Case Western Reserve University doctoral candidate Sarah E. Rubin, with the guidance of Dr. Eileen Anderson-Fye, will undertake research on the cross-cultural relevance of disease categories. Over the past three decades, prevalence studies, diagnostic instruments, and treatment programs have been exported across the globe to diagnose and treat conditions without a complete understanding of whether these diagnostic concepts retain meaning and explanatory power in contexts outside of the Western locales where they were created and codified.
The specific focus of Rubin's research will be postnatal depression, a diagnostic category that may or may not be salient in every cultural or economic context. She will investigate postnatal depression diagnoses in a poor, urban community near Cape Town, South Africa. She will address both the relevance of the diagnostic category and the local experience of motherhood by investigating the intersection of mothers' social roles and emotional experience in the postnatal period. She will explore the processes by which daily adversity influences the motherhood role and practice, perceptions of emotional distress in the postnatal period, and how the concept postnatal depression is used and understood in the clinical context. The study will combine longitudinal interviewing, direct observation, and participant observation with the administration of standardized questionnaires and cultural consensus modeling.
This research is important because it will contribute to our understanding of the cultural construction of motherhood and mothering; to our understanding of the global burden of mental illness on women, specifically as it is affected by social roles such as motherhood and chronic adversity; to theories of how social role, emotion, and social context are iteratively constructed; and to our understanding of the processes and consequences of exporting Western diagnostic concepts to other cultures and communities. This research will also support the education and training of a social scientist.
Research goals: The research set out to explain the relevance of the diagnosis "postnatal depression" in a poor, urban Xhosa South African context by exploring the processes by which the daily adversity of township life influences the motherhood role and practice, perceptions of emotional distress in the pre- and postnatal period, as well as how the concept "postnatal depression" is used and understood in the clinical context. Research methods and activities: The research was ethnographic and mainly qualitative. Research activities included 1) direct observation of mainly Xhosa clinic staff at a public maternity clinic; additional observation of some clinic staff at their homes and in the community; 2) structured and semi-structured interviews with clinic staff; 3) structured, semi-structured, and open-ended interviews with Xhosa women recruited during their pregnancy from the clinic patient pool and followed through their first postnatal year; structured interviews which included a brief survey with qualitative and quantitative aspects; 4) participant and direct observation at their homes. Research findings: During pregnancy, experiences that impact emotional distress focus on whether the pregnancy was desired and mechanisms of disclosure to the family and partner. New HIV diagnosis also affects pregnant woman’s emotional distress since testing is routine at this prenatal clinic. After birth, experiences that impact emotional distress tend to focus on securing and negotiating social support, including emotional support, especially from family and the baby’s father; and securing resources such as money, food, and shelter. Preliminary analysis: This study documented many different experiences that cause Xhosa women emotional distress and two general categories of distress emerged; called, by the researcher, "everyday struggles" and "exceptional struggles." "Everyday" struggles are those experiences that, while negative and upsetting, are perceived by Xhosa women as mundane, and are seen as occurring with frequency in the community. Everyday struggles are coped with primarily by what can be called "normalization," which has three main mechanisms: a) self-talk, e.g. "this kind of thing happens to everyone;" "I’ll persevere" (ndizonyamazela); b) finding others with the same problem who can offer advice; c) avoidance and/or denial, so as to return to their "normal" life. "Exceptional" struggles are those experiences that are seen by Xhosa women as rare, deeply upsetting, and difficult to cope with. Exceptional struggles are coped with by normalization if possible, strategically accessing social support, withdrawing from or paring down of social network, arranging for children to be raised by other family members according to Xhosa kinship customs, seeking professional support. Preliminary conclusions: Through preliminary analysis some aspects of an ethnopsychology of Xhosa mothers emerged. In general, Xhosa mothers understand their emotions as directly caused by and related to their experiences in the world. They are situational, in that a) emotions are always about something, and b) emotions are not seen as capable of transcending experience or existing in the absence of experiences; in other words, once the stimulus is gone, the emotional response disappears or transforms. Or, if the stimulus is long-term (e.g. a cheating husband) or permanent (e.g. a death in the household), different strategies are used to cope, with an ultimate goal of shedding the negative emotions caused by the experience. Although becoming and being a mother creates numerous experiences that can cause emotional distress, Xhosa mothers tend to understand motherhood more by what they do than how they think or feel. Mothers are seen by themselves and the community to have unique bonds with their children; and are usually expected to shoulder more responsibility than other family members for their children’s well-being. While this could be seen as making mothers more vulnerable to emotional distress, Xhosa mothers themselves rarely see their lives as different from anyone else, nor do they see themselves as uniquely vulnerable (or resilient) to emotional distress simply by virtue of being a mother. Intellectual Merit: This study will 1) contribute to our understanding of the cultural construction of motherhood; 2) contribute to our understanding of the global burden of mental illness on women, specifically as it is affected by social roles such as motherhood and chronic adversity such as urban poverty; 3) contribute to theories of how social role, emotion, and social context are iteratively constructed; and 4) contribute to our understanding of the processes and consequences of exporting Western diagnostic concepts to other cultures and communities. Broader impacts: Because maternal emotional distress may not be locally constructed as a medical or mental health issue, this research expands our understanding of "postnatal depression" and invites a critical stance toward pronouncements of the universal burden of "postnatal depression." Nevertheless, sound research illustrates that women suffer under adverse conditions worldwide, regardless of whether we define their suffering as mental illness or more broadly. Understanding how culture and social context impact the subjective experience and understanding of suffering is essential for understanding why women suffer disproportionately from emotional distress, including mental illness, and how we can successfully intervene.
