Psychiatric discourses of woman abuse - CiteSeerX

Psychiatric discourses of womanabuse

Tanya Wilson*21 Alma Road, Rosebank, 7700, South Africae-mail: [email protected]

Anna Strebel12 Robinson Road, Kenilworth, 7700, South Africa

This article presents a qualitative investigation of how South African psychiatric services,in the course of their management and treatment of female psychiatric patients, deal withthe issue of woman abuse. Discourse analysis was used to analyse the case documentsof ten female psychiatric patients who were admitted to a psychiatric hospital in a poorersection of the Western Cape Province, South Africa, all of whom had a history of sexualand/or physical abuse. In this article, the analysis focuses on three broad areas: abuse andthe 'syntaxes' of psychopathology; discourses of blame and responsibility; and the failure of(psychiatric) language. The approach of the investigation was one that critically examinedpsychiatry, at the same time as specifically investigating psychiatry's response to the issueof woman abuse. Given the South African context of widespread violence against women,together with the transformation of mental health structures, this study formed part of alarger research endeavour geared towards developing appropriate services for the treatment and care of women who have been physically or sexually abused.

* To whom correspondence should be addressed.

The high prevalence of physical and sexual violence against women, both internationally and in South Africa, is well documented. There is growing concern about theimplications ofthis for women's health in general and their mental health in particular.Psychiatric institutions continue to hold an important position in the mental healthsector in South Africa and are obviously in a prime position to attend to the mentalhealth issues that woman abuse raises. However, it appears that woman abuse is notbeing adequately taken into account in the management and treatment of femalepsychiatric patients.

If) Psychological Society of South Africa. All rights reserved.ISSN 0081-2463

South African Journal of Psychology 2004. 34(3). pp. 421-442.

421

at PENNSYLVANIA STATE UNIV on May 10, 2016sap.sagepub.comDownloaded from

http://sap.sagepub.com/

TanyaWilsonandAnna Strebel

The non-detection and non-integration of experiences of sexual abuse in medicaland mental health services have been highlighted internationally (e.g., Campbell &Raja, 1999; Dill, Chu, Grob & Eisen, 1991; Laidlow & Malmo, 1990; Warshaw 1993)and a South African study investigating the prevalence, profile, diagnosis and treatment of sexual and physical abuse among women admitted to the three psychiatrichospitals in the Western Cape Province (Strebel & Leon, 1996) showed that while85% ofwomen admitted to psychiatric hospitals reported having experienced sexualand/or physical abuse, written recordings of these experiences occurred in only 10%ofcases. The extent ofthis discrepancy and the enormously high prevalence ofwomanabuse among female psychiatric patients pointed to a need to examine, in greaterdetail, the role of psychiatric services in relation to woman abuse.

The failure ofpsychiatry to take the history of woman abuse into account fuels abroader critique ofpsychiatry, which claims that psychiatric practice obscures socialand political problems and inequalities (Ingleby, 1981). Deconstructing psychiatryand the psychiatric practice of diagnosis and disorder management has been a focusof several theorists (e.g., Foucault, 1967; Parker, Georgaca, Harper, McLaughlin& Stowell-Smith, 1995; Pilgrim & Rogers, 1993), all of whom acknowledge thatnotions ofmadness, mental illness, abnormal psychology and so forth are dependenton cultural and historical contexts.

Critiques of psychiatry have traced and analysed the history of this institution,emphasising its role as a powerful mechanism of social control within a system ofsurveillance and regulation (Foucault, 1967) as well as examining the 'medical gaze'and the appropriation of 'madness' by the medical professions (Conrad, 1981). Feminists have challenged psychiatry as reflecting, maintaining and constructing genderpower imbalances because of its tendency to decontextualise and depoliticise genderinequalities (Al-Issa, 1982; Chesler, 1972; Laidlaw & Malmo, 1990; Ussher, 1991;Willie, Reiker, Kramer & Brown, 1995). Feminists have also examined how the sexism inherent in the historical development and construction of psychiatric theorieshas produced measures ofhealth that serve to normalise men and pathologise women(Broverman, Broverman, Clarkson, Rosenkrantz & Vogel, 1970; Showalter, 1987;Ussher, 1991). Woman-dominated disorders have been understood as consequencesof gender socialisation and sexual discrimination (Cox, Stabb & Hulgus, 2000;Klonoff, Landrin & Campbell, 2000), as well as culture-bound syndromes of thedominant patriarchal culture and exaggerations or parodies of sex-role stereotypes(Kaplan, 1983; Littlewood & Lipsedge, 1986). There have also been examinationsof the sex-role stereotypes implicit in various disorder categories for both women(Willie et aI., 1995) and men (Busfield, 1994), highlighting the complex interrelationof gender and madness.

Critiques of psychiatry and its categories have not often been incorporated intoresearch in the field ofwoman abuse and mental health. In more traditional research,much has been written about the effects ofwoman abuse as part ofa broader concern

422



Psychiatric discourses of women abuse

about women's health (Fischbach & Herbert, 1997; Koss, Heise & Russo, 1994),linking abuse to psychological distress, particularly as it manifests itself throughpsychological or psychiatric disorders such as major depressive episodes, suicideattempts or ideation, substance abuse disorders, anxiety disorders, Post-TraumaticStress Disorder (PTSD), Borderline Personality Disorder, and Multiple PersonalityDisorder (Burnam et aI., 1988; Murray, 1993; Shwartz, 1991; Wexler, Lyons, Lyons& Mazure, 1997; Wood & Rennie, 1994). These studies emphasise the distress experienced by women as a consequence of abuse and have been crucial in exposing andhighlighting woman abuse as a major problem in society and, not least, as a majorburden to women's mental health. They are also important in linking psychological'disorders' to the context ofwoman abuse, since psychiatric labels - often associatedwith 'madness' - have the problematic effect of stigmatising the woman who is distressed and obscuring the causes of that distress. However, these studies also rely onthe very psychiatric categories that they are simultaneously criticising for obscuringthe problem of woman abuse. Thus, in spite of the influence of postmodernism andpost-structuralism on psychological theory, and the fact that psychiatric practice hasbeen a subject ofmuch critique, deconstructionist ideas have seldom been translatedinto research on woman abuse in the context of psychiatric settings.

Outside of psychiatric settings, however, there is a healthy body of discourseanalytic research on woman abuse. Underlying this body of research is an increasing acceptance that male violence against women is linked - albeit in complex ways- to patriarchal structures and gendered power relations. In addition, important linkshave been made between language and violence (Adams, Towns & Gavey, 1995;O'Conner, 1995). Discourse researchers have been interested in studying the waysin which language serves to reinforce such gendered power relations and, by extension, to perpetuate male violence in ways that are both crudely oppressive (Larkin& Popaleni, 1994) and coercive (Gavey, 1993; Wood & Rennie, 1994). There is alsoa growing literature on 'rape myths' and their effects (Lonsway & Fitzgerald, 1994;Vogelman, 1990). Dominant discourses ofsexuality are seen to provide subject positions for women which prescribe compliance with, or submission to, male initiativesand demands (Ehrlich, 1998; Gavey, 1993). The powerful effects of these discourseshave been labelled, 'technologies of sexual coercion' . Indeed, difficulties in resistingdominant discourses of heterosexuality are apparent in the way that women strugglelinguistically to label their experiences as 'rape' (Wood & Rennie, 1994). However,attention has also been paid to subversions of dominant discourses and to the waysin which they are resisted (e.g., Levett, 1989). There has been a growing awarenessof the ambiguities and complex dynamics involved in how people define, understandand experience woman abuse. This has spawned research that delineates the multipleand contradictory discourses that permeate contemporary language as well as examines the dynamics between those discourses that serve to deny and justify male violence, those that accept it, and those that expose and resist it (Bordo, 1993; Hyden &Colgan-McCarthy, 1994; Levett; 1989).

423



TanyaWilsonand Anna Strebel

In attempts to deconstruct psychopathology, discourse analytic researchershave translated critiques of psychiatry into research on psychiatric discourses. Thishas been done, for example, by analysing the language of persons who have beenlabelled with particular psychiatric diagnoses (e.g., Swartz, 1984) and by examiningthe spoken language that takes place in psychiatric settings, especially the dialoguebetween the patient and the clinician (e.g. Katz & Shotter, 1996; West, 1984). Previous research has also analysed the written documentation of psychiatric institutions(Barrett, 1988; Smith, 1974; Swartz, 1996a; Swartz 1996b). Smith (1974) argues thatthe written document is a function of the professional or organisational discourse,in the sense that its production of factual accounts is largely a confirmation of theparameters and boundaries of that profession or organisation. Thus, the writing of apsychiatric document is an intrinsic part of the profession's regulatory procedures.The effects of such regulation have been explored by Barrett (1988), who comparesthe spoken dialogue ofpsychiatric assessment interviews with the written entries inthe psychiatric records, and notes how when the patient is written into the text, he orshe becomes constructed as a 'passive conglomerate which lacks agency' (Barrett,1988, p. 287). Swartz (1996a) also analyses in detail the kinds of constitutive processes that occur in the procedure ofwriting up psychiatric assessments and records.Describing the positioning ofpatients in the process of 'taking a history' and writingit, she notes how 'patients are narrated into spaces which psychiatric knowledge hasthe power to explain' (Swartz, 1996a, p.l50). The complexities and contradictionsofthe patient's narrative are replaced with one, single story that positions the patientas needing psychiatric intervention.

While little research has been conducted which examines the interplay betweendiscourses of woman abuse and discourses of psychopathology, there is someimportant work that has been done in this area. For example, in an examination oftheconnection between trauma and somatisation, Waitzkin and Magana (1999) note howpsychiatric research has classified and re-classified somatic disorders according tovarious taxonomies and given very little attention to the nature ofthe traumatic experiences that are connected to the somatic symptoms. Levett (1989) looks specifically atthe way in which the sexual abuse of women and girls has been appropriated by theprofessional discourses of psychological damage or psychopathology. She suggeststhat, when used in relation to child sexual abuse, these discourses ofpsychopathologytend to deploy the powerful metaphor of psychological trauma, implying as it doesthat an experience of abuse will be followed by a series of inevitable psychologicalprocesses that are damaging to the individual's mental state. Such discourses ofpsychological damage (and of the accompanying stigma) are seen to be part of broaderdiscourses of control of women and girls. Focusing on the effect of legal discourseon the disclosure of abuse, Hyden and Colgan-McCarthy (1994) note how legaldiscourse and practice police processes of disclosure, by emphasising the need for'trustworthy' and unambiguous accounts. The fact that evidence of depression and

424




obvious victimisation increases the chances of being found trustworthy implies thatan acceptable account has its basis in defeat, and that abuse can only be defined assuch if its recipient positions herself as pathologically damaged.

DESCRIPTION OF THE STUDY

Method of data collectionThe study involved an examination of the psychiatric case documents of 10 femalepsychiatric patients, all of whom had a history of sexual and!or physical abuse, andall of whom were admitted during 1995 to a psychiatric hospital in a poorer regionof the Western Cape Province, South Africa. These case documents contained all thenotes written during each patient's admission(s) to the hospital. Notes were written by a variety of clinicians, including psychiatrists, psychiatric registrars, clinicalpsychologists, social workers and nursing staff.

The hospital in which this research was conducted was built during the 1980s tocater for the hugely expanding population in a particular area ofgreater Cape Town towhich many black South Africans were moved after having been forcibly evicted fromtheir homes under the apartheid government's Group Areas Act of 1950 (ApartheidActs, 2001). The growth of these displaced communities has been accompanied bymuch violence, particularly gang violence. At the time ofthis study, admissions to thehospital were controlled by psychiatrists or psychiatric registrars, and decisions aboutwhere a patient ought to be placed were made on the basis oftheir diagnosed disorder(i.e., those diagnosed with depression went to one ward and those diagnosed with apersonality disorder went to another). As a result, patients with common experiences(e.g., sexual assault) were not necessarily placed together. Thus, the very context ofthe study embodies the juxtaposition of individualistic, medical treatment, on the onehand, and widespread social problems, on the other.

While the absence and silence of woman abuse in the written records of femalepsychiatric patients (Strebel & Leon, 1996; Warshaw, 1993) is in itself a topic foranalysis, the focus in this study was on how woman abuse is incorporated into psychiatric practice when it is taken into account. The ward used in this study was thereforechosen because of its reputation at the time of treating abused women. Out of the 91female case documents from this ward in 1995, there were 32 who mentioned incidentsof physical and!or sexual abuse. The 10 documents selected for analysis were thosethat were most expansive in their recording of issues related to abuse.

Method of data analysisAs other researchers have noted, there is a fundamental uniformity of psychiatrichistories, which makes them very difficult texts to use for analysis (Swartz, 1996a).Psychiatric texts are particularly difficult when there is no other version (e.g.,

425




spoken) of the events and experiences inscribed in the texts. Given that the writtentexts were the sole source of analysis, the first level of analysis was to search fordifferent ways in which abuse was positioned within the texts. Despite the uniformityof the psychiatric texts, it became evident that there were a variety oflinguistic processes through which woman abuse was positioned. In other words, within the broaderpsychiatric discourse there were different 'syntaxes' ofpsychopathology. These willbe elaborated upon in the next section.

Analysing the possible effects of psychiatric practices in relation to women'sexperiences of abuse became difficult without making assumptions about knowingthe 'truth' of these women's experiences. It is important to note that we do not claimthat our interpretations made in the analysis constitute the only possible reading ofthe texts. However, because one ofthe basic premises ofthis study was that there hasbeen an evident failure on the part ofpsychiatric practice to take woman abuse intoaccount, one of the main objectives in the analysis was to examine how psychiatricpractice fails in its dealings with abused women. This meant tackling the texts with anapproach that critically examined psychiatry. Conversely, another important aim oftheanalysis was to highlight areas where psychiatric practices might have empoweringconsequences for abused women.

Within the psychiatric texts there was, unsurprisingly, very little deviation frompsychiatric discourse. It was therefore necessary to go beyond the text in order tointerpret possible effects of that dominant discourse. The methodology used was aversion of discourse analysis that incorporated a post-structuralist understanding ofthe production of discourses within power relations (see Burman & Parker, 1993;Fairclough, 1992; Parker, 1992, 1994), as well as certain feminist accounts oflanguageand subjectivity (Bordo, 1993; Squire, 1989), particularly theories on resistance andthe subversion of identity (Butler, 1990). In addition to such discourse theories, theanalysis was also framed by previous research in the areas ofwoman abuse, psychiatryand discourse (e.g., Barrett, 1988; Campbell & Raja, 1999; Crossley, 2000; Hyden &Colgan-McCarthy, 1994; Levett, 1993; Strebel & Leon, 1996).

Ethical considerationsThe use of psychiatric files for the purposes of research raises several ethical questions, including one ofconfidentiality. Permission to use the hospital case documentswas obtained from the hospital authorities. In addition, efforts were made to protectthe identities of the women patients whose files were used. All names (or initials)were changed to ensure anonymity. Furthermore, consideration was given to the useofexcerpts from the files, and any obviously identifying material was excluded fromthe analysis and this article.

426




DISCOURSESIn this section, we focus on the texts included in this study, outlining and examiningsome of the 'syntaxes' of psychopathology that form part of the broader psychiatricdiscourse. We concentrate on the structures oflanguage that have been implicated inobscuring the prevalence ofwoman abuse (Dill et al., 1991; Laidlow & Malmo, 1990;Warshaw, 1993) and criticised for framing responses to abuse in terms of 'damage'(Levett, 1989). These 'syntaxes' (as they are inscribed in the psychiatric documents)are separated into four categories: (a) psychiatric notes, (b) descriptive narratives,(c) explanatory narratives and the (d) medico-legal discourse. After an examination ofeach of these 'syntaxes', we turn our attention to the discourses ofblame and responsibility that pervade the texts. Finally, the possible paralysing effects of psychiatricdiscourses on abused women are explored, and the implications of this 'failure oflanguage' are discussed.

Abuse and the 'syntaxes' of psychopathologyPsychiatric notesThe psychiatric notes were often the very first notes written about a patient in her file(usually by an admissions doctor) and they essentially consisted ofsparse, medicalisedlanguage, such as the following:

Raped 1/12ago by 1unknownmalewhile held by a secondmale. Sincethen: feelsdepressed and emotionally labile;suicidalideation& intentat times;initial insomnia; LOA & LOW [loss of appetite and loss of weight]; flashbacks; bad dreamsabout incident; feels unsafe around men; social withdrawal; poor concentration;hypervigilance; recentlystarted smoking& drinking(VL).1

Above is an example of the quantification of abuse as outlined by Barrett (1988), aprocess whereby qualitative meanings and experiences of abuse are reduced to numbers or categories in the transformation from spoken clinical assessments to writtenentries in the case documents. In this case, the categories depict symptoms that assistin the primary psychiatric task of diagnosing the patient. A diagnosis helps to decidethe kinds ofmedication to prescribe as well as to which ward to admit the patient. Anadditional function of this inscription is to communicate with other clinicians aboutthe patient in a common language of symptomology.

The way in which the rape is positioned in relation to the symptoms above has anumber of other effects. For example, the single sentence about the rape is overshadowed (at least in volume) by the numerous symptoms that follow it, and one couldargue that the rape itself is obscured as a result. Certainly, the rape is not exploredin these notes, other than as the cause of a whole host of symptoms that fit into oneor more psychiatric disorders. The causal position given to the rape in this discourseis one that suggests a hidden assumption (in the words, 'since then:') that the rape

427




caused these symptoms like a car accident causes a broken leg and a fractured hand.As an object to which the symptoms are attached, the rape is thus transformed intoan object of factual science. One effect of such a scientific gaze, as Ussher (1992)argues, is that it directs attention away from women's real oppression by definingdistress as personal (a series of symptoms) and that it fails to examine the widerissues facing women. From this perspective, the rape here becomes an object that isincorporated into psychiatry's work of symptom finding and disorder management.Other possible meanings of the rape are easily lost or disregarded, as the rape itselfbecomes secondary to the symptoms.

Another effect ofthe language used in the case cited above is that the use ofdiscretesymptomatic entities to depict this woman's state ofbeing makes reading about her adistancing and impersonal experience. This distancing effect ofpsychiatric languagemight well be a necessary protective measure for South African clinicians working inviolent areas and who are faced with listening to an unusual number oftraumatic lifeexperiences. However, it also has an alienating effect, creating a dichotomy betweenthe expert who has the power to prescribe the language of understanding and treatment and the patient who becomes a conglomeration of symptoms to be managed. Inthis way, the patient has been stripped of her full experience, which would contain avariety ofdiscourses, some ofwhich might be at odds with the psychiatric discourse.The clinician to whom the patient will be assigned thus receives a written version ofher that has already silenced virtually everything other than her symptoms.

Below is a further example of what we have termed 'psychiatric notes'. Thesewere also the very first notes in one of the women's files:

Problems: allegedlyrapedyesterday(22hOO); rapedon two occasionsby the sameman and forcedto have oral sex; also assaultedby him; moneywas stolenby himtoo; shedoesnot knowhim;hasnotreportedit to thepolice- wantsto but is scared;has washedand bathedherself (EC).

Once again, the woman's spoken account has been reduced to categories, but here theyare different to the symptomology in the previous example. Very little about what isrecorded here can help the psychiatric practice of diagnosis. The absence of symptoms or diagnostic criteria in this extract could imply that the rape itselfjustifies thewoman's admission to a psychiatric hospital. It is no longer required that symptomsbe recorded; they are assumed. Such an interpretation supports Levett's (1993) argument that current discourses of woman abuse imply that an experience of abuse willbe followed by a series ofinevitable psychological processes that are damaging to theindividual's mental state. It is also possible, however, that the absence of symptomsin this extract is an indication of a capacity within psychiatric practice to performfunctions other than that of disorder management. If this is the case, why are theseparticular bits of information of importance to psychiatric practice? To address this

428



Psychiatric discourses of wornen abuse

question, let us examine the bits of information more closely. The categories aboveinclude the time the rape occurred, whether the assailant was known or unknown,and whether or not it had been reported to the police, all ofwhich are commonly usedcategories in the description of female psychiatric patients who have been abused.While the information recorded could be seen to have multiple functions, the notesread strangely like a police report, positioning the abuse in a discourse of criminality. For example, the splitting ofmale assailants into known or unknown emphasisesthe distinction between abuse by a stranger and abuse by a friend or acquaintanceor spouse. This distinction might well be very important to women, both because itcould influence their emotional responses to the abuse, as well as have implicationsfor preventing further abuse. However, in the context of the other categories used inthis quotation, it seems that the predominant function of the distinction is to 'profile'the rapist within a legal discourse that positions the abuse as a 'crime'. Contrary tothe previous quotation in which the woman's 'damaged' internal world was scrutinised, this depiction of abuse as a crime emphasises its existence as a 'wrongdoing'.Naming the experience a 'criminal fact' might well provide a framework in whichthe woman is more easily able to process the unbearable aspects of her experience(Sinason, 2000). However, a crime has to be proven and this takes the abuse into thearena of a legal system, whose discourse and practices often uphold cultural stereotypes ofrape (Campbell & Raja, 1999; Konradi, 1996), prescribe how rape 'victims'ought to respond, and thus result in debilitating rather than liberating effects for manywomen. Further analysis of the overlap between psychiatric and legal discourses isexplored later in this article.

Descriptive narrativesIn the descriptive narratives, abuse is placed into a story. However, in these storiesthere is often a separation of the clinician's description of the patient's life narrativefrom the symptoms attributed to the patient. For example:

She reports that her first husband was very fond ofwomen, alcohol and 'nice times' .She also reports to have had two miscarriages due to her husband physically abusingher. Pt [patient] reports that after +/- 2 years of marriage she was under a psychiatrist at [local general hospital] due to her husband committing adultery, physicalabuse and his reluctance to give money. Pt also said that her husband would bringpeople home and then he would beat her out of the house. [In the margin next tothis narrative, the following is written in pencil, and seems to have been added ata later point] sleeplessness; worthlessness; decreased energy; low self-esteem;suicidal ideation (YJ).

This separation of symptoms from the narrative can be understood to be part of adiscourse strategy ofappropriation and objectification. It is a form oftranslation ofamore experiential rewriting ofthe woman's account into a language ofsymptomology,

429



TanyaWilsonand AnnaStrebel

which is exclusive to the practitioners of psychiatry. This separation of symptomsfrom story points to a disjuncture within psychiatry, between a medical discourse anda narrative discourse. The above quotation is an example of different - even opposing - discourses operating within the same clinical text. The symptoms are entirelyseparate from the narrative, not only in their physical positioning, but also because theunderlying assumptions about where the 'problem' lies are so different in each case.Without the symptomology, the above text locates the cause of the problem almostentirely with the woman's husband. What is of interest here is how the medicaliseddiscourse almost overpowers the narrative. Blaming the husband (as the narrativedoes) does not fit the conventions of psychiatric intervention when the husband isnot the person admitted to the hospital. For the purposes of intervention, it becomesnecessary to position the woman as a psychiatric patient, and this is done throughaccording her a set of symptoms. The way in which these symptoms seem to havebeen added at a later point gives them the appearance ofa self-correction, portrayingsomething of psychiatry's power to regulate its clinicians.

What is problematic about this is that the diagnostic activity substitutes for detailedexploration of the abuse itself, and also locates the problem as internal to the patientrather than lying within the abusive relationship. Positioning her as requiring psychiatric intervention also means that she obtains some kind ofhelp. Without symptoms,the hospital could not justify admitting her.

Explanatory narrativesIn the psychiatric texts, explanatory narratives almost always adopted the form of a'formulation', the technical term for the account that a clinician creates to explain apatient's personality dynamics and psychological symptoms. In the following quotation, an explanation is given as to why a woman responded psychologically in theway that she did to an early experience of sexual abuse, as well as to a more recentexperience of rape:

The climate at home was probably somewhat authoritarian, where the expression offeeling was not encouraged. She has identified with her father's rigid authoritarianstyle and values self-control. She therefore finds it difficult to confide in others. Thispattern was already evident at age 7 years when she experienced an episode ofsexualabuse that she was unable to speak about until after her divorce in 1986 ... Thefeelings ofdepression and poor self-esteem combined with an inability to approachothers for help and communicate her feelings led to her becoming dependent onanti-depressants. Shortly after being treated for substance abuse she was raped byan ex-boyfriend. She responded with her usual defence of isolation and denial, butafter a while these proved inadequate to allay the anxiety and depression. The exboyfriend's attempts to contact her and the incident in the train suddenly re-evokedthe unresolved trauma and precipitated the major depressive episode (MM).

430



Psychiatricdiscourses of womenabuse

This is not an atypical formulation. The shape ofthe explanation is as follows: the abuseis defined as a trauma that has highlighted the woman's inadequate defence structure.Her 'isolation' (lack of 'appropriate disclosure') has led to her 'illness'. The reasonsfor the woman's reluctance to disclose are explained in terms of an internalisation ofher father's value of 'self-control'. The files contain several explanatory narrativeswith a similar shape. Underlying these narratives, however, are implicit judgementsabout the role of dependency and disclosure in (women's) psychological health. Theway in which this woman is described as valuing self-control is one that implies thatthe value of self-control is negative and psychologically unhealthy for her (men'sself-control is seldom questioned in such narratives). The formulation goes furtherto imply that the woman, although she values 'self-control' and being independentfrom others, is inherently dependent, and that her dependence finally catches up withher: her 'inability to approach others for help' is countered by her dependence onanti-depressants. In this discourse, she is positioned as unhealthily independent, andyet her dependence, too, becomes pathologised. There are echoes here of previousstudies' findings of the double standards of health for women and men, where traitsof independence are considered healthy for adults but unhealthy for women, andwhere dependency is considered natural for women, but psychologically unhealthy(Brovennan et al., 1970).

The explanatory narratives challenge some of the psychiatric assumptions aboutpathology that occur in the admission notes and in the descriptive narratives, in thatthey acknowledge the dynamic nature of psychological processes and move awayfrom the notion of symptoms as medical entities. However, prescriptions of what ishealthy for women are implicit in the explanatory narratives, and continue to placewomen in a double-bind. This double-bind is particularly paralysing in the case ofwoman abuse and the disclosure of abuse (Levett, 1989). Yet theories about the difficulties women have in disclosing abuse are limited in these psychiatric texts, totraditional psychodynamic or psychoanalytic theories: there is no incorporation ofrecent understandings of women's difficulties in labelling and naming abuse (Wood& Rennie, 1994).

Abuse and the medico-legalAs suggested previously, the depiction of abuse as a crime seems to emphasise itsexistence as external to the women, and is in apparent opposition to the positioningof abuse as a function of a patient's internal world and processes. Yet there is common ground between the objective language of law and 'facts', and the clinical orpsychiatric language of symptomology. Both have the effect of quantifying humanexperience, and run the risk of objectifying the woman who has experienced beingraped. The following excerpt is an example of how symptoms and legal 'facts' areinterwoven to produce an account of one woman's abuse experiences:

431



Tanya Wilson and Anna Strebel

Pt withdrawn and takes a long time to engage. Was raped 3 years ago by a manknown to her -laid a charge against him but he was acquitted. Was raped 2 monthsago by someone unknown to her. She laid a charge at [name of suburb] PoliceStation - doesn't know name ofinvestigating officer and claims she didn't get a casenumber. Pt has felt fluctuating suicidal ideation - currently asuicidaI. 3 previousODs in past 3 years. Pt denies suicidal ideation at present. Has recurrent intrusiverecollections about the rape. Therapeutic process and contract explained (WM).

The interplay between psychiatric and legal practices is partly influenced by the factthat the written entries in case documents can be legally actionable. However, it is alsoa manifestation oftwo institutional practices whose 'clientele' very often overlap. Partofpsychiatric management in a ward, such as the one used in this study, is to informpatients of their legal rights in relation to abuse. Such a policy has major effects onthe shaping of intervention strategies, and on the positioning and understanding ofthe patients who are admitted to the hospital with a history of abuse:

Plan: focus on court preparation - pt to prepare written account of rape and thenrole-play this on Thurs (TE).

The position of abuse as a crime in society places powerful pressure on women torespond to an experience ofabuse with legal action, and legal action requires detaileddisclosure of the abuse. At face value, this does not appear at odds with the discourseofpsychotherapy, which places value on the role ofdisclosure in the healing process.However, the law demands disclosure of a particular kind. Legal discourses affectprocesses ofdisclosure through their need to place unequivocal blame, their emphasison 'trustworthiness' and their insistence on a single version without contradictions(Hyden & Colgen-McCarthy, 1994). This is at odds with psychoanalytic (as wellas postmodem) accounts of subjective experience, in the sense that psychoanalysiswould assume such accounts to have multiple layers, and to involve memories thatare necessarily ambiguous and contradictory (Swartz, I996a). In the psychiatriccontext, where a powerful medico-legal language already exists, and where an aspectof the intervention strategy is to introduce patients to, and assist them through, thelegal system, it seems that the form disclosure ofabuse takes is often shaped by legalrequirements. Multiplicity of voice is made extremely difficult, if not impossible, inthe shadow of legal and medico-legal discourses.

Discourses of blame and responsibilityDiscourses of blame have been one of the major areas of analysis in the area ofwoman abuse (e.g., Gavey, 1993; Vogelman, 1990; Wood & Rennie, 1994). Theyare particularly pertinent in the psychiatric context, since the psychiatric framingof patients has been seen to perpetuate the blaming of women, simply by the wayin which it positions so many abused women as mentally ill. Issues of blame are a

432



·Psychiatric discourses of women abuse

strong component in the anti-psychiatry and feminist critiques of psychiatry, in thatsuch critiques challenge psychiatry's implicit 'blaming' of the individual for problems that are essentially social in nature. In addition to the general individualising ofsocial problems, there is also a more specific positioning of woman abuse as relatedto women's mental health and not men's.

Discourses ofblame are ubiquitous in psychiatric texts, and are apparent whenevercauses for particular states of distress are sought. The psychiatric writings used inthis study often opposed the explicit blaming of the women, as this was seen to causeadditional distress:

Pt tearful and distressed, particularlyabout the fact that the community are blaming her and accusing her of having voluntary sexual relations with alleged rapist(SO).

However, the implicit blaming of women was not entirely absent in psychiatriclanguage. For example, the diagnostic category ofpersonality disorders, particularlythe categories of Borderline Personality Disorder and Dependent Personality Disorder, when applied to a woman with a history of abuse, have the effect of dismissingthe role ofthe abuser and ofhighlighting the woman's complicity in her own abuse.Of the 10 women whose files were used for this analysis, five were diagnosed withDependent Personality Traits (or Disorder) and two with Borderline Personality Traits(or Disorder). A crude, but not inaccurate, summary ofthe discourses underlying suchlabeling is that a woman's inability to prevent continued abuse by a partner is due toher 'dependent traits'; or that her inability to prevent being raped is due to the selfdestructive traits that are part of the Borderline Personality Disorder. These are notuncommon discourses in ward rounds and case presentations ofpsychiatric patients.Personality Disorders are perhaps the most controversial of all psychiatric labels inthe context of woman abuse, not because the internal dynamics they refer to do notexist, but because their deployment has such a powerful effect of negating any otherunderstanding of the dynamics of woman abuse.

There was evidence in the texts that psychiatric categories were challenged at timesby other discourses or 'reality'. The clinical notes of one particular patient show ashift in the way she is positioned in relation to the abuse. Her first admission focuseson her Borderline traits, but in her second admission, she becomes positioned as a'battered wife'. The following quotation embodies this juxtaposition:

Relationship precedingmarriageandthereafterhasbeenphysically abusive. Pt saysthat shepushesher husbandto abuseher becauseshe is a bad personand thereforedoes not resist the abuse (e.g. punching in the face,nose broken) (BM).

The woman is described as feeling responsible for (and deserving of) the act ofmaleviolence. This description carries the notion, common to several discourses ofblame

433




within the context of gendered violence, that women desire and/or provoke abuse.Simultaneously, however, the clinician attempts to question this patient by presentingthe extreme details ofthe abuse ('punching in the face, nose broken') in brackets. Thisserves as a challenge to the patient's logic or judgement. The clinician's bracketedqualification implies that the patient is irrational and unreasonable. This questioningof her reasoning is part of a dominant psychiatric discourse that identifies pathologyby focusing on those who are seen to be 'unreasonable' (Parker et aI., 1995). At thesame time, such a challenge also exposes the actions of the husband, bringing an'Other' into the picture, and in this way, prevents the reader from looking only at thepatient's role in the abuse. Thus, while the clinician provides evidence for a diagnosticpicture of inner chaos by showing the extremity of the patient's inner sense of badness, he or she is also emphasising the external reality - and cruelty - of the abuser(somebody else actually punched her in the face and broke her nose). In the process,the blame is shifted from the patient to the husband. This double-layered reading ofthe abuse by the clinician is reflected in the final diagnosis of the patient, where sheis diagnosed with Borderline Personality Disorder ('inner madness discourse'), butalso several V-codes (including 'Partner Relationship Problem', 'Physical Abuse ofAdult' and 'Sexual Abuse ofAdult'), which point to interpersonal and social factorsand which de-individualise the problem as much as is possible within the diagnosticframework.

When the above-mentioned patient was re-admitted three weeks after her initialadmission, the reality ofmale violence became further emphasised as notes began tobe written about her husband and his controlling behaviour:

She was particularly distressed by her husband's demands to have the child for 2days and she felt powerless to deny him as he threatened to stop supporting herfinancially ... Pt also reported that husbandhas threatened to hurt her if he findsher flirting with male pts (BM).

During this second admission the intervention shifted to working with the couple.The availability of the discourse of woman abuse as a form of male control not onlyopened up understandings ofher distress, but was also powerful enough to transformthe practice ofpsychiatric intervention.

The failure of languageFeminist and post-colonial theories have highlighted the insidious process wherebycontrol over language and culture can result in the alienation of the identity of thosewho are having language imposed on them (Ashcroft, Griffiths & Tiffin, 1989; Butler,1990). The possible means of resistance to such alienating effects have also been asubject of much debate. These ideas can be extended to examine the imposition ofpsychiatric language and the alienating - or paralysing - effects it has on abused

434




women in particular. There is evidence ofthe difficulties women have in giving voiceto their abuse experiences in the psychiatric context. This is apparent in women'sresponses to the number of forces that pressurise them to put their experience ofabuse into language:

During an OT [occupational therapy] stress management group the pt became veryanxious when two other patients mentioned that something which caused them a lotof stress was when they were raped. The pt started shaking & then when her tumin group came to mention things which cause her stress, she was able to mentionthings like unemployment and then went on mentioning rejection by M, physical,sexual and mental abuse by H and being cheated on. While saying this she started toshake more and more and then ran out ofthe group and started cryinguncontrollably.T comforted pt and she was then able to relate her experience. She described thatwith the shaking she felt her heart throbbing in her, her mind going blank, feelingif she is going to collapse and reliving an experience ofabuse by H. Pt also relatedthat she has nightmares nearly every night and she feels very tired since she hardlyslept last night & also had a nightmare - unsure of content (BM).

Pt feels 'great relief' that her court case is in fact on 31/8/95 as clarified by Mrs H.In addition, she is having difficulty giving a written account of the rape and doesnot appear ready for a role-playas yet. This can be done at a later stage after morepreparation (TE).

In the above quotations, these difficulties are written about with a certain amount ofsympathy: BM 'became very anxious' and deserved to be 'comforted' by the grouptherapist; TE 'is having great difficulty in giving a written account of the rape'; andit is accepted by the clinician that she is 'not ready' and needs more time. However,the tone of the psychiatric entries changes when the patient is viewed as being moreactively resistant to writing the account of her abuse experience. It becomes lesstolerant, more judgmental and more prescriptive:

Pt has not so far presented as being particularly motivated to deal with any issues. Remains passive and has a slightly challenging, disinterested air about her.Confronted about this and requirements clarified in terms oftherapy. Needs to haverole-play and preparation for court appearance. Axis II issues appear to hinderher progress at present - should be given a chance to work, however, in therapy,following firm limit setting last Thurs (TE).

The difference between 'becoming anxious' and deserving 'comfort', and 'not beingmotivated to deal with any issues' and requiring 'confrontation' suggests a discoursein which it is understandable to become tearful and anxious when faced with speakingabout an abuse experience; but it is less acceptable to be actively defiant about it:

435




Participated in role-play of court proceedings. Past few days have been traumaticfor pt. She found it difficult to write her statement - & becametearful and threwbookaround room,slamming doorsetc.Was veryanxious whiledoingtherole-play- said it felt like the real thing. Was given feedback that she needs to stick to thefacts and remaincalm.Tends to behavepassive-aggressively (TE).

In the final line of the above quotation it is apparent that the legal prescription of'sticking to the facts' becomes a psychiatric prescription, since any deviation from,or resistance to this is seen as unreasonable and labelled passive-aggressive. TE'sapparent resistance to writing her statement is understood to be part of a defectivepersonality structure, as can be seen from the comments: 'Axis II issues appear tohinder her progress'; 'tends to behave passive-aggressively'. Two alternative interpretations need to be considered. The first relates to the understanding of traumaticexperiences as representing 'terrible, largely incoherent narratives ofevents too awfulto hold in consciousness' (Waitzkin & Magana, 1997). Such an understanding wouldinterpret the difficulty of writing a statement as due to the nature of the traumaticevent itself. From this point of view, TE might be responding naturally to an eventthat is unrepresentable for her. The second interpretation relates more specificallyto the limitations of psychiatry in offering a language in which to represent such anexperience. Much literature supports the healing effects of 'therapeutic narratives' oftrauma (Crossley, 2000; Herman, 1992), arguing that the 'unspeakable story' oftraumashould be brought into consciousness and put into words as a step towards healingand recovery. TE's resistance to 'putting into words' her experience might be a reaction against the fact that the categories and constraints of the available language(s)cannot do justice to her experience. In the psychiatric context where the degree ofnormalising power is so large and narratives are narrowed by legal constraints, thesewomen's stories may well be 'unrepresentable' (Butler, 1990). Their inability to writeor speak could represent a failure ofthe psychiatric context and its language, to makea healing narrative possible. The women's 'collapsing', their lashing out, which areframed in psychopathological terms, could thus be understood as reactions to, and aprotest against, this failure oflanguage. Such an interpretation connects with Levett's(1989) framing of the non-disclosure of abuse as an active refusal to participate inthe language of victimology. It also strongly calls into question the validity of thepsychiatric framework in the context of helping women who have been abused.

FURTHER DISCUSSIONOne ofthe main threads running through our analysis ofthe psychiatric documents hasbeen an emphasis on the power ofpsychiatric discourse. The extent ofits power is seenin psychiatry's tendency to 'swallow' an issue such as woman abuse, and to positionit as an object that can simply be incorporated into the psychiatric work of symptomfinding and disorder management. Implicit in our analysis is an argument that such an

436




appropriation is not only unsuitable, but also damaging, as it represents a blindnessto the growing need to address woman abuse as a distinctive social psychologicalissue, and also has the effect ofdisregarding the complexities ofwomen's experiencesof abuse. Two areas of discussion emerge from this assertion. The first is in the areaofpolicy planning: should woman abuse be treated as a psychiatric issue at all? Thesecond lies in the area of treatment: what are the implications of the constrainingeffects of psychiatric discourse on women, and how can these be addressed?

The ward discussed in this analysis is one that specifically caters for women whohave been sexually or physically abused. As such, it forms an explicit contrast to thepsychiatric discourses that diminish the importance of social issues. In our analysiswe show how this ward, at times, made use ofalternative discourses ofresponsibilitywith respect to acts of abuse, and in so doing shifted the focus away from women tomen and male violence. We show also how this was a struggle for clinicians, since therecords had to maintain a psychiatric appearance and the recording of the woman'sinternal symptoms had to continue. While there were times when the conventions ofpsychiatric practice were broken by intervention strategies that involved calling inmale perpetrators, the difficulties ofadhering to alternative discourses ofresponsibility, within the psychiatric institution, were clearly great.

Thus, while a ward like the one used in this study opens up some space foralternative discourses to be included in its form of psychiatric practice, it continuesto struggle with discrepancies between the requirements ofpsychiatry and appropriate intervention strategies that contradict psychiatric assumptions. These issues raisequestions about the role ofspecialised clinics or wards for abused women, and whetheror not these clinics should be under the auspices ofpsychiatry at all. Yet, psychiatrichospitals need wards like the one used in this study as an alternative to the medicolegal practices that dominate psychiatric institutions; however, one could argue thatthe legacy ofpsychiatric discourse remains so powerful and so time-consuming thatit hinders and compromises adequate services for abused women within its quarters.At present, abused women's alternative to psychiatric services is non-governmentalorganisations (NGOs), which are not adequately equipped to identify or managepsychiatric symptoms (Lebese, Strebel, McCarthy & van Wyk, 1998). Strategy planning therefore needs to target both psychiatric and NGO services, and provide eachwith the kind of resources and training that are lacking.

In addition to the implications this study has for policy planning around servicesfor abused women, there are implications for the way in which clinicians handle theissue of woman abuse. The normalising power ofpsychiatric practice indicates that,ifalternative understandings ofwoman abuse are to be incorporated, there need to beactive strategies aimed at doing this. This article raises two important mental healthissues that psychiatric work in South Africa needs to accommodate: first, the role ofgendered power relations in woman abuse and, second, understandings of traumathat are more complex than DSM-IV diagnoses. We have already shown how the

437



TanyaWilsonandAnnaStrebel

double-standards in health care for women and men are further perpetuated bypsychiatric and legal institutions' insistence on disclosure, and their simultaneoussuppression of any expression of ambivalence or ambiguity. The implications forpsychiatric practice are that clinicians need to be made more aware of the effects ofsuch constraining and, at times, paralysing forces on abused women's experiences ofabuse, as well as their experiences of treatment. This does not constitute a demandthat the contradictions be disposed of, but is an argument for an acknowledgement ofthese contradictions, as well as a request for sensitivity to the additional constrainingeffects that institutional practices can place on abused women. Bolstering awarenessamong psychiatric clinicians of the issues that this study has raised is crucial if theyare to be addressed. Yet it is important to note that psychiatric regulations have anequally constraining effect on clinicians and unless psychiatric practice has a radicalmake-over, at all levels, its limiting code ofpractice will continue to dominate.

We now turn to some theoretical and methodological issues raised by this research.The analysis ofthe study is based on a view suggesting that psychiatric documents arethe primary medium through which psychiatric knowledge is formulated, circulatedand sustained (Swartz, 1996b). This, by extension, implies that the documents bothrepresent and construct the form that psychiatric practice takes. Yet there remains adisjuncture between what is spoken in psychiatric interviews and how it is inscribedin the documents (Barrett, 1988). Analysing spoken language might give more voiceto women psychiatric patients than we have been able to doin this study, and wouldcertainly provide greater access to alternative discourses that are actually articulatedby these women themselves, rather than assumed by us, as researchers. The use ofdocumentation as text, together with our particular aims as researchers in the field ofwoman abuse, has produced one form ofanalysis ofpsychiatric practice. This couldbe enriched by future discourse analytic research into how woman abuse is spokenabout in psychiatric hospitals.

Finally, it is necessary to acknowledge some of the limitations of discourseanalysis itself, as they have become evident through this study. Discourse analysisis theoretically and methodologically based on the 'turn to language', its main assumption being that language is central to all human activity. There is the danger oftranslating this into a simplistic formula, which argues that language is the carrier ofall social ills and that, if one changes the language, social problems will change forthe better. It must be acknowledged that psychiatric services in South Africa are subject to multiple constraints, some ofwhich stem from the country's political history,including the separation ofservices during apartheid, the necessary transformation ofservices after the change of government in 1994, and the far from primary positionthat mental health has been accorded by the current government in the hierarchy ofsocial needs. Constraints include insufficient funding, the rationalisation ofpsychiatricservices, the vast number ofpeople in need ofpsychiatric services, and the distressingnature of the work itself. While discourse analysis shows up some of the blindness

438



Psychiatric discourses of womenabuse

in South African psychiatry today, the weight of the necessities which burden thesepsychiatric services also may be said to reveal the limitations of discourse analysisitself, at least with regard to its capacity to effect large-scale change. Nevertheless,using discourse analysis to examine psychiatric services, and to expose some of itslimitations, does provide a valuable contribution to the larger challenge ofdevelopingappropriate services, precisely because such services are mediated and legitimatedthrough language.

CONCLUSIONUsing discourse analysis to examine psychiatric texts, this study investigated howSouth African psychiatric services understand and respond to female patients' experiences of physical and sexual abuse. Notwithstanding the limitations of discourseanalysis in the context of a psychiatric hospital that is struggling with multipleconstraints, this study has nevertheless underlined the pervasive effects ofthe languageofpsychiatry. What has emerged is a variety ofissues that have raised questions aboutthe suitability ofpsychiatric institutions, as they operate currently, for dealing effectively with issues ofwoman abuse. In spite of the existence ofresistant forces withinthe psychiatric institution used in this study, the most prominent finding of the studypoints to the unyielding nature ofpsychiatric language and the constraining effects thatit has on experience. Given the likelihood that psychiatric institutions will continue tosee and treat vast numbers ofabused women, there is a need for clinicians to activelyresist psychiatry's constraining effects, by giving themselves, and their patients, thespace to speak the contradictions and ambiguities of experience.

NOTE1. The initials of the patients have been changed.

REFERENCESAdams, P., Towns, A. and Gavey, N. (1995). Dominance and entitlement: The rhetoric men

use to discuss their violence towards women. Discourse and Society, 6,387-407.Al-Issa, I. (Ed.) (1982). Gender andpsychopathology. New York: Academic Press.Apartheid Acts (200I). The Group Areas Act, Mixed Marriages Act andImmorality Amendment

Act. <http://www.history.und.ac.za/soweto/aparthei1.htm.> Accessed on 04 August2004.

Ashcroft, B., Griffiths, G. and Tiffin, H. (1989). The empire writes back: Theory andpracticein post-colonial literature. London: Routledge.

Barrett, R. (1988). Clinical writing and the documentary construction ofschizophrenia. Culture,Medicine and Psychiatry, 12, 265-299.

Bordo, S. (1993). Feminism, Foucault and the politics of the body. In C. Ramazanoglu. (Ed.),Up against Foucault: Some explorations ofthe tensions between Foucault andfeminism(pp. 179- 202). London: Routledge.

Broverman, I., Broverman, D., Clarkson, F., Rosenkrantz, P. and Vogel, S. (1970). Sex-role

439




stereotypes and clinical judgments of mental health. Journal ofConsulting and ClinicalPsychology, 34(1), 1-7.

Buckley, M. (Ed.) (1986). Essentialpapers on object relations. New York: New York UniversityPress.

Burman, E. and Parker, I. (Eds) (1993). Discourse analytic research: Repertoires andreadingsoftexts in action. London: Routledge.

Burnam, M., Stein, J. and Siegel, 1. (1988). Sexual assault and mental disorders in a communitypopulation. Journal ofConsulting and Clinical Psychology, 56(6),843-850.

Busfield, 1. (1994). The female malady? Men, women and madness in nineteenth centuryBritain. Sociology, 28(1),259-277.

Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. London:Routledge.

Campbell, R. and Raja, S. (1999). Secondary victimization ofrape victims: Insights frommental health professionals who treat survivors of violence. Violence and Victims, 14(3),261-275.

Chesler, P. (1972). Women and madness. New York: Doubleday.Conrad, P. (1981). On the medicalisation of deviance and social control. In D. Ingleby,

(Ed.), Critical psychiatry: The politics ofmental health (pp. 102-119). Hannondsworth:Penguin.

Cox, D., Stabb, S. and Hulgus, J. (2000). Anger and depression in girls and boys: A study ofgender differences. Psychology ofWomen Quarterly, 24, 110-112.

Crossley, M. (2000). Deconstructing autobiographical accounts of childhood sexual abuse:some critical reflections. Feminism & Psychology, 10(1), 73-90.

Dill, D., Chu, 1., Grob, M. and Eisen, S. (1991). The reliability of abuse history reports: Acomparison of two inquiry formats. Comprehensive Psychiatry, 32(2), 166-169.

Ehrlich, S. (1998). The discursive reconstruction of sexual consent. Discourse & Society,9(2), 149-171.

Fairclough, N. (1992). Discourse and social change. Cambridge: Polity Press.Fischbach, R. and Herbert, B. (1997). Domestic violence and mental health: Correlates and

conundrums within and across cultures. Social Science and Medicine, 45(8), 1161-1176.Foucault, M. (1967). Madness and civilization. London: Tavistock.Gavey N. (1993). Technologies of heterosexual coercion. In S. Wilkinson and C. Kitzinger

(Eds), A feminism andpsychology reader (pp. 93-119). London: Sage.Herman, J. (1992). Trauma and recovery. New York: Basic Books.Hyden, M. and Colgan-McCarthy, I. (1994). Woman battery and father--daughter incest

disclosure: Of denial and acknowledgement. Discourse and Society, 5,543-565.Ingleby, D. (Ed.) (1981). Critical psychiatry: The politics ofmental health. Hannondsworth:

Penguin.Kaplan, M. (1983). A woman's view of the DSM-III. American Psychologist, 68,786-791.Katz, A. and Shotter, J. (1996). Hearing the patient's voice: Towards a social poetics in

interviews. Social Science and Medicine, 43(6),919-931.Klonoff, E., Landrin, H. and Campbell, R. (2000). Sexist discrimination may account for

well-known gender differences in psychiatric symptoms. Psychology ofWomen Quarterly,24,93-99.

Konradi, A. (1996). Preparing to testify. Rape survivors negotiating the criminal justice process.

440




Gender & Society, 10(4),404-432.Koss, M., Heise, L. and Russo, N. (1994). The global burden of rape. Psychology ofWomen

Quarterly, 18,509-537.Laidlow, T. and Malmo, C. (Eds) (1990). Healing voices: Feminist approaches to therapy

women. San Francisco: Jossey-Bass.Larkin, J. and Popaleni, K. (1994). Heterosexual courtship violence and sexual harassment:

Private and public control of young women. Feminism and Psychology, 4(2),213-227.Lebese, L., Strebel, A., McCarthy, G. and van Wyk, A. (1998). Rationalisation ofpsychiatric

and mental health services in the Western Cape. Cape Town: Department of Health.Levett, A. (1989). Psychological trauma: Discourses on childhood sexual abuse. Unpublished

doctoral thesis, University of Cape Town, Cape Town.Littlewood, R. and Lipsedge, M. (1986). The 'culture-bound syndromes' of the dominant

culture: Culture, psychopathology and biomedicine. In J. Cox (Ed.), Transculturalpsychiatry (pp. 253-273). London: Croom Helm.

Lonsway, K. and Fitzgerald, L. (1994). Rape myths. Psychology of Women Quarterly, 18,133-164.

Murray, L. (1993). Relationship of child sexual abuse to Borderline Personality Disorder,Post-Traumatic Stress Disorder and Multiple Personality Disorder. Journal ofPsychology,127(6),657-675.

O'Conner, P. (1995). Discourse of violence. Discourse and Society, 6(3),309-318.Parker, I. (1992). Discourse dynamics. London: Routledge.-. (1994). Discourse analysis. In P. Banister, E. Burman, I. Parker, M. Taylor and C. Tindall

(Eds), Qualitative methods in psychology: A research guide (pp. 92-107). Buckingham:Oxford University Press.

Parker, I., Georgaca, E., Harper, D., McLaughlin, T. and Stowell-Smith, M. (1995).Deconstructing psychopathology. London: Sage.

Pilgrim, D. and Rogers, A. (1993). A sociology ofmental health and illness. Buckingham:Open University Press.

Schwarz, I. (1991). Sexual violence against women: Prevalence, consequences, societal factorsand prevention. American Journal ofPreventative Medicine, 7(6),363-373.

Showalter, E. (1987). Thefemale malady: Women, madness and English culture, 1830 - 1980.London: Virago.

Sinason, V. (2000, August). The public and private faces of trauma. Paper presented at theUniversity of Cape Town Child Guidance Clinic, Cape Town.

Smith, D. (1974). The social construction ofdocumentary reality. Sociological Enquiry, 14(4),257-267.

Squire, C. (1989). Significant differences: Feminism in psychology. London: Routledge.Strebel, A. and Leon, N. (1996, September). Abuse experiences in the lives of women

psychiatric patients. Paper presented at the Third Annual Conference ofthe PsychologicalSociety of South Africa, University of the Witwatersrand, Johannesburg.

Swartz, S. (1984). Discourse analysis of interviews with manic patients. Unpublished Master'sthesis, University of Cape Town.

-. (1996a). Shrinking: A postmodem perspective on psychiatric case histories. South AfricanJournal ofPsychology, 26(3), 150-156.

Swartz, S. (1996b). Colonialism and the production of psychiatric knowledge in the Cape,

441



TanyaWilsonand AnnaStrebel

1891- 1920. Unpublished doctoral thesis, University of Cape Town.Ussher, J. (1991). Womens madness: Misogyny or mental illness. New York: Harvester

Wheatsheaf.Vogelman, L. (1990). Violent crime: rape. In B. McKendrick and W.Hoffman (Eds), People

and violence in South Africa (pp. 96-134). Oxford: Oxford University Press.Waitzkin, H. and Magana, H. (1997). The black box in somatization: Unexplained physical

symptoms, culture and narratives of trauma. Social Science and Medicine, 45(6),811-825.

Warshaw, C. (1993). Limitations for the medical model in the care of battered women. In P.Bart and E. Moran (Eds), Violence against women: The bloody footprints (pp. 134-146).Newbury Park: Sage.

West, C. (1984). Routine complications. Bloomington: Indiana University Press.Wexler, B., Lyons, L., Lyons, H. and Mazure, C. (1997). Physical and sexual abuse during

childhood and the development of psychiatric illnesses during adulthood. Journal ofNervous and Mental Disease, 185(8),522-524.

Willie, C., Reiker, P., Kramer, M. and Brown, B. (Eds) (1995). Mental health, racism andsexism. London: Taylor & Francis.

Wood, L. and Rennie, H. (1994). Formulating rape: The discursive construction of victimsand villains. Discourse and Society, 5, 125-148.

442



Psychiatric discourses of woman abuse - CiteSeerX

Documents