense and nervous that she cannot care for her family - she may have a mental health problem. These problems are harder to identify than problems in the body, which we can often see or touch. Yet mental health problems need attention and treatment, just as physical problems do.
This chapter describes the most common mental health problems and their causes. It also offers suggestions for how a woman can help herself or others with these problems.
When a woman feels she makes a valuable contribution to her family and community, she is said to have good self-esteem. A woman with good self-esteem knows that she is worthy of being treated with respect.
Self-esteem begins to develop in childhood. The amount of self-esteem a woman develops depends on how she is treated by the important people in her life - like her parents, brothers and sisters, neighbors, teachers, and spiritual guides. If these people treat her as someone who deserves their attention, if they praise her when she does something well, and if they encourage her to try things that are difficult, she will begin to feel she is valued.
In some cases, girls have a hard time developing good self-esteem. For example, if their brothers are given more education or more food, girls may feel less valued simply because they are girls. If they are criticized a lot or their hard work goes unnoticed, they are more likely to grow up feeling unworthy. Then, as women, they may not believe they deserve to be treated well by their husbands, to eat as much good food as others, to have health care when they are sick, or to develop their skills. When women feel this way, they may even think that their lack of importance in the family and community is natural and right - when, in fact, it is unfair and unjust.
As a child, Malika felt less valued than her brothers. The family thought the boys were important enough to be given an education, but that she was not.
Self-esteem is an important part of good mental health. A woman with good self-esteem will feel more able to cope with (manage) daily problems and better able to work for changes that can improve her life and her community.
¨ A woman's self-esteem will influence the choices she makes about her health.
Building self-esteem is not an easy task. This is because a woman cannot just decide to value herself more. Rather, she must change deeply held beliefs that she may not know she has.
Often these changes must happen indirectly, through experiences that allow a woman to see herself in a new way. Change can come through building on strengths a woman already has, like her ability to form close, supportive relationships with others, or from learning new skills. For example:
As a child Malika was expected to be quiet and follow orders. When she was 18, her mother forced her to marry a military man. Malika was in love with someone else, but her mother did not care. The military man was an important man.
After they had been married for a number of years and Malika had given birth to 4 children, her husband stopped coming home at night. Friends would report that he had been with other women. Malika complained to her mother, and her mother told her to just live with it - this was how her life would be. Eventually Malika's husband moved out to live with his girlfriend. Malika felt very sad and worthless.
One day Malika was given the opportunity to enter a program where she would learn to take care of children at the community school. She decided to try, even though she had never worked away from home before. Learning new skills and being with the children and other women in training changed Malika. She began to see she had some worth outside her marriage and that she could be a productive worker. Malika then began to think about what she could do for her family and what she hoped to accomplish in her lifetime.
Not everyone who has to cope with the problems listed below will develop a mental health problem. Rather, a woman usually develops a mental health problem when these pressures are stronger than her ability to cope. Also, not all mental health problems have causes that can be identified. Sometimes we just do not know why someone develops a mental health problem.
¨ To have better mental health, women need to have more control and power over their lives.
Daily activities and events often put pressure on a woman, causing tension in her body and mind (stress). Stress can come from physical problems, like illness or overwork. Or it can come from emotional events, like conflict in the family or being blamed for problems that a woman has no control over. Even events that often bring pleasure - like a new baby or getting a job - can be stressful because they create changes in a woman's life.
¨ It is easy not to notice the stress in daily life because it is always there. But it takes a lot of a woman's energy to cope with this kind of stress.
Most women hove many kinds of stress pressuring them from all sides.
When a woman faces a lot of stress every day and for a long time, she may begin to feel overwhelmed and unable to cope. The problem may be made worse if she has been taught to take care of others first and neglects her own needs. With little time to rest or to enjoy things that could help reduce her stress, she may ignore signs of illness or overwork. And as a woman, she may have little power to change her situation.
Other kinds of stress happen less often, but can also contribute to mental health problems:
When a woman loses someone or something important - a loved one, her work, her home, or a close friendship - she may feel overwhelmed with grief. This can also happen if she becomes ill or develops a disability.
Grieving is a natural response that helps a person adjust to loss and death. But if a woman faces many losses at once, or if she already has a lot of daily stress, she may begin to develop mental health problems. This can also happen if a woman is unable to grieve in traditional ways - for example, if she has been forced to move to a new community where her traditions are not practiced.
In many parts of the world, communities are being forced to change rapidly - because of changes in the economy or because of political conflict. Many of these changes require families and communities to alter their entire way of life. For example:
When families and communities break apart, or when life changes so much that old ways of coping do not work any more, people may begin to have mental health problems.
When something horrible has happened to a woman or to someone close to her, she has suffered a trauma. Some of the most common kinds of trauma are violence in the home, rape, war, torture, and natural disasters.
Trauma threatens a person's physical or mental well-being. As a result, a person feels unsafe, insecure, helpless, and unable to trust the world or the people around her. It usually takes a long time for a woman to recover from trauma, especially if it was caused by another person, not by nature. Trauma suffered as a child, before she could understand what was happening or talk about it, can affect a woman for many years without her even knowing it.
Some mental health problems are caused by physical problems, such as:
· hormones and other changes in the body.
· infections, such as HIV.
· pesticides, herbicides, and industrial solvents.
· liver or kidney disease.
· too much medicine in the body, or the side effects of some medicines.
· drug and alcohol misuse.
· strokes, dementia, and head injuries.
Always consider the possibility of a physical cause when treating mental health problems. Remember, too, that physical problems can be the sign of a mental health problem.
Although there are many kinds of mental health problems, the most common ones are anxiety, depression, and misuse of alcohol or drugs. In most communities, women suffer from these problems more than men do. But men are more likely than women to have a problem misusing alcohol or drugs.
To decide whether someone has a mental health problem, keep the following things in mind:
· There is no clear line between normal responses to life's events and mental health problems.
· Most people have some of the signs below at different times in their lives, because everyone faces problems at one time or another.
· Signs of mental health problems can vary from community to community. Behavior that looks strange to an outsider may be a normal part of a community's traditions or values.
¨ For information about treating mental health problems, see "Helping Yourself and Helping Others".
It is natural for a person to feel depressed when she experiences a loss or death. But she may have a mental health problem if the signs below last for a long time.
¨ Some people call depression 'heaviness of heart' or 'loss of spirit or soul'.
· feeling sad most of the time
· difficulty sleeping or sleeping too much
· difficulty thinking clearly
· loss of interest in pleasurable activities, eating, or sex
· physical problems, such as headaches or intestinal problems, that are not caused by illness
· slow speech and movement
· lack of energy for daily activities
· thinking about death or suicide
Serious depression can lead to suicide (killing oneself). Almost everyone has thoughts of suicide once in a while. But if these thoughts come more and more often or get very strong, a woman needs help right away. See "helping someone who wants to kill herself" for how to identify people who are most at risk for suicide and how to help them.
¨ Other common names for anxiety are 'nerves', 'nervous attacks', and 'heart distress'.
Everyone feels nervous or worried from time to time. When these feelings are caused by a specific situation, they usually go away soon afterwards. But if the anxiety continues or becomes more severe, or if it comes without any reason, then it may be a mental health problem.
· feeling tense and nervous without reason
· shaking hands
· feeling the heart pound (when there is no heart disease)
· difficulty thinking clearly
· frequent physical complaints that are not caused by physical illness and that increase when a woman is upset
¨ When a woman has severe chest pain or difficulty breathing, she should get medical help. These may be a sign of serious physical illness.
Panic attacks are a severe kind of anxiety. They happen suddenly and can last from several minutes to several hours. In addition to the signs above, a person feels terror or dread, and fears that she may lose consciousness (faint) or die. She may also have chest pain, difficulty breathing, and feel that something terrible is about to happen.
After a person has experienced trauma, she may have many different reactions, such as:
· Going over the trauma again and again in her mind. While she is awake, she may keep remembering the terrible things that happened. At night she may dream about them or be unable to fall asleep because she is thinking about them.
· Feeling numb or feeling emotions less strongly than before. She may avoid people or places that remind her of the trauma.
· Becoming very watchful. If she is constantly looking out for danger, she may have difficulty relaxing and sleeping. She may overreact when startled.
· Feeling very angry or full of shame about what happened. If a person has survived a trauma where others died or were seriously injured, she may feel guilty that others suffered more than she did.
· Feeling separate and distant from other people.
· Having outbursts of strange or violent behavior, in which she is confused about where she is.
¨ People suffering from reactions to trauma may also feel anxious or depressed, or misuse alcohol or drugs.
Many of these signs are normal responses to a difficult situation. For example, it is normal to feel angry that a trauma has happened, or to be watchful if the situation is still dangerous. But if the signs are so severe that a person cannot carry out daily activities, or if the signs start months after the trauma has happened, the person may have a mental health problem.
When a person experiences stress, the body gets ready to react quickly and fight off the stress. Some of the changes that occur are:
· The heart starts beating faster.
If the stress is sudden and severe, a woman may feel these changes in her body. Then, once the stress is gone, her body returns to normal. But if the stress is less severe or happens slowly, she may not notice how the stress is affecting her body, even though the signs are still there.
Stress that goes on for a long time can lead to the physical signs common in anxiety and depression, like headache, intestinal problems, and lack of energy. Overtime, stress can also cause illness, like high blood pressure.
In many places, emotional problems are not considered as important as physical problems. When this happens, people may be more likely to have physical signs of anxiety and depression than other signs. While it is important not to ignore physical signs, it is important to also be sensitive to the emotional causes of illness.
A person suffering from mental health problems can begin to feel better with treatment. Although most communities lack mental health services, there are things a woman can do on her own, with very few resources (personal coping skills). Or she can form a 'helping relationship' with another person or group.
The suggestions that follow are just a few of the many ways a person can work toward better mental health. These suggestions will be most effective if they are adapted to a community's needs and traditions.
¨ For severe problems, medicines may be necessary. Try to talk to a health worker who knows about medicines for mental health problems.
Women do not often take time out of their busy day to do something for themselves. But every woman needs to put her problems aside sometimes and do what she likes. Simple things that you may not do very often - like spending time alone, or shopping, gardening, or cooking with a friend - can all be helpful.
Activities to let your feelings out. Making up poems, songs, and stories can be helpful when you have trouble saying things to others. Or you can draw your feelings without using words - you do not have to be an artist.
Creating pleasing surroundings. Try to fix your living space so that it feels right to you. No matter how small it is, you will feel more order and control when it is arranged the way you like. Try to have as much light and fresh air as possible.
Try to have some beauty around you. This could mean putting some flowers in the room, playing music, or going where there is a nice view.
Practice traditions that build inner strength. Many communities have developed beliefs and traditions that help calm the body and mind, as well as build inner strength. For example:
Practicing these traditions regularly can help a person cope better with stress and other difficulties in her life.
In a helping relationship, two or more people make a commitment to get to know and understand each other. This can happen in any relationship - between friends, family members, or women who work together, or in a group that already meets for another purpose. Or a new group may form because the people share a common problem. These are often called 'support groups'.
¨ It is often easier to turn an existing group into a support group than to create a new one. But be careful when choosing helping relationships. Form relationships only with people who will respect your feelings and your privacy.
These women agreed to listen to each other's problems as they worked.
Building a helping relationship
¨ No two people have exactly the same life experiences. There is always more to understand about another person.
Even when two people know each other well, helping relationships develop slowly, because people usually hesitate to share their problems. It takes time to get over these worries and begin to trust one another. Here are some ways to build trust between people or members of a group:
· Try to be open to hearing everything another person says, without judging it.
· Try to understand how the other person feels. If you have had a similar experience, think about how you felt. But avoid seeing someone else's experience as exactly like your own. If you do not understand her, do not pretend that you do.
· Do not tell another person what to do. You can help her understand how the pressures of her family, community, and work responsibilities affect her feelings, but she must make her own decisions.
· Never think of a woman as beyond help.
· Respect the woman's privacy. Never tell others what she has told you unless it is necessary to protect her life. Always tell her if you plan to speak with someone else for her protection.
Starting a support group
1. Find 2 or more women who want to start a group.
2. Plan when and where to meet It helps to find a quiet place, such as a school, health post, cooperative, or place of worship. Or you can plan to talk while doing your daily work.
3. At the first meeting, discuss what you hope t accomplish. If you are in a group, decide how the group will be led and whether new members can join later.
Although the person who began the group will probably need to take the lead at the first meetings, she should not make decisions for the group. Her job is to make sure everyone has a chance to talk and to bring the discussion back to the main point if it wanders off. After the first few meetings members may want to take turns leading the group. Having more than 1 leader can also help shy women lead.
Meeting together with others can help a woman:
· get support. Mental health problems often drain a woman's energy and make her discouraged. Meeting together can give a woman more energy, which then helps her cope with daily problems.
· recognize feelings. Sometimes women hide their feelings (or do not even realize they have them) because they think the feelings are bad, dangerous, or shameful. Hearing others talk about feelings can help a woman notice her own.
· control impulsive reactions.
Group members can help a woman think through a problem, so that she will not act on her first impulse, without thinking.
· understand underlying causes. By talking together, women begin to realize that many of them suffer from the same kinds of problems. This helps them identify root causes of the problem.
· put forth solutions. Solutions that are discussed in a group are often more easily accepted and used than those that a woman thinks of by herself.
· develop collective power. Women acting together are more powerful than a woman acting alone.
Most members of a group need to understand what a helping relationship is and what makes it work before they can really help one another with a mental health problem. These exercises can help:
¨ These exercises are most often done in groups, but they can also be used by just 2 people.
1. Sharing experiences of support. To become more aware of what support is, the leader can ask members to tell a personal story in which they have received or given support. Then the leader asks questions like: What kind of help was it? How did it help? What are the similarities and differences between the stories? This can help the group come up with general ideas about what it means to support and help another person.
Or the leader can pose a story of someone with a problem - for example, a woman whose husband drinks too much and beats her. She becomes withdrawn and pretends nothing is wrong, but no longer participates in the community. Then the group can discuss: How could we as a group help her? How can she help herself?
¨ Some women may feel more comfortable listening as they work with their hands - for example, as they weave or sew.
2. Practicing active listening. In this exercise the group divides into pairs. One partner talks about a topic for about 5 to 10 minutes. The other partner listens, without interrupting or saying anything, except to encourage the speaker to say more. The listener shows that she is listening by her attitude and by the way she moves her body. Then the partners switch roles.
When the partners are finished, they think about how well it worked. They ask each other questions like: Did you feel listened to? What difficulties did you have? Then the leader begins a general discussion among everyone about the attitudes that best show listening and concern. The leader can also emphasize that listening sometimes means talking: asking questions, sharing experiences, or saying something that makes the other person feel understood. It may also mean admitting that you have tried but still do not understand.
Once the group has learned how to help and support one another they are ready to begin working on their mental health problems. Here are some ways for the group to help healing begin:
1. Share experiences and feelings in the group. People who have mental health problems often feel very alone. Just being able to talk about a problem can be helpful. After one person has told her story the leader can ask for other similar experiences. When everyone has listened to these, the group can discuss what the stories have in common, whether the problem was partly caused by social conditions, and if so, what the group might do to change these conditions.
2. Learn to relax. This exercise is particularly helpful for people who are suffering from stress. In a quiet place where everyone can sit down, the leader asks the group to follow these instructions:
· Close your eyes and imagine a safe, peaceful place where you would like to be. This might be on a mountain, by a lake or ocean, or in a field.
· Keep thinking about this place as you breathe deeply in through your nose and then out through your mouth.
· If it helps, think of a positive thought, such as "I am at peace," or "I am safe."
· Keep breathing, focusing either on the safe place or the thought. Do this for about 20 minutes (as long as it takes to boil rice).
¨ If you start to feel uncomfortable or frightened at any time during this relaxation exercise, open your eyes and breathe deeply.
A woman can also practice this exercise at home whenever she has difficulty sleeping, or feels tense and afraid. Breathing deeply helps calm nervous feelings.
3. Creating a story, drama, or painting. The group can make up a story about a situation similar to those experienced by members of the group. The leader starts the story, and then another member continues to tell another part - and so on until everyone has contributed something and the story is complete. (The group can also act out the story as it is told or paint a picture of the story.)
¨ If you tell a story about a problem, it is important to also talk as a group about ways to overcome the problem.
Then the group analyzes the different ideas that have been developed. These questions can help people begin to talk:
· What feelings or experiences are most important in this story?
· Why did these feelings occur?
· How is the person coping with these feelings?
· What can help her develop a new balance in her life?
· What can the community do to help?
¨ If a group has lived through a trauma and enough time has passed, they can analyze their own experiences rather than creating a story.
4. Creating a picture of your community. This exercise works best after the group has been meeting together for a while. The leader first asks the group to draw a picture of their community. (It may help for the leader to draw a simple picture to get things started.) Then the group adds to the picture, drawing in those parts of the community that contribute to good mental health, and those that cause mental health problems.
Then the group studies the picture and starts to think about ways to improve the community's mental health. The leader can ask questions like these:
· How can we strengthen those parts of the community that now contribute to good mental health?
· What new things need to be done?
· How can the group help bring about these changes?
In El Salvador, a group of women from an urban squatters' community decided to form a support group. They had lived through the civil war and now worked with victims of the war through their church. One member tells how the group began and how it has helped her:
"One day, all of us felt sad without knowing why. It wasn't as though anything special had happened that day, but all of us were feeling this way. Then one of us realized that it was the anniversary of the war that all of us had lived through. That was when we decided to form this group. We needed to feel close, to understand the things we had experienced, and to cope with how we felt about losing our sons, daughters, husbands, and neighbors to the war - and for what?
In the group we spoke of many experiences we had never been able to share with anyone else. This way we slowly left behind the silence and the feelings of helplessness each of us had. We learned that fears become smaller when we can give them a name. We discovered that we all had the same fears: the fear that others wouldn't understand, of not finding an answer, and that in speaking of our memories they would become more painful.
We spoke, cried, and laughed, but this time we did it together. The group supported us, helped us to change, and helped us see new directions for our lives. We were able to bring new energy and strength to our work. Now we help victims of the war - not just to rebuild their homes and health, but also to overcome their fears and hopelessness. This way they can create a new future for themselves and for their community.
Even though we all lost so much to the war - and peace has not delivered on its promises - we feel as though we have given birth to something new. And like a new baby, this group brings new spirit into the world and gives us the strength to go on."
· The most important way to help someone suffering from trauma is to help her learn to trust others again. Let her control how fast the relationship between you develops. She needs to know you are willing to listen, but that she can wait until she feels ready to talk. Doing everyday activities together may be best at first.
¨ Once a woman understands her reactions, the feelings usually have less control over her.
· It may help a woman to talk about her life before the trauma as well as her current experiences. This may help her realize that although life has changed a lot, in many ways she is the same person as before. If it seems right, encourage her to do some of the same activities she enjoyed before or that were part of her daily routine.
· Some painful things may be too difficult to talk about, or may be 'buried' away where they cannot be remembered. Exercises like drawing or painting, or a physical activity like massage, can help a person express or relieve these painful feelings.
· If a woman dreams of the trauma, she can put an object from her new life next to her as she sleeps. This helps her remember, when she wakes from a bad dream, that she is safe now.
· If reminders of the trauma make a woman react in fearful ways, help her make a plan for those reminders that cannot be avoided. For example, a woman might tell herself: "His face is like the man who attacked me, but he is a different person and does not wish to hurt me."
· If a person was tortured or raped, remind her that she is not responsible for what she said or did while being tortured. All responsibility lies with those who tortured her Help her understand that one aim of torture is to make a person feel she can never feel whole again, but that this is not true.
Massage can help relieve painful feelings.
Anyone who suffers from serious depression is at risk for suicide. A woman may not readily talk about thoughts of suicide, but she will often admit them if asked. If she does, then try to find out:
· Does she have a plan about how to kill herself?
· Does she have a way to carry out the plan? Is she planning to kill others as well (for example, her children)?
· Has she ever tried suicide before?
· Is her judgment affected by alcohol or drugs?
· Is she isolated from family or friends?
· Has she lost the desire to live?
· Does she have a serious health problem?
· Is she young and going through a serious life problem?
If a woman has made a plan for killing herself, she needs help right away.
If the answer to any of these questions is 'yes', she is at a greater risk for attempting suicide than other people. To help, first try talking with her. Some people may begin to feel better simply by telling you about their problems. If so, or if she still feels bad but is more in control of her feelings than before, ask her to promise that she will not hurt herself without talking to you first.
If talking about her problems does not help, or if she cannot promise to talk to you, then she needs to be watched closely. Always tell the person considering suicide that you plan to talk with others to help protect her. Talk to her family and friends, encouraging someone to be with her at all times. Ask them to remove dangerous objects from her surroundings.
If there are mental health services in her community, find out if someone can talk with her regularly. Medicine for depression may also be helpful.
A person may be mentally ill if she has any of these signs:
· She hears voices or sees unusual things that others do not hear or see (hallucinations).
· She has strange beliefs that interfere with daily life (delusions) - for example, she thinks that loved ones are trying to rob her.
· She no longer cares for herself - for example, she does not get dressed, clean herself, or eat.
· She behaves in a strange way, like saying things that make no sense.
¨ Similar signs can be caused by illness, poisoning, medicines, drug abuse, or damage to the brain.
People who are not mentally ill sometimes act this way, particularly if these behaviors are part of their community's beliefs or traditions. For example, if a woman says that she received guidance in a dream, she may be drawing upon traditional sources of knowledge and guidance - not suffering from mental illness. These signs are more likely to be signs of mental illness if they come so often and are so strong that a person has difficulty carrying out daily activities.
¨ No matter what treatment is given, a person with a mental illness should be treated with kindness, respect, and dignity.
Getting care for mental illness
Although in most places family members care for those who are mentally ill, it is best if the person can also be treated by a trained mental health worker In some situations medicines are necessary, but they should never be the only treatment.
Traditional healers can also play an important role in treating mental illness. If they come from the same community as the person with the problem, they may know and understand her. Some healers also have treatments or rituals that can help a woman overcome her problem.
Ask these questions before deciding on a treatment:
· What is the purpose of each step in the treatment? What should be expected to happen?
· Do any of the treatments cause physical harm or shame?
If someone must be treated in a hospital, always ask to see it before leaving her there. Make sure that the hospital is clean, that patients are safe and can have visitors, and that they will get regular treatment with trained mental health workers. Patients should be free to move about, unless they are a danger to themselves or others. Also, make sure you find out what must be done to have the person let out of the hospital later
Identify those who are at risk for mental health problems. Women are at risk if they have:
· had mental health problems in the past
· lost family members or are separated from their families.
· witnessed violence or have violent partners.
· little social support.
Look for other behaviors that may indicate mental health problems. If you suspect that someone has a mental health problem, get to know her better. Listen to what other people are saying about her behavior and the ways she has changed. Since mental health problems often have roots in the family or community, think about how these may contribute to the problem.
Build on a woman's strengths. Every woman has developed ways of coping with everyday problems. Help a woman identify the positive ways she has dealt with problems in the past and how she might use these strengths in her present situation.
Work within a woman's traditions and culture. Every community has traditional ways of dealing with mental health problems, such as prayer and ritual. These practices are not always helpful, but they should always be considered and used as much as possible. Try to learn as much as you can about a woman's traditions and how they may be a source of strength for her. Anything that helps a woman recognize or give meaning to her experience can help her mental health.
¨ The most important pan of any treatment is to make the woman feel supported and cared for. Try to involve her family and friends in the treatment
Remember that there are no quick solutions to mental health problems. Beware of anyone who promises this.
Ask for help when you need it. If you do not have experience with a mental health problem, try to talk to a trained mental health worker who does. Listening to other people's mental health problems can make you feel burdened, especially if you listen to a lot of people. Watch yourself to see if you are feeling pressured, if you are losing interest in helping others, or if you get irritable or angry easily. These are signs that you are making other people's problems your own. Ask for help, and try to get more rest and relaxation so you can work effectively.