DOWN BUT NOT OUT IN THE BUSH:
WOMEN’S EXPERIENCES OF DEPRESSION
IN RURAL NEW SOUTH WALES
Stephanie Johnson Bachelor of Social Work Master of Social Work
Supervisors Associate Professor Mark Brough Dr Rosalyn Darracott
Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy
School of Public Health and Social Work Faculty of Health Queensland University of Technology 2018
Keywords
Depression Feminist Rural Support Women
2 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Abstract
Biomedical research reports that depression is twice as common in women as men (American Psychiatric Association, 2013; Piccinelli & Wilkinson, 2000). Rural women’s experiences of depression are of concern because of the barriers they face in accessing services and health care, due in part to factors such as isolation, violence, stigma, stoicism, and poverty (Alston et al., 2006). Despite numerous studies on depression, the literature contains only one mixed methods study and one qualitative study that address the topic of rural Australian women’s experiences of depression. This thesis argues that women’s experiences and experiential knowledge, as well as the challenges faced by women living in the bush, have not been adequately considered by previous research and that the accounts of these women are valid as a source of knowledge in their own right. Hearing from women about their lived experiences provides a rich source of information that may not be revealed without a qualitative study that begins and ends with the women as the central focus.
The overall purpose of this study was to understand the lived experiences of women who were experiencing depression within the context of rural NSW. To do this, four broad objectives were developed:
• to explore the women’s own understandings of the lived experience of depression and its causes;
• to consider whether the experiences of women living in rural NSW may have affected or influenced their depression experiences and, if so, in which ways;
• to identify what intervention/support options women chose, if any, and the reasons for their choices; and
• to examine how these women coped with and recovered from their experiences of depression.
The dominant discourse in health has been the biomedical model, which can be seen as politically conservative and individualistic in orientation. This thesis explains the positions of both biomedical and psychological perspectives, and expands upon the biomedical discourses by including other discourses such as feminist and social constructionist frameworks. This study does not necessarily endorse the biomedical diagnosis of depression as “truth” but instead
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 3 uses the term depression as an ever-evolving package of contested meanings. A critical starting point for this research is women’s own experiences and definitions of depression. Therefore, participants in the study may have received a biomedical diagnosis of depression, or the women themselves had defined their experiences as depression. While most had accessed professional help, this was not a requirement of participation in the study.
There were 27 women who participated in the semistructured interviews, which were informed by qualitative methods using a feminist standpoint framework. Thematic analysis was employed to analyse the data from the interviews. Seven themes were identified from the data analysis: women’s understandings and explanations of depression, how depression disrupts everyday life, living in rural NSW with depression, abusive childhood experiences, grief and loss, accessing professional help and services, and accessing informal help and support. Drawing from these themes overall there was a sense that the women’s stories held multiple meanings of living with depression, and there was diversity in their understandings of their rural experiences, and how they coped with their depression experiences. The women used a variety of creative means to get assistance for their distress, and some rejected biomedical help.
In the final analysis, the underlying premise of a possible lack of service provision in rural areas seemed to serve more as a distraction from the critical issues of violence, male privilege, and oppression that the women had experienced. The study found that difficult relationships, loss, and childhood abuse and violence had been a part of and had continued to impact many of the women’s lives. In fact, it seemed that depression may not have been an appropriate term for what many of the women were experiencing; instead, the findings suggest that the term depression as it is biomedically used may need to be challenged: What many of the women seemed actually to be experiencing was oppression rather than depression.
4 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Table of Contents
Keywords ...... 2
Abstract ...... 3
List of Figures ...... 9
List of Tables...... 10
List of Abbreviations...... 11
Statement of Original Authorship ...... 12
Acknowledgements ...... 13
Chapter 1: Women’s Experiences of Depression ...... 14
Research Standpoint ...... 15
Justification for the Study ...... 16
Purpose of the Study ...... 17
Operational Definitions ...... 17
Brief Description of Methods...... 18
Organisation of the Thesis ...... 19
Chapter 2: Approaches and Understandings of Depression...... 21
Historical Understandings and Therapeutic Interventions of Depression...... 21
Mental Health Service Delivery in Contemporary Australia ...... 23
Explanatory Theories of Depression ...... 25
Biomedical explanations...... 25
Critique of the biomedical model...... 28
Psychological and psychosocial explanations...... 31
Critique of psychological and psychosocial explanations...... 32
Intersectional feminism and social constructionist explanations...... 33
Intersectional feminism...... 34
Social constructionism...... 35
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 5 Critique of feminist and social constructionist theories...... 37
Summary ...... 38
Chapter 3: Literature Review...... 39
International Literature Regarding Women’s Experiences of Depression ...... 40
Notions of self, intimate relationships, and gendered role expectations. ... 40
Loss, poverty, and family and life stressors...... 43
Abusive childhood experiences and violence...... 45
Australian Qualitative and Mixed Methods Studies on Women’s Depression .. 47
Summary ...... 51
Chapter 4: Rurality and Mental Wellbeing in Rural Australia ...... 52
Rural Australian Landscapes: The Impact of Place on Health ...... 52
Health Status ...... 54
The Economy, Education, and Employment in Rural Australia ...... 56
Rural Australian Culture, Values, and Community ...... 58
Social class structures...... 58
Help-seeking and the barriers to access help for rural women: Gossip, stigma, and anonymity...... 59
Women and rural Australia...... 61
Power and violence...... 63
Summary ...... 64
Chapter 5: Research Methodology...... 66
Qualitative Methodology ...... 66
Feminist Research and Feminist Standpoint Theory ...... 67
Feminist standpoint theory...... 67
Location of the Study ...... 70
Methods ...... 73
Recruitment and sampling...... 73
Size...... 74
6 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Participants...... 74
Data collection methods...... 78
Interviews ...... 78
Interview rationale and process...... 79
Interview context...... 80
Data Analysis Techniques ...... 81
Ethical Issues ...... 83
Limitations of the Study ...... 86
Summary ...... 86
Chapter 6: The Women’s Voices ...... 88
Women’s Understandings and Explanations of Depression ...... 88
Biological understandings...... 88
Social-environmental understandings...... 89
Multiple understandings...... 90
How Depression Disrupts Everyday Life ...... 92
Women’s ongoing depression experience...... 95
Living in Rural NSW with Depression ...... 96
Rurality as an aid to coping...... 97
Rurality as a hindrance to coping...... 100
Rurality as both a hindrance and a help: Multiplicity of views...... 101
Abusive Childhood Experiences ...... 102
Grief and Loss ...... 108
Accessing Professional Help and Services ...... 113
Accessing Informal Help and Support ...... 118
Spiritual faith as an aid to coping...... 121
Summary ...... 124
Chapter 7: Discussion ...... 126
1. Multiple Meanings of Depression ...... 126
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 7 2. Diversity of Rural Experiences and Help-Seeking ...... 128
Differing access and help experiences in rural NSW...... 128
Social factors impacting on help-seeking in rural NSW...... 130
Help-seeking and spirituality...... 131
3. Difficult Relationships, Loss, and Childhood Abuse ...... 132
Self-worth, identity, and relationships...... 132
Loss and powerlessness...... 133
Childhood abuse and violence in women’s lives...... 134
Summary ...... 139
Chapter 8: Conclusion ...... 141
Reflections...... 141
Main Findings, Recommendations, and Implications for Practice ...... 144
References ...... 149
Chapter 9: Appendices ...... 160
Appendix A: Social Demographics Information and an Overview of the Women160
Appendix B: Social Demographics Questionnaire ...... 162
Appendix C: Selection Criteria Interview Schedule ...... 163
Appendix D: Interview Question Guide ...... 164
Appendix E: Participant Information and Consent Form ...... 165
Appendix F: Ethics Approval...... 170
8 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW List of Figures
Figure 1. Rural Landscape, Riverina, NSW...... 54
Figure 2. Commonwealth Electoral Division of Riverina Map...... 72
Figure 3. Lake Albert, Wagga Wagga, NSW...... 73
Figure 4. Rural Landscape, Riverina, NSW...... 98
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 9 List of Tables
Table 1. Social Demographics of Participants…………………………………….75
10 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW List of Abbreviations
APCs Aspirin, phenacetin, and caffeine (tablet) CBT Cognitive behavioural therapy DSM–5 Diagnostic and Statistical Manual of Mental Disorders (5th edition) EMDR Eye movement desensitisation and reprocessing GP General practitioner ICD–10 International Statistical Classification of Diseases and Related Health Problems (10th edition) NSW New South Wales RRMA Rural, remote, and metropolitan areas classification
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 11 Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made.
QUT Verified Signature Signature:
Date: 20/02/2018
12 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Acknowledgements
Firstly, I would like to thank the 27 women who gave up their time and shared their stories for this study in the hope that their stories would help other women living with depression. I was privileged to hear the women’s stories of persistence, courage, and determination in the face of oppression and adversity.
Secondly, this thesis is a culmination of years of work and I would like to express my sincere gratitude to my principal supervisor, Associate Professor Mark Brough, for his continuous support of my PhD thesis and for the patience, motivation, and immense knowledge that he has given me over the years.
I would also like to thank the rest of my thesis committee, Dr. Ros Darracott, for her insightful comments and encouragement, but also for her commitment to excellence in research. She has been very helpful to this thesis topic and to the progression of my PhD, and I am grateful.
I would like to thank my editor, Kylee McDonagh, who has provided copyediting and proofreading services according to the guidelines laid out in the university-endorsed National Guidelines for Editing Research Theses.
I would like to thank my mother, Jannette, for her helpful comments and support in the early stages of the PhD, and am grateful to both my parents, who have been supportive of me in this endeavour.
Last, but not least, I would like to thank my family, my husband Mark and my children, for supporting me throughout the research and writing of this thesis.
This thesis is dedicated to my grandmother, Inga Madge, who faced adversity and hardship throughout her life; she was not afforded any opportunity to publicly display her intelligence and so I dedicate this thesis to her and also to my sister, Jennifer, who has been my best friend and my inspiration: This is dedicated to both of you.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 13 Chapter 1: Women’s Experiences of Depression
Depression, as constructed by biomedical discourses, is seen as a leading cause of disability among women and is one of the major health concerns for the World Health Organisation (World Health Organisation [WHO], 2012). In developed nations, it has been found that women are more likely to be diagnosed with a depressive disorder than men (American Psychiatric Association [APA], 2013; Nolen-Hoeksema, 2001). The experience of depression is considered more prevalent in younger women who are caring for children at home, those living on low incomes, and those who are divorced or separated or subjected to violence (Bifulco & Moran, 1998; Brown & Harris, 1978; McGrath, Keita, Strickland, & Russo, 1990; Mirowsky, 1996; Stoppard, Scattolon, & Gammell, 2000). Compared to men, women are more likely to experience negative life events such as physical and sexual abuse, violence, and poverty (Nolen-Hoeksema, 2001; Piccinelli & Wilkinson, 2000), and these negative life events are often risk factors for women receiving a diagnosis of depression. Women living in rural locations, such as rural Australia, can experience considerable barriers to accessing help and can be among the country’s most vulnerable populations because of their isolation, which also requires them to travel long distances to access help and support networks (Alston et al., 2006). Added to these challenges is a reluctance to utilise available health services or their own support networks due to concerns about confidentiality, the stigma generally attached to mental illness, the value and attitudes of stoicism, and the negative connotations of seeking help outside of the family by receiving assistance from professionals (Alston et al., 2006; Dolja-Gore, Loxton, D’Este, & Byles, 2014).
Numerous international qualitative studies have explored women’s lived experience of depression and its interconnectedness with relationships, gender, and social contexts (Hurst, 2003; Jack, 1991; Lafrance, 2009; Scattolon, 1999, 2003; Schreiber, 1996, 2001; Stoppard, 2000; Stoppard & Gammell, 2003; Stoppard et al., 2000). However, among the Australian qualitative and mixed methods studies of women’s depression, only two have focused on rural Australian women and depression: the work of Day (2000) and that of Fullagar and O’Brien (2009). Of these, only Fullagar and O’Brien adopted a qualitative, exploratory approach to women’s lived experience of recovery from depression, and their study included both urban and rural Australian participants.
14 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Research Standpoint
The stories of women’s life experiences that I have heard for more than 25 years in my professional career as a social worker and counsellor inspired my decision to embark on this research topic. My particular interest stemmed from working with women who had experienced emotional, sexual, and physical abuse. In addition to the ongoing negative impact of the violence on these women’s lives, I observed that many of my clients reported experiencing depression and other mental health concerns. Having been privileged to listen to women’s stories of their journeys, I became interested in documenting these stories as a means to informing policy and practice in this area. Over the years, I observed that some women’s stories of overcoming depression did not necessarily fit within an expert biomedical view of depression; instead, some of the women had multiple meanings of their depression experience, often based in relational and social understandings. This thesis is my attempt to give voice to feminine wisdom and the knowledge base of women, as well as to provide an opportunity to hear from an often silent and marginalised group.
I am interested in the feminist approach to research, as it seeks to take account of and highlight the oppression and discrimination that women are often subjected to in both private and public spheres. Feminist research is interested in the lived experience of the participants, namely (but not exclusively) women. Feminism aims to raise public consciousness, and seeks to demonstrate how oppression, violence, and abuse keep women in vulnerable and marginalised positions. Feminist theory also highlights that power differentials exist in all spheres of life, including among researchers; for this reason, I adopted a feminist framework to assist me in an awareness of power differentials between the researcher and the researched (Letherby, 2003).
In feminist research, it is important to name any personal beliefs that may impact on or influence the study’s direction. This is based on an assumption that no researcher is free from subjective opinions. Feminist research encourages both reflection in practice and transparency about preexisting beliefs in order to foster an openness and willingness to discover and consider the alternative perspectives that participants may hold. In keeping with this notion, some preexisting beliefs that I hold as a researcher are
• humans construct the meaning of an experience through their own preexisting beliefs, experiences, values, and filters;
• human existence is not independent of the world, but interacts with it;
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 15 • people, in general, want to be well;
• women are, in general, relational and seek out relationships in order to be fulfilled;
• depression is up to the individual to self-define if they so choose;
• women can have multiple understandings of the causes of depression; and
• women are vulnerable to violence, oppression, gender inequality, and poverty.
Justification for the Study
There were two Australian studies on rural women’s depression. The earliest of these studies was a doctoral mixed methods study conducted by Day (2000) that focused on the psychological model of learned helplessness to explain and treat rural women’s depression. The learned helplessness model is a theory about how people view their problems and the extent of their agency over them (Day, 2000). Day involved 76 women participants in a three- week group-work program. One group received no treatment, one received cognitive behavioural therapy (CBT), and one received the prevention strategies from the learned helplessness model. Day demonstrated that interventions aimed at preventing depression in rural Australian women can be assisted by the use of traditional treatments such as CBT, and advocated the use of prevention strategies derived from the learned helplessness model. The learned helplessness model group did better overall in the post-six-months’ follow up regarding depression experiences. Day’s mixed methods study is the only research identified that focused solely on rural Australian women experiencing depression, and was treatment-focused rather than lived-experience focused.
The second study, from researchers Fullagar and O’Brien (2009), was a qualitative exploration of how both rural and urban Australian women gave meaning to their experiences of recovery from depression. Fullagar interviewed 80 female participants aged 20 years and over and found that complex relationships, gender inequities within the family, and unrealistic gendered expectations of self were identified in relation to their depression experiences. These two studies will be discussed in more depth in Chapter 3, but the fact that no studies were found that focused solely on rural women’s lived experiences of depression suggests that the experience of women in rural Australia who identify as living with depression is not well researched nor well understood.
16 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW This study adopts a feminist and social constructionist approach that begins with the women themselves and orientates the researcher (myself) to learn from the women’s experiences and standpoints, rather than just assuming knowledge of their positions. In keeping with feminist research, it was crucial to seek out and to give voice to the women by hearing their own accounts of their lived experiences of depression, with the intention of better informing society’s understanding of women living with depression in rural New South Wales (NSW). In addition, by using a feminist framework, I was able to provide a platform from which to understand depression in a range of contexts: social, cultural, relational, structural, and environmental. Furthermore, from this reference point, I was able to explore the role that gender and the social constructions of depression play in the diagnosis of depression in women.
Purpose of the Study
The overall purpose of this study was to understand the lived experiences of women in rural NSW with depression. To do this, four broad objectives were developed:
• to explore the women’s own understandings of the lived experience of depression and its causes;
• to consider whether the experiences of living in rural NSW may have affected or influenced the women’s depression experiences and, if so, in which ways;
• to identify what intervention/support options women chose, if any, and the reasons for their choices; and
• to examine how these women coped with and recovered from their experiences of depression.
Operational Definitions
In this study, the participants were free to use their own terms to define and describe their experiences of depression, some of which did not necessarily fit the biomedical criteria. It is noted that, depending on the women’s own expression of their experiences, some participants used biomedical terms as a way of naming their experiences while others used no biomedical terms.
A second key definition relates to the geographical location of the study. While definitions of rural are generally based on population size or location, some definitions also
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 17 include types of occupations—such as farming, fishing, and hunting—that are often applicable to a rural context. The rural, remote, and metropolitan areas classification (RRMA) was used as a geographical measurement to identify areas as being rural and remote. In particular, the R1, R2, and R3 classifications of rural, which are based on population, are relevant to the Riverina area of NSW where this study was located:
Rural—R1: Large rural centres with a population 25,000–99,000
Rural—R2: Small rural centres with a population 10,000–24,999
Rural—R3: Other rural areas with a population of less than 10,000 (Australian Institute of Health & Welfare [AIHW], 2016c).
Using this measurement, the Riverina in NSW, where the participants in this study were located, is defined as rural. Wagga Wagga is the largest town in the Riverina, with a population of 64,272 in 2017 (Wagga Wagga City Council, 2017). All the participants in this study lived in the region, on small and large holdings or hobby farms, or in small villages, townships, or large regional towns such as Griffith or Wagga Wagga.
In this study, however, rurality is a different concept and is seen as a social construct whereby individuals give their own meaning to place or geographical location. Using this approach, different understandings of rurality are created by each individual, and rurality becomes understood as not just a physical location, but also as the social, cultural, spiritual, economic, and environmental contexts and landscapes in which the individuals live (Cheers, Darracott, & Lonne, 2007).
Brief Description of Methods
It was appropriate to use a qualitative research method for this study for two reasons. Firstly, I used qualitative methods to give voice to and seek out the richness and depth of the women’s stories, something it is not possible to do when quantitative methods are used. Secondly, there have been very few qualitative studies which have focused on women’s experiences of depression in rural Australia, and a qualitative study allows for semistructured interviews which enable the participants to discuss what is important to them in their own words. In seeking to understand the perspectives of women regarding their experiences of depression, a feminist standpoint was considered to be the most appropriate choice of framework. This is because feminist standpoint theory begins from the perspectives of women and takes into account the role that gender and culture play in the development of depression.
18 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW A thematic data analysis method was chosen to analyse the women’s stories and to draw out important themes from the women’s interviews.
Organisation of the Thesis
The thesis is organised into eight chapters, with Chapter 1 introducing the purpose and approach to the study. Chapter 2 explores a brief historical account of attitudes, views, and treatments towards women’s experiences of distress and depression and includes a discussion of present-day service delivery practices within Australia. This chapter also explores explanatory frameworks for understanding the term depression, including dominant biomedical theories and alternative perspectives such as feminist and social constructionist theories. This chapter also provides a discussion of the theoretical framework of the overall study, including an analysis of power and gender in relation to the construction of women’s depression.
Chapter 3 presents a review of the international mixed methods and qualitative research on women’s depression and distress, including rural women’s experiences of depression in other contexts/localities, and finally narrows to review mixed methods and qualitative studies on women’s depression within the Australian rural setting.
Chapter 4 provides an exploration of rurality within the Australian context and pertaining to women’s health. Rurality includes notions of culture, landscape, belonging to land, community, social connection, economic hardship, and lifestyle. These influence people’s attitudes, perceptions, values, and experiences, and the accessibility of help. The issues of confidentiality, gossip, stigma, domestic violence, gendered cultural narratives, and issues of accessible health services are also discussed in relation to women’s access to help and support for depression in this chapter. The chapter also includes an understanding of how power and place interact and how rurality intersects to influence and shape women’s experiences.
Chapter 5 describes the research design and methods. This chapter discusses the design as a one-time-point qualitative feminist standpoint study. The research design entailed semistructured interviews with 27 women in the Riverina in rural NSW, Australia. This chapter discusses the feminist standpoint framework used and the structure of the methods and interview process, and contains an explanation of the thematic data analysis methods that were utilised. This chapter also demonstrates how ethical issues were managed and how accountability and reflexivity were established and maintained.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 19 Chapter 6 presents the thematic data analysis of the interviews and explores the seven themes from the analysis. Chapter 7 provides a critical analysis of the data and a full discussion of the findings of this research, and goes on to draw conclusions about the significant findings and to suggest new understandings of women’s lived experiences of distress.
Finally, Chapter 8 concludes the thesis by reviewing the research endeavour, summarising the thesis and the main findings, providing new understandings of women’s experiences, acknowledging the limits of the study, and proposing recommendations for action and implications for practice and further research.
20 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Chapter 2: Approaches and Understandings of Depression
This chapter provides an account of the understandings of depression that have been in use in Australia during the 20th and 21st centuries, particularly regarding women, and includes reviews of current treatments and service delivery models. Some definitions of depression are provided, as well as various contemporary explanatory theories of depression, including biomedical and alternative theories such as feminist and social constructionist theories.
Historical Understandings and Therapeutic Interventions of Depression
Western discourses have often constructed women’s distress as a mental illness (Gammell & Stoppard, 1999; Taft, 2003). A review of the historical biomedical practices used to treat women with a mental illness reveals a consistent point of view: that women are naturally more predisposed to mental illness than men due to their biological weaknesses. Theories in the 20th century focused around the notion that women’s depression was biologically driven, either by their hormones or because they were the weaker sex—all of which naturally made them more prone to hysteria and diseases of the womb: a gendered response to women’s distress (Russell, 1998; Taft, 2003; Stoppard, 2000; Ussher, 1991, 2010). Biological theories of mental illness were given precedence over alternative understandings of women’s mental health (Stoppard, 2000; Taft, 2003), and during the early part of the 20th century, women who were deemed “insane”, often because they would not or could not conform to society’s norms and expectations, were treated with paraldehyde, bromides, chloral hydrate, cold baths, and isolation—as well as straitjackets, frontal leucotomy (brain surgery), insulin shock therapy, and later, electroconvulsive therapy (Bentall, 2009; Callahan & Berrios, 2005; Rogers & Pilgrim, 2005). The biomedical approach saw women as the weaker sex, fragile due to reproduction functions, or immoral and as needing to be contained and controlled through the vehicle of psychiatry (Chesler, 1972; Russell, 1998; Ussher, 1991).
From 1950 until the 1970s, many Australian women living with distress, abuse, or other “emotional upset” who sought care from their doctors were often given either a Bex or a Vincent’s—both were a combination of two analgesics (aspirin and phenacetin) and a stimulant
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 21 (caffeine), and were known generally as APCs—and told to have “a good lie down” (Hennessey, 1993; Stewart, 1978). Unfortunately, it was at least partly due to women’s composite burdens of caring for small children, working at domestic labour, and, often, working outside the home as well that was pushing some women to exhaustion. Women turned to these compounds as a “lift” so that they could keep working and still maintain the domestic ideal of being a “good wife, mother, and home keeper” (Hennessey, 1993). Consequently, Australian women were one of the highest user groups of these over-the-counter medications during the 1950s and 1960s (Stewart, 1978). However, a woman’s distress and depression experience was not often perceived as being due to overwork, violence, or poverty, but rather as either personal inadequacy on the woman’s part or as a consequence of being of the weaker sex (Russell, 1998; Stoppard, 2000).
After APCs were recognised in the 1970s as being harmful and contributing to kidney failure (Hennessey, 1993; Stewart, 1978), Valium (diazepam) took their place, and once again biomedicine was used to combat “emotional upset” and depression for women in Australia. In the 1970s, Valium became the most commonly prescribed medication worldwide (Callahan & Berrios, 2005). In Australia, Valium was prescribed mostly in primary health care by general practitioners (GPs) in local practices to treat mild to moderate emotional symptoms, particularly in women. A woman’s GP would diagnose her with emotional exhaustion or a “breakdown”, and would prescribe Valium to help her manage her symptoms in order to reduce the stigma of her having a mental illness. Valium, however, was found to be addictive; consequently, reporting measurements were placed on this medication and prescriptions were reduced over time (Shorter, 1997).
From the late 1970s onwards, benzodiazepines like Valium were prescribed less often than previously, and doctors began to medicate depression symptoms with new drugs such as antidepressants. The “emotional upset” label was on the way out, and by the 1980s the term depression began to be more frequently used (Callahan & Berrios, 2005). Imipramine was the first of the tricyclic antidepressants and was trialled and on the market by 1961. Prozac was developed and was available from the late 1980s, and by 1990 it had become the number one drug prescribed by psychiatrists (Shorter, 1997).
Feminists such as Ussher (2010), Stoppard (2000), and Stoppard and Gammell (2003; Gammell & Stoppard, 1999), as well as the antipsychiatry movement, aim to raise awareness that medication is not necessarily the answer for all women’s experiences of pain, exhaustion, or abuse. Emphasis on biomedical explanations and treatments means that women are primarily
22 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW treated with pharmacological therapy; this means they are often medicated (which causes other side effects) with minimal reference to any understanding of their experiences and seldom considering the social, cultural, or gendered dimensions of women’s lives (Fullagar & Gattuso, 2002; Gammell & Stoppard, 1999). Despite these critiques, the biomedical model continues to dominate current medical treatment models in Australia.
Mental Health Service Delivery in Contemporary Australia
Australia is a federation of six states and two territories and has two parallel and intertwined health systems, one public and one private. Public hospitals are government funded and admission is free. Most private practice GPs and medical specialists, including psychiatrists, are privately employed and charge a fee. In terms of payment, either the practitioner chooses to accept a Medicare allocation (government funded) for the whole bill— known as “bulk-billing”—or the patient is required to pay the greater amount up front and then applies to receive the Medicare allocation as a reimbursement. GPs act as gatekeepers to specialists and may refer patients with mental health concerns to psychiatrists, social workers, psychologists, or other allied health services through the Medicare system for further treatment in an outpatient community setting (Perkins et al., 2013). In most cases, treatment is shared between psychologists, social workers, and GPs, with some seeing psychiatrists through the public health system, or privately.
In 2008, the National Mental Health Policy 2008 was endorsed by health ministers from all states and territories and became the new National Mental Health Policy for Australia (Commonwealth of Australia, 2009b); whilst technically expired, this plan is still in place until the new 2016 policy is officially released. The policy provides an overarching vision for mental health care and mental health systems in Australia. The vision was for
a mental health system that enables recovery, prevents and detects mental illness early, and ensures that all Australians with a mental illness can access effective and appropriate treatment and community support to enable them to participate fully in the community. (As cited in Commonwealth of Australia, 2009a, p. ii)
This policy is now embedded in public mental health systems across Australia and entails the whole of government approach to reform. The principles that underlie the policy include the following:
• respect for the rights and needs of consumers, carers, and families;
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 23 • commitment to a recovery approach in service delivery;
• social inclusion;
• recognition of social, cultural, and geographic diversity and experience;
• recognition that the focus of care may be different across the life span;
• support in service delivery for continuity and coordination of care;
• equity in services—across areas, communities, and age groups; and
• consideration of the spectrum of mental health, mental health problems, and mental illness (Commonwealth of Australia, 2009a).
Implemented on the ground, this policy could, for example, look like a woman concerned about her mental health and wellbeing who initially seeks help from her local GP. The GP may then:
1. refer the woman to a psychiatrist in the private or public system—depending on her wishes and financial position (e.g., if she has private health insurance)—or to the closest community adult mental health team for assessment and triage (if she is in a mental health crisis at that time); and/or
2. discuss and draw up a mental health treatment plan with the woman so that she can be referred to allied health professionals for up 10 sessions of focused psychological interventions that are subsidised by government funding; and/or
3. prescribe medication for the woman, with or without the mental health treatment plan. The doctor would then monitor the woman’s condition while she takes a course of antidepressant medication.
There is very limited access to free or subsidised counselling outside of the Medicare health system. Many women, therefore, rely on their GPs to diagnose, treat, and review their mental health treatment plans under an essentially biomedical framework.
In NSW, Mental Health Access Line is a 24-hour telephone service that allows rural and remote clients access to specialist mental health information, advice, and counselling. The service, locally known as Access Line, can organise psychiatric appointments via the phone or by video link-up so that psychiatrists and mental health professionals can remotely assess, diagnose, and treat women with mental health concerns. Other online and telephone services, such as Farmer Assistance Hotline (Centrelink), Bush Support Line, and Lifeline also provide
24 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW out-of-hours or 24-hour help to rural Australians who are in crisis situations (Maidment, 2012). Some larger rural towns, such as Wagga Wagga, have inpatient treatment centres within the public hospital for those who require an inpatient stay.
Mental health services are provided by state governments; they use a biomedical framework for understanding women’s depression and use medication to treat it. Thus, the biomedical approach is usually the one that is used and reinforced when a woman is seeking help for her experiences (Fullagar & Gattuso, 2002; Gammell & Stoppard, 1999; Stoppard & Gammell, 2003). Some feminist organisations use alternative frameworks to understand women’s experiences of depression—understandings that are based in feminist therapy principles and which address the gendered nature of society, its inequity, and its power imbalances (Crawford & Unger, 2004). Feminist therapy principles strive to highlight the context of women’s daily lives, such as the realities of women being vulnerable to violence and abuse, and to validate women’s experiences, as well as working to empower women and raise awareness of male privilege and the gendered nature of social interactions. Unfortunately, these types of services are not necessarily widely available in rural areas, nor are they funded by Medicare in Australia (Mason, 2008).
Explanatory Theories of Depression
Biomedical explanations. Differing and competing theories propose various concepts and understandings on the topic of women’s distress and depression. The biomedical explanation conceptualises depression as a disease and considers it to be biological in origin, in terms of biochemical processes within the brain, and genetic influences (Slade, 2009).
Over the last half of the 20th century, professional use of the term depression has been influenced by the definitions given within diagnostic classification systems such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM–I, II, III, III–R, IV, IV–TR, and 5) and the World Health Organisation’s International Statistical Classification of Diseases and Related Health Problems (ICD–1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). The DSM is widely used in research and in practice; the most recent version is the DSM–5 (APA, 2013), which is one of the leading biomedical reference guides for the classification and diagnosis of mental disorders, and is widely used in Australia.
The DSM–5 classifies major depressive disorder under the group of conditions known as depressive disorders, which includes “disruptive mood dysregulation disorder, major
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 25 depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder” (APA, 2013, p. 155). Major depressive disorder (commonly known as major depression) is the most frequently occurring of these depressive disorders, and the DSM–5 provides five criteria (A–E) for its diagnosis, as follows:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A–C represent a major depressive episode. D. The occurrence of the major depressive episode is not better explained by schizoaffective
26 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. (APA, 2013, pp. 160–161)
The goal of biomedical assessments is to understand the nature of illness (Bertrando, 2009; Healy, 2005). Furthermore, biomedical assessments and interventions aim solely to address deviations by correcting them, rather than by adapting the environment to accommodate variations (Healy, 2005). Thus, the biomedical theory purports that mental illness has an underlying biological cause and that the removal of the cause will encourage a return to health (Slade, 2009).
The DSM-5 acknowledges that females tend to have a higher rate of depression when compared to men, stating that “females experience 1.5- to 3-fold higher rates than males beginning in early adolescence” (APA, 2013, p. 165). This tendency has been cited in and described by many other studies, with women being diagnosed with depression at a rate that is double that of men (Piccinelli & Wilkinson, 2000). However, biomedical explanations often understand women’s depression through a focus on the reproductive biology of women’s bodies, including women’s reproductive functions and hormones (Chesler, 1972; Russell, 1998; Stoppard, 2000; Taft, 2003; Ussher, 1991, 2010). In this approach, depression is biomedically explained in terms of hormonal influences linked to estrogen and progesterone (Stoppard, 2000), particularly noting the effects of changes in these hormones, such as, for example, premenstrual tension, menstruation, giving birth, and entering menopause. It is argued that during these times, women’s hormones affect their moods, and therefore women are naturally more susceptible to depression (Nolen-Hoeksema, 2001). This approach is similar to the historical notion of women being the weaker sex and being “hijacked by their hormones”, which theory situates the problem solely within the women and denies the social, cultural, and structural issues that affect and impact women’s lives (Stoppard, 2000).
The biomedical theory and model and the common adoption of the DSM–5 and ICD–10 classification systems continues to be common practice in mental health settings, despite criticism from within and from outside of psychiatry. General practitioners and mental health professionals work predominantly with the biomedical theory of mental illness, although some acknowledge the biopsychosocial approach (Slade, 2009). The biopsychosocial approach
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 27 proposes that mental health issues do have a biological component, but it also acknowledges that psychological, social, and contextual issues impact on mental health and wellbeing (Slade, 2009). However, some who use this latter model often still tend to give primacy to biological causes of disease (Slade, 2009) and, importantly, fail to create a broader solutions framework that acknowledges issues of gender, violence, inequality, and the power imbalances that impact women (Stoppard, 2000; Ussher, 1991, 2010; Western, 2013).
Critique of the biomedical model. Feminists have been critical of the individualistic biological explanations of depression given to women (Gammell & Stoppard, 1999; Lafrance, 2009; Scattolon, 1999; Stoppard, 2000; Stoppard & Gammell, 2003; Stoppard, et al., 2000; Taft, 2003; Ussher, 1991). One of the main criticisms of the DSM–5 and the ICD–10 is that both are reductionist in framework and de-emphasise the social, cultural, and gendered contexts in which women live (Lafrance & McKenzie-Mohr, 2013). Some feminists assert that psychiatry perpetuates the traditional model of intervention—that of the expert “white man” standing in authority over a subordinate female patient (Bentley, 2005). Chesler’s work, Women and Madness (1972), exposed the Western patriarchal practice of defining women’s experiences as pathological and its use of psychiatry to gain and maintain control over women’s lives. Critics argue that the biomedical model has been responsible for perpetuating an ideology that mental health conditions are real entities and are located solely within the individual, and that it discounts the contributing social, cultural, and systemic factors of power, control, and oppression in women’s lives (Bentley, 2005; Chesler, 1972; Stoppard, 2000; Stoppard & Gammell, 2003; Taft, 2003; Ussher, 1991, 2010).
Feminists such as Chesler (1972), Stoppard (2000), and Ussher (1991) believe that, historically, women have had a narrowly defined range of acceptable behaviours in society and that if they deviated from this script they were often labelled and “treated” accordingly by psychiatry. For example, in the 19th and 20th centuries, women who did not conform to the gendered roles and norms of the day, who stood up against the culture of male privilege, or who would not be treated like servants or as “less than” by their husbands often paid the price of their refusal by being punished through imprisonment in mental health institutions. Chesler (1972) states that psychiatry has been used for centuries as a vehicle to control and oppress women and their bodies in order to maintain the status quo and power. These feminists argue that depression in women needs to be seen in the light of the material, social, and political constraints in their lives, rather than as a biological error (Gammell & Stoppard, 1999; Lafrance & Stoppard, 2006; Stoppard, 2000; Ussher, 1991, 2010).
28 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Critics claim that psychiatry lacks the science to either prove or cure mental illness. In determining other medical diagnoses, such as diabetes, for instance, a simple blood test can easily confirm or rule out the condition, but in psychiatry there are no such tests, nor is diagnosis free from bias or neutrally obtained, but instead is laden with gendered Western cultural biases that have traditionally labelled women’s sadness and experiences of violence, poverty, and oppression as mental illness, consequently subjecting women to stigma and control (Lafrance & McKenzie-Mohr, 2013; Stoppard, 2000).
Some theorists and researchers such as Lawlor (2012) and Watters (2010) argue that depression and culture are intertwined and that the biomedical definitions are not necessarily transferable to other cultures. In fact, Watters argues that the “one size fits all” approach to mental health classification is merely the West’s attempt at globalising the mental health pharmacotherapy market. Behind this promotion of the illness, there is the belief that Western countries, through medication, have the definitive answer to mental illness. Japan is an example, where there was no word in Japanese for mild depression until antidepressant medication was promoted by a pharmaceutical company in 1999 (Currie, 2005; Watters, 2010).
Moreover, Lawlor (2012) argues that, over the decades, the nonconsensus by the medical fraternity on the demarcations of depression has put in doubt the “science of madness”. Lawlor refers to the US–UK Diagnostic Project (conducted in 1972) in which it was found that, in the United Kingdom, psychiatrists diagnosed depression five times more often than their US counterparts. Lawlor believes this, in itself, is evidence of the subjectivity of mental illness. He states that psychiatry and the DSM classification system have pathologised and individualised life events such as grief and loss, unemployment, divorce, and poverty as depression and in doing so have ultimately weakened the validity of the DSM and the biomedical classification system of mental illness (Lawlor, 2012). The DSM–5 does clarify that depression is different in nature from normal grief or sadness, however, despite this distinction being made, the medical profession has been criticised at times for merging the normal human condition of sadness into mental illness.
Feminists such as MacKay and Rutherford (2012) argue that “dualistic thinking [which] upholds the medical model falsely universalises women’s health and health care experiences; [it] reinforces a preoccupation with the ‘abnormal’ thereby pathologising women’s bodies and minds; and minimises the opportunities for alternative health care” (p. 181). Like Chesler, feminists such as Ussher (1991, 2010) and Stoppard (2000) believe that any suggestion that depression is due to women’s faulty bodies is merely a vehicle for the patriarchal system to
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 29 control and silence women, and that depression is not the result of a chemical imbalance in the brain but is compounded by the gendered nature of social and familial life and inequality in women’s everyday experiences.
Further, observations by Neizke (2016) suggest that the label of depression may act to silence women who are experiencing oppression, by focusing attention on the individual instead of social causal pathways:
In medicalization, mental illness becomes conceived of as a problem of individuals, and largely unrelated to the workings of social systems in which they are embedded. . . . The historical processes that led to women being identified more often as depressed, melancholic, or mad seem to be stripped away in the biological present, creating a problem for illness experience and the medical imaginary. This relegates operations of gender, at best, to the margins of psychiatry and neuroscience. Instead, depression is better understood as a biomedical disease construction . . . . (Neitzke, 2016, p. 66)
Stoppard and Gammell (2003; Gammell & Stoppard, 1999), too, are critical of the biological causation theory described by the biomedical model, arguing that the medicalisation of women’s bodies has the potential to interpret women’s distresses and social contexts as mental disorders, and that this can lead to the disempowerment of women. Similarly, Scattolon (1999), Stoppard (2000), and Lafrance (2009) argue that the biomedical understanding of women’s depression does not take into account the lived experience of women’s daily lives or their contexts. They further assert that the biomedical model constructs women’s sadness and pain as depression through health policy, medical journals, pharmaceutical company literature, women’s magazines, and the media (Currie, 2005; Fullagar & Gattuso, 2002; Stoppard & Gammell, 2003; Ussher, 2010; Watters, 2010). However, it is often easier for GPs to offer a solution to women in the form of medication than it is for them to address the social and structural issues that women live in, such as domestic violence, oppression, and poverty.
Yet, in contrast, others argue that the DSM–5 provides a universal framework and consistent guidelines for the formal diagnosis of mental illnesses where previously there was no widely accepted classification system. Moreover, some women feel that receiving a biomedical diagnosis gives relief and validation to their experiences (Lafrance & McKenzie- Mohr, 2013). In addition, some believe that the biomedical diagnosis can provide women with a “legitimate health condition” that is not seen as the woman’s fault or due to any personal failings (Gammell & Stoppard, 1999; Lafrance & McKenzie-Mohr, 2013). Some women may find the biomedical framework helpful for accessing treatment, particularly where free,
30 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Medicare, GP-bulk-billed consultations and psychological counselling are available that otherwise would be unaffordable to them.
Psychological and psychosocial explanations. There are many differing theories that offer an explanation on the causes of depression within the psychological domain—positive and critical psychology, labelling theory, and other theories too vast to explore in this study. However, this section will explore the current dominant psychological theories on depression. The first psychological explanation for depression is that of psychological susceptibility. The theory of psychological susceptibility argues that women may be more susceptible to depression due to their personality type or personality traits. It is believed that some personalities are less flexible, and that this explains their struggle to cope with and adapt to change or adversity, while other personalities are more accommodating and are therefore able to deal better with life’s stressors and events (Nolen-Hoeksema, 2001). In summary, some people with less flexible personalities will struggle to cope effectively with life’s adversities, making them possibly more susceptible to depression.
Another psychological theory on women’s depression centres around cognitive negative self-talk and rumination. Beck and Alford (2009) assert that some people have a specific vulnerability to depression due to their constellation of negative self-talk—about themselves, the world, and the future—and that once this talk dominates their thought life they are susceptible to depressive symptomatology (Beck & Alford, 2009). Some believe that women are more susceptible to negative self-talk, negative thinking, and rumination, which can interfere with the way they view themselves, people, problems, and situations in their life. Rumination is thinking over and over about situations or events in one’s life or dwelling on negative situations, past, present, or future, and staying stuck in this cycle. The theory states that if a person has unhelpful core beliefs, cognition distortions, and constant negative thoughts, their thinking will tend towards viewing everything through that negative lens, which can then increase their susceptibility to depression. Cognitive behavioural therapy, commonly known as CBT, is a psychological approach that is often used to help clients gain and increase their awareness of the thinking errors and unhelpful core beliefs that contribute to their cycle of negative thinking and rumination. This theory has been influenced by the work of Albert Ellis (Ellis & Harper, 1975), and has been implemented as a psychological intervention for people living with depression for decades. However, this theory places women’s experiences of depression solely within the individual and does not take into account other factors that may
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 31 cause rumination, such as social and cultural expectations and the gendered oppression in women’s lives.
Another relevant theory is the psychosocial stressor explanation of depression. This theory asserts that psychosocial and economic stress may develop from women’s experiences of their social roles, such as stereotyped role expectations, the pressure of women’s domestic responsibilities, discrimination, gender-based violence, and poverty. This explanation is based on the belief that life stressors, such as major loss or death, divorce, poverty, or trauma, can increase the chances of a person being unable to cope with life, and can make them more susceptible to depression, especially when these negative events are not a single occurrence but are ongoing and persistent (Nolen-Hoeksema, 1987, 2001). This theory states that multiple hardships and life stressors compound against one’s ability to cope, and impact on one’s ability to bounce back, which can then lead to depression. In addition, the way women interpret and understand the causes of the negative events that occur in their lives also influences their perception of those events. For example, those who attribute negative events to causes that are internal are more likely to feel depressed than are those who attribute negative events to causes that are external to themselves (Girgus & Yang, 2015). For example, women may blame themselves for living in poverty, oppression, and abusive situations; according to this theory, this internal blaming of the self can lead to feelings of depression. Although this theory acknowledges that major life stressors impact on women’s everyday lives and can contribute to depression, like the biomedical model, it still ultimately considers the source of depression as being within the woman.
Critique of psychological and psychosocial explanations. Whilst psychological interventions such as CBT are intended to help women with their depression experiences, some studies suggest that the biopsychosocial approaches may unintentionally contribute to normalised understandings of the depressed self. Fullagar & O’Brien argue that “a normalised clinical approach to recovery constructs illness as impairment of the mind (whether biochemical or cognitive) and through treatment, outcomes such as symptomatic and functional improvements return the self to ‘normality’, and recovery is equated with cure” (2014, p. 117).
These feminists are often critical of the domain of psychology, as historically, psychology has sought to define “reality” and to create new social and moral authorities for society (Rose, 1996). Historically, too, psychology was initially a male profession that established itself as an objective and scientific discipline and sought to closely align itself with the medical and psychiatric domains. It provides solutions based in reductionist and
32 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW individualistic notions, seeing itself as an authority on people and their psychological and emotional problems, and giving “objective” advice with minimum regard to the sociopolitical issues of power, gender and oppression within the social contexts of women’s everyday lives (Rose, 1996). More recently, however, there has been a movement within psychology based in feminist and social constructionist understandings that has embraced a self-critical approach to study and research, and includes the work of Canadian psychologists Janet Stoppard (2000, 2003) and Yvette Scattolon (1999).
Fullagar and O’Brien (2014) propose that a relational understanding of recovery, with insight into the social, cultural and material world that women come from, needs to be considered when women come for assistance. The dominance of biopsychosocial approaches to depression often results in women relating to themselves through an identity that defines them as depressed and who require certain kinds of medical or psychotherapeutic “treatments” such as CBT, to “fix” their problems, which further de-politicalises women’s distress (Fullagar & O’Brien, 2014). Alternative explanations to women’s depression that destablise the psy- domains are those of feminism and social constructionist theory.
Intersectional feminism and social constructionist explanations. The theoretical underpinning of this study is influenced by the feminist and social constructionist approaches to understanding women’s experiences. The work of Michelle Lafrance (2009), Yvette Scattolon (1999), and Janet Stoppard (2000) constitutes some of the foundational research and theorising about social constructionist theory regarding depression in women whilst also using the lens of intersectional feminism; hence, my understanding of feminism and social constructionism are influenced by these theorists.
Feminist theory has numerous viewpoints and understandings, with diverse principles and beliefs existing within the domain, however, feminists all share several core principles. These principles include:
• a belief in integrating private and public spheres—that the personal is political;
• valuing the worth and diversity of women;
• seeking a fairer, more egalitarian form of relationships and society; and
• transforming the existing social order that currently devalues women and children (Dominelli, 2002).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 33 Broadly, feminism is concerned about the unequal distribution of power, and more specifically, the use of such power and how it is implemented in society to control different subgroups within it. Feminist theory asserts that society is governed by a patriarchal system in which women are devalued and oppressed. Contemporary feminists may see the end goal to be equality at all levels of society: that is, the end of the domination of the patriarchal culture and the sexist oppression of women (bell hooks, 1998). Feminists are concerned, too, about the social and material inequities that are often the external manifestation of women’s oppression and disempowerment (Bowden & Mummery, 2009). Bowden and Mummery argue that
many feminists have come to realize that the issue of women’s oppression is, at its most fundamental level, a matter of knowledge or epistemology (that is, ideas and theories concerning the origins of knowledge and how it is authorised). After all, many of the practices that have prevented women from achieving their potential are ultimately based on biased views or alleged facts about women’s lives and aspirations. (2009, p. 24)
The development of feminist theory also cannot be divorced from its political context, which reinforces that the personal is the political. Feminist theory contains diverse viewpoints and has many “internal” divisions. The theoretical framework employed in this study is that of intersectional feminism and social constructionism.
Intersectional feminism. Feminism also acknowledges that many factors and contexts influence and intersect with the oppression of women. Intersectional feminism is a theory which considers that the differing aspects of human life, such as class, race, gender, and ability do not exist separately from one another but instead form complex interactions; understanding these interactions is a vital part of understanding human experiences (Gouws, 2017).
Intersectional feminism was historically led by black feminists in America, such as Anna Julia Cooper, and more recently Kimberle Crenshaw, who felt that white, middle-class women had differing experiences of oppression compared to black, poor women; the intersectional feminist framework helped to describe and identify the ways in which gender, race, culture, and class intersected with each other to create women’s differing levels of oppression (Gouws, 2017). Advocates of intersectional feminist theory argue that racism, sexism, and classism do not act in isolation from each other. Instead, these forms of oppression interrelate, creating a system of multiple and complex oppressions that reflects the “intersection” of many forms of oppression (Gouws, 2017). Women’s experiences, therefore, cannot be observed in isolation from their daily lives but need to be examined as simultaneously interacting with each other
34 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW and as affecting their personal standing and perception in society; ultimately, intersectional feminism is an analysis of power.
The framework of intersectional feminist theory therefore provides an insight into how multiple systems of oppression interrelate and affect women (Gouws, 2017), and this is particularly useful in rural spaces where the dominant order can produce experiences of exclusion for particular social groups, including women. Although individuals’ identities are complex and fluid, power operates in and through the spaces in which women live, and the generation and maintenance of existing patriarchal attitudes and cultures continues within these spaces (Valentine, 2007).
Intersectionality, therefore, may be a useful framework from which to offer a feminist understanding that includes an awareness of those intersections of oppression that are indivisible from the cultural and geographic aspects of rural spaces; an understanding of intersectional feminism assists reflections on the connections between the experiences of the women in this study, their oppression, and their rurality (Gouws, 2017).
Social constructionism. Historically, in English speaking countries, it has been “white men” that have determined the “truth”. The social constructionist framework, however, asserts that there can be no predetermined view of the nature of the world or people, and that there is no such thing as an objective fact—that any sense of knowledge or reality is likely to be through one’s own perception. These theorists argue that knowledge, values, beliefs, and behaviours are socially constructed in dialectics between people and their societies (Stoppard, 1998, 2000). Further, it is held that understandings and meanings are socially constructed within groups of people, and those with greater power often determine what is considered the truth (Stoppard, 2000). In this way, human behaviour is seen as an active process of construction and interpretation in which people define the nature of their social situations and encounters, and that, therefore, the definition of reality is more flexible and open to negotiation.
Stoppard’s understanding of women and their experiences of depression is derived from the material-discursive perspective, where both knowledge and how one makes sense of one’s experience are socially constructed within interpersonal interactions. She argues that structural inequalities situate women in less powerful positions in society, and the way society constructs language (including medical language) can further disempower women (Stoppard, 2000). As White (2018) also argues:
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 35 The social construction of gender roles results in women’s minds and bodies being medicalised in a framework which defines them as inherently at risk of mental illness and, physically, always in need of monitoring by the medical profession. This leads to the over-surveillance of women in ensuring conformity to social roles and policing gender roles through the psy-professions. (p. 28)
Social constructionism does not deny women’s distress, but understands that some parts of it are only “permitted” via an “acceptable” feminine quality or emotion—where “acceptable” is determined and constructed by the dominant in society (Crawford & Unger, 2004). Social constructionists and feminists believe it is crucial to identify how women are “taught” to describe and label their experiences, and how these labels fit into gendered roles in society (Crawford & Unger, 2004). Women expressing anger or being vocal about oppression in the private and public spheres, for example, are often seen as unfeminine; such behaviour could be socially discouraged.
Hatcher (1993) states that gender refers to a “socially constructed and relationally defined social practice” (p. 108), suggesting that gender, too, is not a predetermined truth, but is rather a complex and dynamic construction of interactions between people and society. Gender and gender roles are socially constructed and can be used by the dominant group within society to enforce particular values on individuals such as women. Moreover, in relations to social construction of gendered behaviour, Horwitz (2002) argues that women are more likely than men to internalise their feelings, while men tend to cope with their distress by engaging in antisocial behaviours, alcohol, and substance abuse. The socialisation of women gives them permission to be sad and anxious, but not aggressive, so that they may therefore tend to express their distress through such passive, subordinate, and anxious symptoms as are culturally permissible; this behaviour then lends itself towards a diagnosis of depression when women present to the GP, and this may be one of the reasons for the gender difference in the rates of depression. Horwitz (2002) states, “not femaleness, but the prevalence of women in subordinate roles, could account for the greater incidence of distress among women” (p. 174).
Horwitz (2002) therefore suggests that in order to explain gender differences in the rate of depression, a theoretical approach is required that focuses on how power relations in society are associated with gender roles and expectations of appropriate feminine behaviour, which he argues lead women to manage their distress by internalising it. As Bluhm (2011) also argues:
36 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW women may be more likely than men to experience depression due both to their disvalued social status and relative lack of power and also to the way in which they express the distress that results in part from these social circumstances. (p. 78)
In summary, feminists and social constructionists understand the biomedical concept of women’s depression as being a social construction of the biomedical domain that exists in order to maintain power over women and to keep the status quo in society. They see women’s distress as better understood via the social, cultural, and material burdens that women are subjected to by the patriarchal society. Both the social constructionist and the intersectional feminist perspective assert that women’s distress is more accurately reflected through the intersections between race, gender, place, and the social and cultural contexts in which women live, and through understanding the oppressive nature of women’s everyday lives (Gammell & Stoppard, 1999; Jack, 1991; Jack & Ali, 2010; Lafrance & Stoppard, 2006; Scattolon, 1999; Stoppard, 2000; Ussher, 1991; Western, 2009, 2013).
Critique of feminist and social constructionist theories. Feminist theory reflects a worldview that values women and confronts injustices based on gender inequality. However, much has been written about the weaknesses of feminist theory. Some argue that feminist theory is only interested in women and the supremacy of women in society at the expense of other groups (Letherby, 2003). Moreover, within feminism’s own domains, consensus cannot be reached about feminist goals or even definitions of feminism; hence, within feminism there are many factional subgroups and differing beliefs that often confuse those outside the movement.
Feminist theory has also been blamed for causing hostility between the genders and encouraging political correctness at the expense of others in society. Critics argue that feminist theory is only concerned about researching issues concerning women, and neglects other important issues in society. In addition, while feminism and feminist theory state that women are oppressed by the patriarchal society, critics argue that not all women may feel that they are oppressed, and that in fact some men could also be oppressed by the same patriarchal system. Another criticism of feminist theory is that the proponents of it are often white, middle-class European or English-speaking women, speaking on behalf of women from all backgrounds, who they in fact may not even represent; moreover, some women may not want to be represented, nor do they agree with feminism, feminist theory, or its ideals (Alston, 1995). However, intersectional feminism is aware that women’s experiences are different and highlights that women do have differing levels of oppression depending on how their social,
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 37 cultural, and racial contexts intersect in society (Gouws, 2017). This and many other differing approaches to feminism reflect the diversity within the movement, and the argument that feminism is only made up of white, middle-class women has been long-defeated. Just as diverse and differing elements make up feminist theory, so too are the women that make up feminism.
Criticisms of social constructionism centre around the problem that occurs once it is stated that there is no objective truth: who, then, for example, decides who is oppressed or victimised? How can we say that particular groups are oppressed if these groups and their oppression are constructions which can have no greater claim to truth than any other? Who then decides what is right or wrong when there is no objective truth or reality to define such things? Critics of this theory argue that society cannot fully function without having some agreed construction of the terms of how to live and behave. However, social constructionists argue that the dominant in society have constructed meanings and values as “truth” to suit their interests, often at the expense of marginalising others in society.
Summary
Although the biomedical term for depression has evolved over time and different treatment theories and options have emerged and developed, the validity of the diagnosis as a real entity remains to be well established because of the lack of attention it gives to the gendered social and political contexts that women come from. For this reason, the biomedical understanding of depression has been challenged at times by women themselves, and by the feminist and antipsychiatry movements, as a social construction and an interpretation of women’s distress and oppression. The biomedical model, therefore, with its understanding of depression constructed through a lens of an individual’s pathology, is a target for criticism; however, it is still the dominant model used in the treatment of depression in Australia. When medication is often then given as the gold standard treatment (Brogan, 2016), without acknowledging the individual’s social, cultural and environmental contexts, or how they intersect with one another, considerable work still needs to be done to understand the experiences of distress and depression that women bring, and how these can contribute to a greater understanding of the lived experiences of rural Australian women. Whilst no single explanatory framework can adequately account for all women’s experiences of distress, when women’s experiences of inequality and oppression begin to be understood as a gendered experience influenced by social structures, culture, and economic contexts, the dominance of the biomedical model of depression can only be further challenged.
38 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Chapter 3: Literature Review
This chapter provides a review of the international and Australian literature on women and depression, with a focus on Australian qualitative studies and women’s lived experiences of depression within a rural Australian context. The focus of the review also accords with the feminist and social constructionist approach to women’s understandings of depression that is taken by this study.
The available literature on the subject of women’s depression has been predominately led by the medical domain, is principally quantitative, and most often focuses on post-partum depression in women. My focus was quite different—it was towards qualitative and mixed methods research about women’s experiences of depression, and also specifically looking for studies that addressed rural Australian women’s lived experiences of depression. In addition, seminal work which used quantitative methods and was deemed important to the overall review of the literature was also included. Many of the qualitative studies on women’s depression included in this review came from international studies, mostly from Canada, North America, England, and New Zealand.
In order to extensively review the literature that would best inform and situate my study, several databases were searched. These included: Cochrane Library, EBSCO, Elsevier, Google Scholar, Ingenta Connect, JSTOR, ProQuest, PsychoINFO, Psychology’s Feminist Voices, PubMed, and Springer Link. The search terms included: “women”, “depression”, “rural”, “Australia”, “qualitative”, “lived experiences”, and “feminist”. The literature selected included seminal works (including work from earlier than 2000 if it was judged to be relevant to the overall study) from e-journals, journals, books, theses, and conference proceedings.
After reviewing the qualitative and mixed methods studies on women’s depression globally, three themes emerged from the literature: (a) notions of self, intimate relationships, and gendered role expectations; (b) loss, poverty, and family and life stressors; and (c) abusive childhood experiences and violence. These three themes form the basis of the first part of this international literature review; the second part addresses Australian qualitative and mixed methods studies on women’s experiences of depression and then, specifically, rural women’s experiences of depression.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 39 International Literature Regarding Women’s Experiences of Depression
Much of the research in the area of depression regarding gender differences has tended to focus on sex differences rather than gender differences (Stoppard, 2000). The term sex is assigned to the biological aspects of being male or female; however, gender is a term that considers a more encompassing understanding of the behavioural differences that are assigned to males and females; these appear to develop through a process of socialisation that reinforces gender roles, often through a division of labour and the inequality of value given to different work in society (Stoppard, 2000).
The literature identifies that women are more susceptible to depression than men (Bebbington, 1996; Maier et al., 1999; Mirowsky, 1996; Nydegger, 2016), but it seems clear that the reasons for this are not solely located in biology. Numerous studies show that there is a complex relationship between biology, life stress, and sex-role socialisation (McGrath et al., 1990; Nolen-Hoeksema, 2001). Some research has put particular emphasis on the impact of sex-role socialisation, since women who accept typically stereotyped female roles appear more likely to experience depression (Jack, 1991). This theory suggests that women are more vulnerable to the effects of unhappy interpersonal relationships than men, and are seduced into accepting narrow definitions of what a “good woman” or a “good wife” should be (Jack, 1991). These theories and studies will be discussed in more depth in the following sections.
Notions of self, intimate relationships, and gendered role expectations. Using semistructured interviews, Jack (1991) conducted a feminist qualitative longitudinal exploratory study of 12 women in North America who identified as depressed. Her theoretical framework was derived from relational theory, which maintains that people are intrinsically social and are most content in relationships and in connection with others. Jack’s approach to this phenomenological study was that she believed the women were best situated to discuss their experiences about depression themselves and that their stories should be seen as valid knowledge. After the first set of interviews, Jack interviewed the women again two years later to see if anything had changed in their lives. From these interviews, Jack found that women’s experiences of depression were gendered, and that a woman’s sense of self was often tied to her male partner (Jack, 1991). Jack noted that the women interviewed experienced themselves primarily in connection with others; their sense of self was both tied up with and organised in the context of important relationships such as intimate partner relationships, and so these relationships often defined their identity (Jack, 1991). Jack (1991) coined the term “self-
40 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW silencing” (p. 129), and argued that by internalising their emotions, the women contributed to their experiences of depression. In fact, as these women felt that their emotions could not be understood or validated, and that expressing them could potentially threaten their relationships with their male partners, silencing themselves was deemed necessary to maintain their relationships. When intimate relationships and social connections that Jack (1991) describes were derailed, the women who had worked hard to maintain them were frequently derailed with them, making them more susceptible to distress and feelings of depression. Jack asserts that women are scripted into behaving in certain ways in order to “keep their man”, and to meet the gendered societal role expectations of a being a “good woman”, such as compulsive caretaking, pleasing others at their own expense, and avoiding conflict. Jack maintains that women silence themselves to avoid male partner dissatisfaction and potential rejection in their relationship, and found that the women’s sense of self was strongly tied to this. Jack also found that women had to silence themselves to get along in “a man’s world”, and to maintain their relationships, and that this suppression of their feelings and ultimately of their selves contributed to their experiences of distress (Jack, 1991). Jack found that women were socially conditioned to believe that they were responsible for relationships and therefore blamed themselves if their relationships failed; this, in turn, contributed to their distress, which was tied up in their disconnection from self and from others.
Scattolon’s doctoral research (1999) focused on 15 rural Canadian women who self- identified as depressed and who had not sought professional help. Scattolon used a feminist standpoint approach for her qualitative study and employed semistructured interviews to gather the data. A standpoint approach to research takes account of the relationship between women’s experiences and the generation of scientific knowledge by examining how research is produced and the relationships it is produced in (Scattolon, 1999). Scattolon was interested in exploring with women who were living in rural Canada (specifically the central New Brunswick area) and who self-defined as depressed how they understood, experienced, and coped with feelings of distress. Using thematic and discourse analysis methods, Scattolon identified five main themes in the data, including making sense of and dealing with depressive experiences. From within this main theme, three subthemes emerged: how women experienced depression, how they understood and explained these experiences, and how they coped with their depressive feelings. Many of the women understood their depression as stemming from external life stressors, such as financial problems and child-rearing burdens, similar to the findings of Jack’s research (1991); and a common thread of the accounts was the isolation and loneliness that the
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 41 women felt within their intimate partner relationships. It was evident that discourses of femininity were strong in the women’s lives, as the women’s recovery from depression was associated with their perception of whether they could perform adequately as a wife and mother and were meeting society’s expectations of being a “good woman”. Scattolon found that life stressors and social contexts impacted on these women’s experiences of depression. Collectively, these feminist studies by Jack (1991) and Scattolon (1999) suggest that depression is gendered and that women whose identities are strongly tied to keeping their intimate partner relationships and gendered role expectations maintained are often doing so at the expense of their own emotional needs.
Moreover, a qualitative study by Canadian feminist researcher, Susan Hurst (2003), interviewed seven women from a major city in western Canada who self-identified as being depressed and who had not received counselling. Hurst was interested in the women’s personal understandings of how they become depressed, using a grounded theory approach. From the data analysis, Hurst found that the women often depended heavily on their intimate partner relationships and sought to obtain their self-worth and identity from their partners. When that relationship ended, often through betrayal, the woman was often left feeling depressed, worthless, and hopeless. Hurst coined the term “becoming demoralised” to highlight this theme (2003, p. 142). The women took their value and worth from being in the relationship and when it ended they felt they were not worthy of love; these women had often had several betrayals in childhood that also interfered with their sense of self and self-worth as adults. The women became demoralised and felt rejected and abandoned by their partners, and as if nothing was going to get better in their lives. Hurst states that such “demoralisation stems from the profound betrayals by the most significant figures in one’s life” (2003, p.155). Hurst found that issues of feeling unworthy and rejected in relationships affected the women’s sense of self and that this was at the heart of the women’s experiences of depression, echoing similar findings to those of Jack (1991) and Scattolon (1999).
Another feminist qualitative study conducted in Canada, by Lafrance (2009), involved 19 women who self-identified as having recovered from or overcome depression. Lafrance conducted in-depth interviews. Using discourse analysis, she in particular identified how women struggled to legitimate their emotional distress and relinquish gender expectations that emphasised the needs of others over the self. She found that women who had recovered from depression did not have the usual gendered stereotypes of, for example, being pleasing, silent, deferential, and self-sacrificing in relationships, but rather had different discourses of
42 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW femininity. Some of the participants had resisted these gendered discourses and had “talked back”, rejecting the gendered role expectations of women; in fact, Lafrance found that by increasing their own self-care and in taking the time to invest in their own wellbeing and health, these women had found their priorities shifting, which had helped them in their recovery from their experiences of depression (Lafrance, 2009).
A negative sense of self, betrayals, difficult relationships, and the gendered ways women self-sacrifice in order to keep their relationships seem to all play a part in women’s experiences of depression. A sense of identity that is tied to an intimate partner relationship and how women feel they have to keep silent and please others at the expense of their own wellbeing are also factors which have bearing in women’s experiences of depression. It appears from these studies that women can internalise their disappointments and difficulties, and then subsequently feeling low and distressed they seek help often from their GP, who then labels this experience as depression. In this way, a transformation occurs where women’s experiences of betrayal, loss, and the toll of self-sacrificing to please others are converted into a medicalised understanding of depression, instead of being identified as the result of oppression.
Loss, poverty, and family and life stressors. One of the early significant studies that highlighted the impact of social factors on depression in women was Brown and Harris’s (1978) mixed methods study conducted in England over a 30-year period. Brown and Harris studied 458 women from a working-class area of London and found that about 15% of the participants were depressed. Brown and Harris conducted three separate sets of surveys and face-to-face interviews with the women over the 30-year period. They observed that life stressors usually preceded the depression: 90% of the women who had depression had also endured a severe life-threatening event in the year prior to the onset of their depression experience. Brown and Harris concluded that severe events, usually involving a major loss, could possibly lead to depression for women, and it appeared that severe major difficulties or life events, and even the threat of loss could be contributing social causal factors. Brown and Harris’s research noted that working-class women appeared to have a higher rate of depression when compared with middle- and upper-class women, and also found that women who had children less than six years old in the home had a higher rate of depression. They also found a significant association between past loss and severity of depression. Life stressors such as poverty, child care burdens, financial debt, and housing issues were all social and relational concerns that influenced the women’s experiences of depression.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 43 In addition, Brown’s (2002) follow-up research on women in the UK who had experienced depression suggested that women’s experience of depression was partly related to humiliation—for example, separation from a partner due to infidelity or abuse, criticism for poor parenting by professionals, or finding out a child had been stealing and deceiving them (Brown, 2002). Brown found that four protective factors appeared to make women less likely to experience depression after a critical event. These factors were:
1. an ability to confide in someone such as a spouse or lover;
2. part-time or full-time work outside the home;
3. fewer than three children at home; and/or
4. serious religious commitment or involvement.
Brown argued that depression is based on psychological factors such as isolation and entrapment and major life stressors, coupled with not being able to speak or find support, being isolated at home with small children, or having no meaningful connections outside the home. The women in Brown’s (2002) study expressed feelings of entrapment, betrayal, and humiliation in their intimate relationships, confirming Brown and Harris’s earlier (1978) research findings. These studies highlight that relationships and being valued are important to a woman’s sense of self, and, in turn, to her wellbeing.
Another key feminist qualitative study on women identifying as depressed, conducted in Canada, was a doctoral study by Guptill (2005), which involved interviewing 11 women over the age of 40 using a semistructured interview approach. Guptill’s study specifically aimed to understand older women’s experiences of depression through their personal accounts and from their standpoints. From a thematic analysis of the data from the women’s interviews, Guptill found that these women experienced depression predominantly as loneliness. Guptill also found that the women identified gender-related experiences, such as domestic violence, traditional sex roles, and financial issues, coupled with ageist and sexist experiences, had influenced their lives and experiences of depression (Guptill, 2005). This study is particularly relevant, as it looked qualitatively at women specifically over the age of 40 and reviewed their life course experiences of depression in relation to gender.
McGrath et al. (1990) suggest that women with more children have higher rates of depression, especially those who do not work outside the home. Mirowsky (1996), also, found that depression rates were higher among women who did not work outside the home, or who only worked part-time, or who had constricting employment and difficulties with child care
44 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW and household burdens. Bifulco and Moran (1998) likewise found these factors increased the risk of depression, and also noted a higher rate of depression among women who were experiencing economic hardship: Poverty is seen as a general risk factor for women who may be susceptible to depression (Belle & Doucet, 2003; Bifulco & Moran, 1998; McGrath et al., 1990). These studies all suggest that the interrelationships between poverty, gender, and the social and cultural expectations of women do compound women’s distress and culminate in creating a system of oppression.
Abusive childhood experiences and violence. A landmark quantitative research study into adverse childhood experiences conducted by Felitti et al. (1998) found that adverse experiences in childhood affected men and women in adulthood. This research study, conducted between 1995 and 1997, involved a questionnaire that was sent to 13,494 adults who were patients of the Kaiser Permanente Hospital in San Diego, California, USA. Seventy percent of the 13,494 patients responded to the questionnaire, which asked the participants (both men and women) to describe their adverse childhood experiences in the following subcategories: neglect; sexual, physical, and emotional/verbal abuse; high conflict marital breakdowns; significant loss; trauma; witnessing domestic violence; parental psychiatric disorder; parental drug and alcohol abuse; parent death/suicide; and parent incarceration. When compared to those who had experienced none, participants who had experienced four or more of these subcategories had a 4- to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempts as adults (Felitti et al., 1998). Felitti and colleagues found a graded relationship between the number of adverse childhood experiences and negative health conditions in adulthood, including depression.
Bifulco and Moran’s (1998) longitudinal qualitative study had similar findings to Felitti et al., although the study was methodologically different, and included only women participants. Bifulco and Moran (1998) conducted qualitative research into women’s experiences of neglect and abuse in childhood and their experiences of depression as adults. The research was conducted in England over 18 years (from 1977 to 1995), during which time the authors interviewed over 800 women, all whom had had adverse childhood experiences. The study took a biographical approach called “history-taking” where the authors collected detailed information laden with both context and meaning about childhood experiences from each woman. The 800 women involved in the study came from four separate research projects that Bifulco and Moran conducted over the 18-year period. Even though the researchers did not have a clearly articulated theory for the study, they were interested from the outset in
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 45 knowing if there was a connection between childhood experiences and adult depression. They asked a series of questions about the participants’ childhood experiences. Their analysis and conclusion was that there was a strong link between a woman’s experience of abuse in childhood and the likelihood that she would suffer depression as an adult. Bifulco and Moran (1998) also found that women participants who experienced maternal loss as children had twice the susceptibility to depression as adults, and it was clear from their findings that the legacy of child abuse, trauma and maternal loss was clearly related to the women’s distress in adulthood. The study observed that this distress and loss had been medicalised and defined as “depression” by the women’s medical practitioners.
Wilson’s doctoral thesis (2007) was a qualitative narrative enquiry into women’s journeys beyond the disruption of depression, and was conducted in New Zealand. In 2000, Wilson interviewed 18 women from various cultural backgrounds who were between the ages of 32 and 70, and who had experienced depression. She found a strong presence of violence and abuse in the women’s childhoods, as well as grief and loss, interpersonal trauma, and further experience of violence as adults. Recovery from depression for these women had diverse meaning-makings and expressions that were unique for each woman. Wilson found that depression and recovery needed to be seen in a gendered and contextualised manner, with women finding their own right formula for recovery (Wilson, 2007).
In addition, Danese et al. (2008) conducted a quantitative longitudinal cohort study of 1000 individuals who were followed from birth to 32 years of age in the Dunedin Multidisciplinary Health and Development Study (New Zealand). The participants were assessed for history of childhood maltreatment and current adult depression. They found that a history of childhood maltreatment contributed to depression in adulthood and also to medically elevated inflammation levels in the body. Moreover, Nanni, Uher, and Danese (2012) conducted a meta-analysis of 16 epidemiological studies (23,544 participants) and found that childhood maltreatment such as child abuse was associated with an elevated risk of developing depression and recurring depression in adulthood.
The existing qualitative, mixed methods, and quantitative research shows that childhood abuse and adverse childhood experiences contribute to psychological distress and poor health later in life. Of particular significance is that it appears to be specific types of negative or abusive events in childhood and adulthood, particularly those to do with intimate and primary caregiver relationships, that most strongly predict the experiences of distress and depression in later life (Bifulco & Moran, 1998). The greater an individual’s exposure to abusive childhood
46 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW experiences such as violence and abuse, the greater their potential risk for poor health outcomes, including depression (Felitti et al., 1998). Piccinelli and Wilkinson (2000) suggest that early traumatic experiences such as child abuse may be partly responsible for a preponderance of women’s depression, as females are at greater risk of violence and abuse.
Women who have experienced high rates of gender-based violence (such as childhood sexual abuse, domestic violence, and rape) have been found to be more likely to experience mental health issues including depression (Bifulco & Moran, 1998; Browne & Finkelhor, 1986; Nolen-Hoeksema, 2001). Gender differences are demonstrably relevant; factors such as adverse childhood experiences, sexual violence, domestic violence, and stressful life events, in combination with narrow social roles, are all likely to contribute to women’s distress (Nolen- Hoeksema, 2001; Piccinelli & Wilkinson, 2000).
From the overwhelming literature on this subject, it is reasonable to conclude that violence and abuse in childhood does contribute to distress and experiences of depression in some women. But clearly, there are no simple explanations as to why depression disrupts the lives of some women; however, if depression is seen as a gendered construction, women may be diagnosed more than men not necessarily because women are more susceptible to depression but because health professionals view women as depressed without taking into account the social, racial, economic, cultural, and oppressive systems that women come from, and how these intersect to create multiple levels of oppression and distress in women’s lives.
Australian Qualitative and Mixed Methods Studies on Women’s Depression
In the Australian literature on women’s depression, four qualitative and mixed methods studies were found to be relevant to this research: Houghton (2007), Vidler (2002), Day (2000), and Fullagar and O’Brien (2009).
Houghton’s (2007) study in Canberra, Australia, focused on women over the age of 40 who had been diagnosed with depression. The qualitative study conducted face-to-face semistructured interviews with four women who were identified as living with depression. The study was based in constructivist and interactionist theoretical perspectives, both of which conceptualise meaning as being individually constructed via interactions with others in society. Houghton’s approach did not accept the biomedical explanation for depression, and her objective was to see the interplay of recovery and hope in people’s lives. Houghton analysed the data using thematic analysis and found that five major themes emerged: disconnection,
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 47 isolation and despair, meaning-making, being-versus-doing, and reconnection. Houghton found that the women often felt silenced in their depression experience, as well as hopeless and invisible. Despite this study being located in an urban environment, it was important to include it as it was lived experience-focused with older depressed women. The themes uncovered share similarity both with Jack’s research (1991), of women self-silencing in order to maintain their intimate partner relationships, and with Scattolon’s findings (1999), that isolation, disconnection, and loneliness are factors for women living with depression. However, Houghton found that the women knowing that they could recover from depression and having hope of this was vital to their recovery. The feeling of hope gave the women a sense that things would get better, and this aided their healing and recovery from depression.
In her doctoral study on women’s beliefs about being depressed and their understandings of their experiences of depression, Vidler (2002) used mixed methods approach and in-depth, semistructured interviews within a phenomenological framework in order to better understand the experiences of urban women living with depression in the inner region of Melbourne, Australia. As part of her study, Vidler conducted one-time-point, semistructured, in-depth interviews with 22 women, of 120 minutes each. The semistructured questions were designed to draw out an understanding of the women’s experiences of depression as being different from sadness. The women were asked what led them to feel depressed; what professional help, if any, they had accessed; and what helped them, if anything. She also gathered other data in her mixed methods approach by using self-reporting, via the Centre for Epidemiological Studies Depression Inventory (CES-D; Radloff, 1977), and other scales, with the women. Vidler administered the CES-D prior to the interviews with the women participants. Her research found that a mixture of negative life events, such as losses of significant relationships, childhood abuse, isolation, domestic violence, negative self-judgements, and other stressful life events were central to the experience of depression for these women. From the qualitative analysis of the in-depth interviews, Vidler found that relationships and social interactions with others were central to any understanding and assistance given to women with depression. She found that recovery from depression for these women was also about increased self-caring and self-agency, including active involvement in decisions about their own treatment. The analysis also revealed that all of the women in the study were dealing with more than one adversity or negative life event. Experiences of adversity in childhood, such as childhood abuse or the loss of a parent, as well as a personal betrayal, were identified by several of the women in the study. This observation of the intersection effects of various life experiences is similar to the findings
48 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW of Bifulco and Moran (1998) and Brown and Harris (1978). Although Vidler studied depression in urban rather than rural Australian women, the study does observe some similar themes to those found by Scattolon (1999) as well as by Jack (1991). Difficulties in relationships, unrealistic gendered role expectations, abuse, and loss were recurring themes in all these studies.
As noted earlier, only one study specifically recruited rural Australian women with depression, that of Day, for her doctoral research study. Day (2000) used mixed methods approach to see if prevention strategies derived from the psychological model of learned helplessness would reduce depression symptoms in rural Australian women. The learned helplessness model is a theory about how people view their problems and the extent of their agency over them: When people feel they have no control of their lives or an aspect of their lives over a period of time, often in response to an event or events, they begin to feel there is no point in trying—hence the term, learned helplessness. It also needs to be noted that the learned helplessness model is an individualistic psychological theory that understands problems to be located within the woman herself and does not examine any social, economic, or cultural contexts that could be influencing the woman’s distress. A sample group of 76 women were involved in Day’s study, recruited from rural areas of Western Australia to be involved in a “personal development course”. After initial testing of the group, 34 participants reported mild to severe depression. The women were then each randomly assigned to one of three groups: a standard group with traditional CBT interventions, an experimental group with preventative strategies based on the theory of learned helplessness, or a control group with no intervention, all over a three-week period.
Day found that the control group showed no changes in their depression scores across the research period or at post-test follow-up times. The standard group received CBT intervention one day per week for three consecutive weeks, and Day found that the participants in this group had a reduction in their depression symptoms at the post-test point (three weeks after treatment ended) but no effects at either their 6-week or 6-month follow-up points (Day, 2000). However, the experimental group that were treated based on the prevention strategies derived from the learned helplessness model of depression (Petersen, Buchanan, & Seligman, 1995) still had a reduction in depression symptoms at the 6-week follow-up point, and the effects were even more pronounced at their 6-month follow-up point (Day, Kane, & Roberts, 2003). Day found that the prevention strategies derived from the learned helplessness model were helpful for the rural Australian women who identified as having depression. It is noted
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 49 that this study was individualistic in its focus on women’s experiences of depression, and used psychological approaches such as the learned helplessness model and CBT to “treat” depression. Although this framework was reductionist and individualistic, it was the only study in the literature that specifically recruited rural Australian women, of which 34 were identified as depressed using biomedical criteria.
Fullagar and O’Brien’s research (2009) is a feminist qualitative exploratory study that was interested in how urban and rural Australian women gave meaning to their experiences of recovery from depression. Even though the study did not solely focus on rural Australian women, 28% of the female participants identified as living in a rural or regional area of Australia. Fullagar conducted in-depth interviews with 80 women aged 20 years and over. In the interviews, the women were asked to give metaphors that described their experience of depression and recovery: how depression affected their life, what strategies or events helped or impeded them in recovery from it, any gender expectations that contributed to depression, and what changes they noticed in themselves in the process of recovery. Fullagar and O’Brien’s analysis of the in-depth interviews using reflexive analysis found that complex and difficult relationships, gender inequities, and child care burdens within the family; women’s critical viewing of themselves, feeling like they did not live up to the “good woman” ideal, and having unrealistic expectations of themselves; and emotional caretaking of the family were identified in relation to these women’s depression experiences (Fullagar & O’Brien, 2009). According to the study’s findings, the emotional burden of caretaking and self-sacrificing, combined with expectations of being superwoman, tended to impede recovery from depression. In summary, this study found that unrealistic role expectations, gender inequalities, family disharmony, and child care responsibilities all contributed to the women feeling depressed (Fullagar & O’Brien, 2009). These findings are similar to findings by both Scattolon (1999) and Jack (1991), where the women’s sense of self was tied to their ability to be “good mothers and wives” for their partners and their families, so that the women’s perceptions of their inadequacy to perform caring and housewifely duties contributed to their distress and depression experiences.
From the review of the qualitative literature on Australian women’s experiences of depression, it would appear that more research is needed in this area. Out of the four studies, only one—Day’s (2000) study—was specifically located in rural Australia, and it was a psychological approach using the learned helplessness model and was treatment-focused; the other three were conducted in urban areas of Australia, with the exception of the feminist work of Fullagar and O’Brien, which included urban and rural participants. It seems that what is
50 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW lacking in the literature is the voices of rural Australian women about their lived experiences of depression, and what these can bring to the body of research. There appears to be few Australian qualitative studies that have acknowledged the women’s voices and experiences; thus, the direction and imperative of my research.
Summary
The literature identifies that women’s experiences of depression are connected to social factors such as traumatic childhood experiences, loss, domestic violence, poverty, and abuse. Furthermore, negative notions of self and identity, unhappy intimate partner relationships, and unrealistic, socially-acquired self-expectations of being a “good mother” and a “good wife” are all interconnected, and intersect with women’s experiences of distress.
There is no lack of interest in the experiences of depression, as is clear from the review of the international and Australian literature, but what is still lacking is an understanding of the lived experiences of rural Australian women living with depression, from a feminist and social constructionist standpoint. Within the literature, Scattolon’s (1999) study is the most methodologically similar to this study, insofar as her theoretical framework and methods are similar to my feminist standpoint framework; however, her study was based in Canada and not in rural Australia. And this is what is lacking from the literature: hearing from rural Australian women in their own right.
This study is not only significant because of this gap in knowledge but because it also seeks to address the geographical imbalance in the current research, as most of the qualitative research into women’s depression within Australia has concentrated on urban environments. This study is interested in understanding the unique perspectives of rural Australian women who are experiencing depression. What knowledge and wisdom can they share about their experiences of distress? With this in mind, this study seeks to shed light on the voices of rural Australian women’s lived experiences of depression from a feminist and social constructionist standpoint.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 51 Chapter 4: Rurality and Mental Wellbeing in Rural Australia
This chapter explores the impact of rurality on the depression experience—the intersection between the places and spaces of the environmental context where the participants live, and the women’s experiences of depression. It situates the study in the unique landscapes and against the social backdrop of the towns and district of the Riverina, pursuant to understanding how these factors, and practical ones such as access to services, may create barriers for women living with depression in rural Australia. It is these intersections of gender, rural place, violence, and mental health that can create multiple layers of oppression and discrimination for women in rural Australia experiencing distress and depression.
Space and place can have significant bearing on self and wellbeing; the atmosphere of a place and its landscape, as well as the culture of the community can be particularly important to health. How the intersections of space and place interact with women’s’ sense of wellbeing and their experiences of distress is relevant to this study, therefore, and this will be discussed later in this chapter.
Photos have been used in this study to create for the reader a sense of the place and the landscape that the women in this study came from. The photos are not of the women’s locations per se but of the general area of the Riverina where the study was conducted.
Rural Australian Landscapes: The Impact of Place on Health
Rurality still tends to be positively associated with the familiarity of knowing other community members, and the perceived friendliness that small communities appear to offer; thus, the attraction and appeal of a rural lifestyle may, for some, embody a broad, romanticised sense of how life for those living in rural areas differs from that of their urban counterparts (Ragusa, 2011).
Yet, the notion of rural Australia is contentious, and different viewpoints exist about what constitutes rural and rurality. It has been noted that rurality is not merely a geographical location or place; indeed, rurality has to do with the economic, social, and cultural contexts, and the relationships, interrelationships, and identities of individuals and groups and how all
52 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW of these factors are constructed and related to the land and environment. So, while rural can be described in terms of geographical location, rurality is a term that has been used to describe a generalised sense of place and belonging, a connection to the land, and the social, cultural, and community connections (Cheers et al., 2007; Pugh & Cheers, 2010). Rurality is a place of diversity, with various cultures, ethnicities, faiths, and social structures; however, at times, rural Australians have been stereotyped as a group of homogenous Anglo-Australians, which does not reflect the diversity of rural Australian populations today, and myths such as this will be explored further in this chapter.
For the purposes of this research, rurality is seen as a social construct, where individuals give their own meaning to place or geographical location comprised of all the social, cultural, environmental, spiritual, and economic topography in which they live (Cheers et al., 2007).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 53
Figure 1. Rural Landscape, Riverina, NSW. Photograph shows the local Riverina landscape, with the crops, green pastures, and sloping paddocks that are common in the area. From “Meet the Maker: Riverina Squabs, Junee,” 2014, by Inside the Riverina, Spring, p. 10. Copyright 2014 by Inside the Riverina, Riverina Squab Pty Ltd.
Health Status
Despite enjoying the advantages of relatively unpolluted environments and open spaces, the health status of rural Australians tends to be poorer overall than that of Australians in urban areas (Alston et al., 2006; Smith, 2016). Rural Australians have been reported as having higher rates of smoking, obesity, poverty, and instances of chronic diseases than their city counterparts (AIHW, 2014, 2016a). In 2010, the AIHW recorded that remoteness appeared to be associated with higher mortality rates, and that motor vehicle accidents and suicides were the two major factors responsible for the deaths of young adults in rural Australia. Although studies suggest that the rate of depression in rural residents is the same overall as for their city counterparts, the rate of male suicide is higher in rural and remote areas, a statistic that is attributed to greater ease of access to lethal means, such as firearms (Bourke et al., 2004; Caldwell, Jorm, & Dear, 2004; Hogg & Carrington, 2006; National Rural Health Alliance [NRHA], 2017). In fact, the rate of suicide among males aged 15–29 who live outside cities is almost twice as high as it is for same-age males living in cities (NRHA, 2017).
The social determinants of health are highlighted by the link between poverty and poor health outcomes. A report by Cannon and the South Australian Council of Social Service
54 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW (SACOSS; 2008) found that income distributions were significantly related to negative health outcomes such that the lower income groups demonstrated higher levels of poor health. People in rural and remote Australia tend to have lower average incomes than their urban counterparts (Smith, 2016), and according to the NRHA (2013), the rate of poverty in rural and regional areas in Australia is slightly higher than it is in capital cities. Cannon and SACOSS (2008) have argued that living in poverty has been established as a significant social determinant of health, and indeed, issues such as smoking, drinking, and environmental dangers are more prevalent in rural areas and in lower income groups (AIHW, 2004; Alston et al., 2006; Hogg & Carrington, 2006; Smith, 2016). Residents of rural and remote Australia are more likely to drink alcohol and smoke than their metropolitan counterparts (AIHW, 2004, 2016a; Smith, 2016); they also tend to have higher blood pressure levels, and rural women are more likely to be overweight when compared with their urban counterparts (AIHW, 2004, 2014, 2016a; Bourke et al., 2004; Smith, 2016).
Indigenous Australians make up a large part of the health statistics in rural Australia since approximately 68% of the total Indigenous population live outside of major cities (Australian Bureau of Statistics, 2010; Smith, 2016). In nearly all the measurements, Indigenous Australians are disadvantaged when compared with the total population (Smith, 2016). In particular, Indigenous Australians are “3.5 times as likely to have diabetes, . . . 5 times as likely to have end-stage kidney disease, twice as likely to die from an injury, and . . . twice as likely to have coronary heart disease” as non-Indigenous Australians (AIHW, 2016b, p. 30).
Practical and logistical discrepancies between urban areas and rural/remote areas in Australia affect both the health and economic status of rural Australia compared to urban Australia (AIHW, 2008; Alston, 2007; Alston et al., 2006; Smith, 2016). The AIHW (2008) claims that health status decreases as the distance from metropolitan areas increases. The reasons for this are complex, and include everyday factors such as the higher cost of petrol, food, and services; the decrease in access to health services and social and support networks; and a decline in overall opportunities to participate in the wider society. Rural Australians are disadvantaged by fewer specialised health and mental health services (AIHW, 2008), often having to endure long waiting lists for appointments to see doctors (and other health professionals, such as dentists), or having to travel long distances to access specialist services. These situations are rarely faced by urban residents who, for the most part, tend to have better and easier access to intervention and care (Alston et al., 2006).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 55 Furthermore, Smith (2016) notes that lower overall health and wellbeing can be the ramifications of socioenvironmental factors that are present in the bush, including the difficulty of access to goods and services, ongoing general economic decline, droughts and floods, service closures, and variable telecommunication services and accessibility (Alston, 2007; Smith, 2016). Mental health is known to be affected by such socioenvironmental factors as poverty, violence, stress, extreme weather conditions, and the degree to which communities and their residents feel socially connected or isolated (Rajkumar & Hoolahan, 2004; Wainer & Chesters, 2000). And although approximately one-third of the Australian population live in rural and remote Australia, just 21% of GPs work in rural settings, with only 2% or less in remote areas (Rajkumar & Hoolahan, 2004), and only 8% of psychiatrists live and practise in these areas (Porche & Margolis, 2006).
Moreover, the environment significantly affects those living in rural contexts. Extreme weather conditions such as fire and flood, the poor quality of rural roads, lack of public transport, and the length of time required to travel to access health services can all potentially compromise access to services, which can, in turn, influence and impact the health and wellbeing of rural Australians (Alston et al., 2006; Bourke et al., 2004; NRHA, 2013). And yet, the advantages of rural living and the connection to land, family, and communities often keep rural Australians from leaving, or from viewing their location and lifestyle as putting them at a disadvantage.
The Economy, Education, and Employment in Rural Australia
The change in rural Australia’s economic position over the past 40 years has placed pressure on many rural communities. There are many factors that have had a direct impact on farming and have resulted in major social and financial changes in rural Australia (Alston, 2007; Connell & Dufty-Jones, 2014; Fraser et al., 2005), including government policies related to economic and fiscal deregulation, agricultural globalisation and a decline in commodity prices, the development of large corporate agri-businesses, controversial water entitlement conditions, degradation of the land, over-grazing, and increased costs associated with greater use of technological components and machinery in the agricultural sector (Chenoweth, 2012; Fraser et al., 2005). Moreover, changeable rural land values, diminishing terms of trade for primary producers, and the centralisation of agriculture have placed political, physical, economic, and emotional pressures on the rural landscape and its residents (Connell & Dufty- Jones, 2014; Fraser et al., 2005).
56 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW In addition, the modern economic story of rural Australia is based around the “patchwork economy”. This notion, described by Connell and Dufty-Jones (2014), describes a “patchwork effect” from the impact of the mining boom—beneficial for some rural communities, while others have been in economic decline, and still others have missed out on the mining wealth altogether (Connell & Dufty-Jones, 2014). However, on closer inspection, these mining employment opportunities are often given to “out of towners” who are flown in and out on a rotational basis, curtailing the economic spin-off to the local residents and to local businesses in general. This, together with the declining rural population, rural youth outmigration, and a generally ageing rural population, has had a negative impact on many rural communities (Connell & Dufty-Jones, 2014; Fraser et al., 2005). Chenoweth (2012) also notes that there have been significant changes in rural economies in recent years. The declining economic situation and shift in government priorities has had a flow-on effect into local employment opportunities. Family farming businesses have been slowly decreasing since the mid-1950s, and those that continue often survive from an off-farm income and family-only labour on the farm (Hogg & Carrington, 2006).
Tourism can provide work opportunities in some parts of rural Australia, mostly in hospitality, and the agricultural sector provides seasonal work in produce harvesting for both local and interstate workers. However, these forms of employment are usually casual, with low pay rates and with few long-term opportunities. Decreasing household income and overall decreasing employment opportunities have severely affected some rural communities (Connell & Dufty-Jones, 2014).
Educational opportunities in rural Australia tend to be restricted to primary and secondary schooling, with small regional centres also offering TAFE courses. Larger regional centres may have higher levels of tertiary education, but regional universities, such as Charles Sturt University, are often spread across multiple campuses located in several regional centres, and do not necessarily offer a comprehensive list of courses or the desired level of prestige; inevitably, rural residents must move to the cities to gain access to courses at urban universities (Alston, 2004). However, some rural residents struggle to even afford the cost of attending a regional university, let alone the expense of relocating to the city; it is perhaps unsurprising that, on average, the educational achievements of rural residents tend to be lower than those of their city counterparts (Connell & Dufty-Jones, 2014; NRHA, 2013).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 57 Rural Australian Culture, Values, and Community
Even though the specific attitudes, values, and norms held by individuals residing in rural Australian communities will differ one from another, it is possible to identify some general social patterns. For example, Fuller, Edwards, Procter, and Moss (2000) and Smith (2016) observe that both the value placed on self-reliance and an attitude of stoicism tend to be stronger in rural areas. Common statements such as “I don’t need an outsider’s help—I can do it myself”, and a “she’ll be right” attitude in relation to one’s own health problems are examples of this; it has been suggested that the strongly-held belief in self-reliance and the value of stoicism amongst some rural Australian men and women may prevent them from seeking help for physical and mental health issues (Fuller et al., 2000; Hogg & Carrington, 2006; McColl, 2007; Smith, 2016). Handley et al. (2014) have also noted that rural stoicism could contribute to rural residents not seeking professional help for mental health issues. Moreover, at times, health professionals are considered “two-bob blow ins” who owe no loyalty to the town, and are often treated with suspicion by the long-term residents of the community (Dempsey, 1990; Smith, 2016). These kinds of attitudes can form barriers for women seeking help on a range of health concerns.
Social class structures. Rural connectedness and social life have long been a topic of interest to rural researchers; the traditional class system that is often presented in rural settings is an entrenched structure that can prove to be exclusive, and a clear distinction frequently exists between “landed gentry” farmers, small hobby farmers, town dwellers (“townies”), and professionals (“blow ins”) (Dempsey, 1990; Smith, 2016). Connections are frequently made through historical family gatherings, such as being fellow-members of the local hunt club, tennis or other clubs, and through generational business and farming connections.
Sometimes the rural “landed gentry” do not mix socially with small hobby farmers or the “townies”. This could be partly explained by the fact that for generations many of the “landed gentry” have employed “townies” as farm hands and domestic labour on their properties. Such attitudes are often passed down through generations and, in part, remain today.
Also in rural settings, there is frequently an “us versus them” mentality that acts as cohesive glue between residents of small communities. These others may include the government, city dwellers, and/or “tree changers” (those moving from the city to a rural lifestyle) (Connell & Dufty-Jones, 2014; Smith, 2016). Such attitudes can hinder rural social connectedness and cause isolation and divisions within the community.
58 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Help-seeking and the barriers to access help for rural women: Gossip, stigma, and anonymity. In small rural communities, the ideas that people have about place are often strongly linked to their beliefs about identity and social position (Pugh & Cheers, 2010). Cultural and community issues of belonging, gossip and talk, social visibility, social connections, reputation, and confidentiality all have significance to the rural health context. A sense of place and belonging is constructed through networks of kinship, neighbourhood associations, friendships, occupational connections, religious associations, and organisational memberships—such as the Lions Club, Rural Youth, football clubs, netball clubs, or the Country Women’s Association.
Gossip and community talk is frequently painted as a negative feature of rural life, but it does serve the function of channelling information so that people learn what is going on in their community (Pugh & Cheers, 2010). Community familiarity can be a blessing and a curse: Information transfer can be used helpfully to assist members of the community who are in need, such as with providing meals, care, and support; however, it also can have a negative effect, where information can be used to stigmatise, and overfamiliarity can blur boundaries. Confidentiality and privacy can also be compromised in rural communities owing to visibility issues (where there may only be one supermarket), existing networks (where people are already known in other settings, such as attending the same church), and relationships—where some individuals have dual roles within the community (Hogg & Carrington, 2006; Pugh & Cheers, 2010). Local residents often play multiple roles in rural settings in order to fulfil necessary functions in a rural community: a doctor may serve as a football coach, a nurse may be a part of the State Emergency Services, teachers may be involved in the Rural Fire Service, and a minister of religion may volunteer at the local pony club. Community service of this sort is not as apparent or obvious in the city due to the relative anonymity afforded to people who live in densely populated areas. In the rural context, however, this overlap often places people in difficult and challenging situations (Pugh & Cheers, 2010). Boundaries may become blurred and confused, confidentially can be compromised, and individuals may feel reluctant to access services in case their information is leaked to others in the community.
Being seen entering a particular service or the local hospital may provide an opportunity for gossip and speculation in rural areas. The stigmatisation of people with mental health issues is reported as a barrier to seeking help in rural Australia (Barney, Griffiths, Jorm, & Christensen, 2006; McColl, 2007; Pugh & Cheers, 2010). Women living with depression are often fearful of losing credibility and being rejected by their local community if their condition
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 59 becomes known (Hogg & Carrington, 2006). Research by Barney et al. (2006) has highlighted this: themes of feeling embarrassed about seeking help from professionals, and fear of others’ negative views about them doing so hindered men and women from accessing help for depression. Furthermore, some participants in the research feared that even health professionals might respond negatively towards them (Barney et al., 2006). Stigma and perceived stigma from others in the community, fears about a lack of confidentiality, and their own and others’ values of self-reliance and stoicism can all make rural women reluctant to access help when they need it (McColl, 2007; Smith, 2016).
All these barriers place rural women in distress in a bind. If they are able to access mental health services in their community, to decide to access them is to potentially risk being gossiped about and labelled by the community as being “mad” or not coping. In contrast, Judd, Komiti, and Jackson (2008) found in their research that rural women tended to be more likely to access help for mental health issues than rural men, and this seemed to be due to proportionately lower levels of stoicism held by women compared with men, and the lower levels of stigma associated with mental health concerns in women compared to those associated with men in rural Australian settings. Feminist theory suggests that some women may feel more comfortable accessing help for depression than men because women are socialised at a young age to internalise their feelings and problems, and in doing so, they can more easily believe that something is wrong with them as individuals and may therefore be more likely to seek out medical services to “treat” their problems. Moreover, women may also be more likely to feel comfortable talking to their health professional about sadness or depression because they are generally socialised to talk about their feelings (Bluhm, 2011; Horwitz, 2002).
A review of the literature shows that there are numerous barriers that rural Australians face when they want to seek help for their health concerns, and that these barriers intersect and interrelate to women in both general and specific ways. The usual rural pressures of travelling long distances for services, coping with environmental challenges, finding employment in a diminishing job market, and living in a traditional rural cultural are, for women, often combined with pressures of role limitation, unequal power, and financial inequality that they uniquely face because of their gender (Wendt, 2009). When experienced together, the intersectionality of rural inequality, mental health stigma, and gender may create several layers of discrimination that compound each other. These might include a widespread lack of understanding in the rural community about women’s distress, a lack of access to appropriate health professionals and informal support networks, and a strong patriarchal culture, that, taken together, intersect to
60 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW create multiple levels of oppression for women experiencing depression and distress in rural Australia.
Women and rural Australia. Within rural Australian communities, more traditional and conservative perceptions of the roles women can play in society still persist. While some traditional values, norms, roles, and attitudes may serve a purpose within the context of rural places and communities, they can also be restrictive, disempowering, and limiting. Those who fail to, or choose not to, conform to normative expectations can face significant challenges and may be treated with contempt or suspicion in some rural communities (Dempsey, 1990; Hogg & Carrington, 2006; Smith, 2016; Wendt, 2009). The gendered roles attributed to rural women are often described as being narrow and limited when contrasted with the more contemporary societal norms that are likely to be found in urban areas (Alston, 1995; Dempsey, 1990), such as the view that a woman’s primary role should be as homemaker and mother (Allen, 2002). Discourses of rural women often focus on ideas of stoicism, adversity, and determination, and gendered constructions of the work they do and the roles they perform are still commonly portrayed by contemporary media. Rural women come from a range of differing backgrounds with a variety of social and cultural demographics and a diversity of characteristics, values, and views. Many who make up the overall demographic of rural Australians are not associated with the rural stereotype of family farming, but are professionals, service workers, small business owners, and tradespeople who live in small rural towns or regional centres within rural communities (Allen, 2002).
Yet, often rural communities are spaces characterised by traditional gender roles that are led by narrow gendered assumptions of how men and women are to behave and interact with one another. Some rural spaces allow the continuation of the patriarchal system to go unabated and social orderings are often therefore more traditional and conservative in nature (Alston, 1995). These spaces can serve to enhance and reinforce patriarchal attitudes, which in turn serve to disempower less valued social groups within the community, such as women and children.
An assessment of gender roles in rural geography begins with a review of the division of labour in agricultural production and the experiences of women on the land. Brandth (1995) discusses how maintaining traditional gender roles on the farm and their association with a hegemonic form of masculinity is vital, in which men’s dominance over technology and the environment is essential to rural men’s sense of identity and masculinity. Bryant (1999), also, argues that the hegemonic masculinity within farming hinges on an ability to tame nature and
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 61 to maximise profit. Definitions of what it means to be a successful farmer and a man are based in the gendered ideals of male dominance over the land and nature. While historically women have not been publicly visible within farming practices in rural Australia, this is slowly changing, often due to financial constraints: farmers are not able to afford to employ farming staff, so the family members (men and women) are required to work on the farm (Alston, 1995). Often women accept that “this is the way life is”, and do not challenge male privilege within their own spaces. As Little (1986) argues:
while such structures of power may not be as strictly ordered within contemporary rural society, in that relations in agriculture have undergone considerable change, a woman’s status is still very much a function of her husband’s position within the community or, more accurately, his status as conferred by income and wealth. (p. 3)
Even if women in rural areas are not associated with agriculture and farming, rural patriarchal values still permeate the rural landscape and the communities in which they live. If women are perceived to not adhere to the values and culture of the local community, these women may be ostracised by the community, for example, by not being invited to a community or social gathering, or by pressure being put on their husbands to “control your woman”. In such cases, gossip and social isolation can occur, and the effects of these may be more obvious in small communities. Refusing gendered norms in some rural communities, therefore, may not be well received, and backlash could occur (Alston, 1995; Dempsey, 1990).
In addition, if rural women living in a culture of male privilege where women have narrowly defined caring and domestic roles do challenge their “lot in life” and the injustice of unfair work and power distribution, this may not be tolerated even by their own families and friends (Dempsey, 1990). Fear of losing credibility and standing in the community is a real risk, and family members can sometimes pressure and censure each other to “toe the line” within rural spaces.
These traditionally held patriarchal values can also make it difficult for rural women to seek fulfilling employment, especially in those fields that are not seen as “appropriate” for women. Rural women are often responsible for child care, regardless of their employment status, and practical considerations such as increasing transport and child care provision are a paramount issue in accessing employment for rural women (Alston, 1995; Little, 1986). Moreover, rural decline and the lack of openings for long-term employment in rural areas mean that some rural women are kept financially dependent on their male partners in economic
62 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW disadvantage—a result that gives advantage to and so reinforces the existing patriarchal culture (Alston, 1995; Wendt, 2009).
However, in some circumstances, rural women are the main regular income earner in the family, and may hold a position in teaching, nursing, or another traditionally female-dominated profession to supplement the income gained by their partners from primary production, so providing cash flow for the ongoing farm and family expenses (Alston, 1995; Wendt, 2009). These women are often obliged to do a double shift of full-time work—professional work during the day, and domestic and caring work in the evenings. The long distances on poor quality roads that they frequently need to travel to get to and from their work locations places additional pressure on them (Alston, 1995).
Moreover, historically, power, finances, and resources in rural family farming businesses were often unequally shared across the genders, with men often controlling the resources and finances and therefore having more power and control (Allen, 2002; Alston, 1995; Dempsey, 1990). However, these unequal gendered power and resource arrangements are now less common in modern farming practices and are changing, especially with the changing social demographics of rural areas in recent years (Wendt, 2009). Rurality can be a place of family connection and belonging, however for those who challenge the patriarchal values it can be a place of isolation and oppression.
Power and violence. Until recently, there has been a lack of understanding of and documentation about the levels of domestic violence faced by women in rural and remote areas of Australia (Wendt, 2009). It is well documented that the burden of violence, abuse, and poverty can increase women’s levels of distress and depression (Taft, 2003; Western, 2009, 2013). Mason (2012) has argued that there are particular elements of rural culture that increase women’s vulnerability to violence and restrict their ability to leave and get help. These elements include isolation, their partner’s ease of access to firearms, a culture of reluctance to report problems to police, a lack of perceived confidentiality amongst community members, access issues to appropriate services, and restricted resources with which to travel to safety. Moreover, the numerous social connections within rural communities can make it difficult for women to report or escape from domestic violence because the police and other service providers could be friends with the perpetrator (Wendt, 2009).
Moreover, a general culture of stoicism, as well as the shame and stigma related to formally accessing professional help in rural regions, also inhibits women and children from
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 63 leaving violent relationships (Hogg & Carrington, 2006; Mason, 2012). Women often internalise the violence as their fault and blame themselves, sometimes staying in the abusive relationship in the hope that it will get better, and holding onto traditional notions such as not wanting to break up the family. These views and values often keep women in violence and oppression. Social conditioning for women to be caretakers of relationships also inhibits some women from leaving violence and abuse (Wendt, 2009). Moreover, safety from domestic violence often means relocating to a larger town or city to seek anonymity and to ensure confidentiality and safety, so women also stand to lose friends, support networks, and social connections by moving away. Such an alternative comes at a great financial and emotional cost for women, leaving them with both fewer avenues of support and fewer opportunities by which they can sustain themselves. In addition, affordable housing is often difficult to secure, child care options are scarce, there are limited public transport options, and there is often little opportunity for meaningful employment in rural areas to help women start again, so if they leave their partners, they are also subjected to poorer living standards, and are often plunged into economic hardship (Alston, 1997; Hogg & Carrington, 2006; Mason, 2012; Wendt, 2009).
Rural women escaping from domestic violence face considerable disadvantages and barriers (Alston, 1997; Mason, 2012; Wendt, 2009). Being subjected to degradation, violence, and abuse from their partners can have lasting effects, including undermining a woman’s sense of self-worth and identity, particularly as often their identify is tied to their partner and the relationship (Jack, 1991); couple this with experiences of depression and the barriers to accessing help and support in rural communities and it is not difficult to see that these interrelationships can create multiple levels of disadvantage and discrimination for rural women experiencing oppression and distress.
Summary
Rurality is not just a geographical location but is a connection to place and land. Many rural and remote Australians prefer to live outside of the cities because of the open spaces, the unique connection to the land, the proximity to animals and wildlife, their family and community connections, and the more affordable housing and perceived safety of these areas. Rural communities can give a sense of connection and of belonging and acceptance—walking into a local business means being greeted by name. However, they can also be a place of alienation, isolation and oppression, depending on your circumstances and standing within the local community (Dempsey, 1990).
64 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW The health disadvantages faced by rural Australians are considerable, and ironically, many of the issues that add to this picture of disadvantage can increase the risk of rural women requiring the health assistance that can be so challenging to obtain. Not only do rural residents experience at times poorer access to services than their urban counterparts—long waiting list times for medical appointments, the high cost of travel to access help, and limited specialist services—but the challenges posed by extreme weather conditions and poor road conditions, as well as statistically higher rates of smoking and heart conditions compared to their city counterparts, all increase the level of health risk and disadvantage for rural Australians (AIHW, 2016a; NRHA, 2017; Smith, 2016).
In summary, the “downside” of rural communities may be a perceived lack of confidentiality and the risk of stigma and social exclusion, coupled with stoicism and strong patriarchal values, which can all intersect to create layers of oppression and disempowerment for rural women. However, for some women, the difficulties they face are not necessarily seen as contributing to poorer health or to distress, but are just accepted as a part of life in rural Australia.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 65 Chapter 5: Research Methodology
In this study, I was informed by feminist standpoint theory, and I employed qualitative methodology to the research endeavour. Feminist standpoint theory and the methodology of this research study will be discussed in detail in this chapter. Limitations of the study are also addressed.
In addressing my interest in rural women’s experiences of depression, I developed four broad focal points to inform my enquiry. These were:
• to explore the women’s own understandings of the lived experience of depression and its causes;
• to consider whether the experiences of living in rural NSW may have affected or influenced the women’s depressive experiences and, if so, in which ways;
• to identify what intervention/support options women chose, if any, and the reasons for their choices; and
• to examine how these women coped with and recovered from their experiences of depression.
Qualitative Methodology
Qualitative research allows for flexibility in the research process. It is possible for one or more aspects of a topic to be studied in depth. This can result in richer understandings of participant perspectives and the subject matter under consideration (Alston & Bowles, 2003; Silverman, 2005). Most qualitative research, including feminist research, rejects the notion that research can be neutral or value free. Human interactions are socially constructed and based in values and culture; thus, we are inseparable from our view of the world and therefore our research. Knowledge is fluid because it is socially constructed and therefore meanings are intrinsically subjective (Alston & Bowles, 2003; King & Horrocks, 2010).
In consideration of this, the interviews I conducted were deliberately flexible and semistructured to allow the participants as much freedom as possible to discuss what was important to them.
66 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Feminist Research and Feminist Standpoint Theory
It is important to recognise that there are multiple feminist theories and understandings. I chose for this study to be informed by feminist theory, and in particular, feminist standpoint theory, which provides a space in which to claim that there is no objective stance, and to acknowledge that an individual’s position is in relation to the dominant group understanding of reality (Monroe-Baillargeon, 2004). Feminist standpoint theory is concerned with how knowledge is gained or produced, and the relationships within which it is made (Banister et al., 1994).
Feminist standpoint theory argues that the personal is political, in research and in all areas of life (Letherby, 2003). There are five general principles recognised in the overarching feminist approach that underpin all feminist research:
• “Giving voice to women’s experience;
• Moving away from dichotomous and other forms of simplistic thinking;
• Incorporating reflexivity;
• Adopting a collaborative approach; and
• Using research as a tool for emancipation” (Cosgrove & McHugh, 2000, p. 816).
Feminist standpoint theory. A feminist standpoint epistemology takes account of the relationship between women’s experiences and the generation of knowledge by examining how research is produced and the relationships it is produced in (Harding, 2012). According to this epistemological position, knowledge derived in the research process begins from the standpoint of women’s experiences, and also includes the subjectivity of the researcher (Harding, 2012).
Thus, my background, culture, and values influenced the choice of research topic, the interviews, how I understood and analysed the data, and how I formulated the discussion. As a feminist researcher, I was interested to conduct the research using methods that enabled women’s experiences of depression to be explored directly and subjectively, rather than those that were objectifying and disqualifying. Feminist standpoint epistemology means starting with the women and their knowledge and experiences. Being attentive to the power of knowledge, to boundaries, power differentials, and our situatedness as researchers within the research process is important to feminist standpoint research, and ultimately means valuing the women’s stories and exploring these as a valid source of knowledge (Ackerly & True, 2008). Being
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 67 aware of the power of knowledge and my own epistemology enabled me to ask vital questions throughout the study, about relationships in context to power dynamics, about boundaries, and about the interrelatedness of the research and the participants. I was concerned about boundaries and the power to marginalise; not all boundaries are unjust, but one must be aware of their power to exclude and to marginalise participants (Ackerly & True, 2008). I was particularly mindful of this, and it is one of the reasons my study was open to women who self- defined or who were biomedically defined as experiencing depression who lived in the Riverina area. Ultimately, a feminist researcher such as myself aims to be attentive to the social, cultural, political and economic relationships to herself and her participants, and how these intersect with knowledge-gathering and with making sense of the knowledge during the research process.
My research goals seemed best served by working from this feminist standpoint epistemology, for several reasons. Firstly, there is congruence in using a feminist lens when the researcher is a woman and a feminist and when all the participants are women. Secondly, the feminist approach was in accord with my desire to understand women’s depression from their own standpoints, as it was important to intentionally provide opportunities for women’s lived experiences to be heard on their own terms and to acknowledge and recognise their viewpoints as valid (Alston & Bowles, 2003; Monroe-Baillargeon, 2004). Thirdly, and importantly, feminist theory, and in particular, feminist standpoint theory provides an awareness of power differentials in the researcher/participant relationship. Some have argued that since a feminist perspective is concerned about the abuse of power, it encourages the researcher to be aware of how they themselves impact and influence the research process through their own beliefs, interests, and experiences. Researchers who implement the feminist standpoint framework view the participants in their research projects as equals in the relationship, rather than merely as objects for study or experimentation (Letherby, 2003; Stanley & Wise, 1990). It also recognises that the researcher brings their own subjective views and positions to the research, that being neutral is neither possible nor desired, and that information, knowledge, and meanings are socially constructed. In using such a framework, therefore, I was attempting to work alongside the participants to form a respectful, authentic, and equal research interaction, and to limit the potentially exploitative nature of research relationships.
Leading from this, the fourth key reason to use a feminist approach, and in particular, feminist standpoint theory, is its emphasis on reflexivity within the whole research process.
68 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Reflexivity is not unique to feminist standpoint theory, but it is integral to feminist qualitative research; it is a critical position from which the researcher continually reflects on and interprets the participants’ data within the framework of the social context in which the participants live, while also reviewing their own subjective lens as they interpret the information. As King and Horrocks (2010) state, “For most qualitative researchers, reflexivity enables a critical stance to be taken towards the impact of both the researcher and the context in which the research takes place” (p. 126); reflexivity is based on the premise that all findings are constructions or personal views of reality and are subject to change. The researcher, therefore, does not claim to be neutral or objective either, but acknowledges that since all information is socially constructed, all research is carried out from a particular standpoint (Banister et al., 1994), and the researcher, too, brings their values and meanings to the endeavour.
I intentionally engaged reflexively in the whole research process from the outset—in choosing the topic and the methods, in understanding the participants and the participant relationship, and in how I gathered the data and analysed and interpreted it. I felt that the voices of the women participants needed to be accurately expressed by the process, and that it was up to me as the researcher to make choices about how to gather and interpret those voices so that they could be presented as authentically as possible. This meant that I critically reflected on and evaluated the entire research process within the framework of acknowledging differing “lenses” and worldviews, and kept in mind that because information is filtered from one’s own personal views of reality into other situations, it was important to reflect on my own interpretations of the data during every stage of the research process. This approach also meant that I had an awareness of how I conducted myself in the interviews with the participants and how my presence as a researcher could influence what the women would disclose.
Finally, I chose to use feminist standpoint theory because it also provides the researcher with a framework in which observations of different aspects of social life—such as poverty, oppression, power, abuse, and patriarchal influences—can be identified and understood (Monroe-Baillargeon, 2004; Stanley & Wise, 1990). Research based on feminist theory has made a considerable impact on the position of women in society by exposing oppressive, patriarchal structures (Reinharz, 1992). Feminist theory and feminist standpoint theorists believe that masculinised knowledge has often inappropriately defined women’s experiences. As such, the approach rejects male “objectivity” because it has been traditionally defined by men, and subsequently argues that traditional research approaches and methods may have little validity for studies with women (Letherby, 2003).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 69 Therefore, I intentionally chose feminist standpoint theory and qualitative methodology because I felt that rural women have not yet been fully heard by the predominantly nonfeminist quantitative research available on this topic. Women with mental health concerns are often voiceless in the public sphere. By using feminist standpoint theory and qualitative methods, I intended to give voice to the lived experience of women who are living with depression in rural NSW, and to women in the public sphere of mental health generally.
Location of the Study
Since I live and work in the Riverina and have a home and two small children there, my association with this area, local knowledge, and connection to the community made it an ideal location for my research, particularly as it contained a population from which to access an appropriate sample of suitable (i.e., rural) participants.
The Riverina region is located in the south-west part of NSW and has many typical characteristics of rural Australia, and agriculture is one of the main primary industries. The Riverina has a combination of low hills and flat plains, a warm-to-hot climate, and a good supply of water. This has allowed the region to develop into one of the most productive and agriculturally diverse areas in NSW. Major population centres in the Riverina include Wagga Wagga and Griffith.
Wagga Wagga is just under 50 km from the Hume Highway and just over 450 km from both Sydney and Melbourne. It is the region’s main centre for health-care provision and has two large hospitals, a hospice, several nursing homes, and a cancer treatment facility. Wagga Wagga has a campus of Charles Sturt University, which is the only locally-based provider of university education in the region, and Wagga Wagga is also home to two Australian Defence Force establishments. These institutions provide services, diversity, and income to the region.
Geographically, Wagga Wagga is situated on a large artesian basin beside the Murrumbidgee River, which provides a constant and reliable water supply for the district. Wagga Wagga is surrounded by fertile farming land. Since 2001, the shire has experienced a population growth of 1.3% per annum—equivalent to an average of 753 additional residents each year—and in 2017 had reached a population total of 64,272 (Wagga Wagga City Council, 2017). Wagga Wagga tends to absorb relocated rural residents from smaller rural towns, however, which may explain why it, as a regional centre, has experienced an increase in
70 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW population growth while there has been a decline in the population of some outlying townships (Ragusa, 2011).
The second largest town in the Riverina area is Griffith, which has a population of 26,125 (Griffith City Council, 2016). Griffith is located 570 km south-west of Sydney in one of the largest rice- and wine-growing regions in NSW. A large irrigation system has allowed this dry area to be reclaimed as fertile agricultural land well suited for growing fruit and other produce. In the years after World War II, Griffith received a large influx of Italian immigrants who were mostly employed within the agricultural industry. Their cultural background has contributed to shaping the social characteristics of the Griffith area.
The participants in this study come from a broad range of locations within the Riverina, some from small villages, towns, and farms (large and small) and some from regional centres such as Griffith and Wagga Wagga.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 71
Figure 2. Commonwealth Electoral Division of Riverina Map. Shows relative proximities of Riverina towns and surrounding geographical area where study participants live and work. From “Commonwealth Electoral Division of Riverina: Boundary Gazetted 22 December 2009,” by Australian Electoral Commission, 2009, http://www.aec.gov.au/profiles/nsw/files/2009/2009-aec-a4-map-nsw-riverina.pdf. Copyright 2009 by Pitney Bowes Software Pty Ltd & 2010 by Commonwealth of Australia.
72 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW
Figure 3. Lake Albert, Wagga Wagga, NSW. This lake is often a source of recreation activity for the residents and is popular on weekends for families and for fishing and boating enthusiasts. The picture also captures the landscape and topography of the Wagga Wagga district. From “Wagga Wagga Attractions: View of Lake Albert from Willams Hill,” 2012–2017, by Highway Traveller. Copyright Bidgee/Highway Traveller.
Methods
Recruitment and sampling. With the time and resources available to me, it was my intention to conduct 25–28 face-to-face interviews with any woman aged 18 years or over who identified as living with depression and who was residing at that time in the Riverina area of NSW. I was interested in obtaining a group with a broad social demographic background; however, I did not deliberately target specific subgroups of women or any ethnic group with my recruitment process. I intentionally used local media services in the Riverina to recruit participants for the study, and advertised on the local radio station, 2AAAFM, which is a not- for-profit community radio station based in Wagga Wagga and transmitted throughout the Riverina district. I also distributed information flyers to local medical centres, community and women’s health services, the Wagga Wagga library, and to nongovernment services in the local areas in an effort to source women who may have been experiencing depression and possibly using these services. The flyers were left in the waiting rooms of these services for the women to access. I also placed advertisements on many occasions in the community noticeboard section of the main Riverina newspaper, the Daily Advertiser.
I also used a snowball sampling technique, which involved asking confirmed participants to recommend other women suitable for the study. The participants often said they knew someone who would be interested in the study and that they would be willing to contact them.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 73 If these referred women then consented to the study and met the criteria of having depression (whether self-defined or professionally defined), were not in a current acute mental health crisis, and were living in the Riverina, they joined the study. I am aware, however, that using a snowballing technique can at times decrease the diversity of the sample population, and acknowledge that the lack of diversity in the study sample may be attributable to this process.
Size. I recruited 27 participants for the study; this number was sufficient for gathering enough data for saturation point but was not too large to handle for data analysis purposes. It took me 12 months (from 2012 to 2013) to recruit and interview the 27 participants for the study. The study was a one-time-point entry, with one interview per participant of approximately 60–100 minutes in length, interviews being held over a total of a 12-month period.
Participants. Most of the 27 participants were born in Australia and had lived, if not all their lives, then at least a major part of their lives in rural Australia, mostly in the Riverina of NSW. Two of the women were born outside Australia, in England, but had spent most of their adult lives in Australia. The women were mainly living in Wagga Wagga and its surrounding areas: One woman was from the Narrandera/Griffith area; another was from the Tumbarumba area, which is about 110 km from Wagga Wagga and is a small township surrounded by forests and farms; and another was from The Rock, which is a small township 40 km south-west of Wagga Wagga with under 1000 residents. Overall, however, most women were from Wagga Wagga or from within a 50 km radius of Wagga Wagga, from the surrounding farms/hobby farms in the Riverina district.
The participants in the study were all over the age of 30 and were from Anglo-Australian backgrounds. Many of the women were over the age of 50 and a few women were over 70 years old. Most of the women had lived in rural Australia for most of their lives, with two women coming originally from large farming families within the Riverina. Two of the women were farmers and were living on mid-size holdings at the time of the interview. Some of the women were retired and living on a pension, some were working part-time, and a few were working in full-time employment. Many of the women were nurses, teachers, administrators, or were self-employed. Some of the women were in a current relationship at the time of the interview, although some were also divorced. However, many of the women lived alone and were not in a relationship. Table 1 shows the social demographics of the participants in the study (see also Appendix A).
74 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Table 1
Social Demographics of Participants
Name Age Marital Children Currently Type of Ethnicity status working employment
Dee 45 Single 2 No On pension Anglo- Australian
Rosie 51 Married 2 (1 Part-time Admin worker Anglo- adopted Australian out at birth)
Paula 68 Single 2 No Age pension Anglo- Australian
Claire 65 Single; 0 Retired Nurse Anglo- previously Australian divorced
Kathy 36 Single; 3 Yes Self- Anglo- previously employed in Australian divorced business
Dira 65 Widow 0 Retired Admin worker Anglo- Australian
Jay 54 Married 3 Part-time Teacher Anglo- Australian
Maree 55 Married 2 Yes Teacher Anglo- Australian
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 75
Table 1 Social Demographics of Participants (continued)
Name Age Marital Children Currently Type of Ethnicity status working employment
Di 47 Married 2 Yes Nurse Anglo- Australian
Sam 45 Married 0 Yes Self- Anglo- employed— Australian farmer
Margaret 53 Partnered, 3 Yes Self- Anglo-
Previously employed— Australian farmer divorced
Deb 60 Married 1 (adopted Yes Welfare Anglo- out at worker Australian birth)
Lin 45 Divorced 2 Yes Accountant Anglo- Australian
Jade 34 Married 5 Yes Nurse Anglo- Australian
Maria 68 Married 1 Retired Bank clerk Anglo- Australian
Pam 70 Married 2 Yes Nurse Anglo- Australian
76 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Table 1 Social Demographics of Participants (continued)
Name Age Marital Children Currently Type of Ethnicity status working employment
Mona 74 Divorced 1 Retired Welfare Anglo- worker Australian
Stevie 38 Partnered 0 Yes Admin worker Anglo- Australian
Laura 59 Married 1 Retired Defence Anglo- force Australian personnel
Lorrie 59 Divorced 3 Retired Office worker Anglo- Australian
Gay 60 Divorced 2 No On pension Anglo- Australian
Jenny 36 Separated 2 Yes Teacher Anglo- Australian
Peta 52 Married 3 Yes Admin worker Anglo- Australian
Cin 44 Married 2 Part-time Welfare Anglo- worker Australian
Mia 71 Married 2 (adopted Retired Teacher Anglo- children) Australian
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 77 Table 1 Social Demographics of Participants (continued)
Name Age Marital Children Currently Type of Ethnicity status working employment
Vera 59 Married 0 No Disability Anglo- pension Australian
Ange 41 Divorced 5 Yes Self- Anglo- employed— Australian shopkeeper
Note. Names have been changed to ensure confidentiality; n = 27
Data collection methods.
Interviews. Semistructured interviews were used to collect the data for this study. Participants were asked to complete a short, social demographic questionnaire (see Appendix B) at the preinterview stage and had a short, informal conversation with me about their suitability for the study (see Appendix C). This conversation was an opportunity to give the women information about the study so that they could make an informed choice about whether the study was appropriate for them. I purposely chose not to include a biomedical measurement of depression in the suitability assessment so that involvement was open to participants with formal and self-diagnoses—whether they had sought professional help or not. Consistent with my feminist framework, I do not necessarily accept the biomedical criteria and I also wanted the study to be open to as many women as possible who wanted to share their story of depression, whatever that looked like, and I also wanted to avoid an extensive set of exclusion criteria, since this could have set some women up for rejection.
The face-to-face interviews were approximately 60–100 minutes long, depending on participant responses, and were audio-recorded by me in the interview and subsequently transcribed by a professional transcriptionist. In consideration of their comfort and accessibility, the location of each interview was negotiated beforehand with each participant. Options included participants’ homes or neutral sites (such as hired rooms), or my office. The majority of the women chose my office and were happy to travel to Wagga Wagga to meet there. Eight women chose to have the interview in their homes, which were in various parts of
78 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW the surrounding districts and farms within the Riverina; they were all very welcoming of me (and one woman cooked lunch for me, which was a lovely gesture).
The interview questions were open-ended and the women could discuss their experiences in their own time and in as much depth as they felt comfortable. Questions were based on their experiences, understandings, and causes of depression, and ways of managing depression; on ways, they had sought to cope and recover; and on their experience of living with depression within a rural setting (see Appendix D for the interview questions guide).
Safety protocols for the interviews, for both the participant and myself, were planned beforehand; I was particularly concerned about ethical and safety considerations, and not just the physical safety, but the emotional safety of the women during the interviews. All the participants were given a consent form and information sheet on the study (see Appendix E), which also included information on help services so that if the women were distressed after the interview they had access to services for support. Since, however, I am an experienced counsellor and social worker with over 25 years of experience in working with clients in distress, I was confident in my own skills in being able to sensitively conduct the interviews and manage the potential for participant distress during and after the interview.
I conducted one interview with each participant, but participants were given the option of contacting me again later if they wanted to give additional information; however, only one participant did contact me again. Moreover, the participants each agreed that if I needed to ask additional questions for clarification, I could do this via telephone or email.
Interview rationale and process. I chose to use semistructured interviews for three reasons. Firstly, this interviewing style allows for the possibility that rich information will be captured; secondly, it provides a platform to hear in-depth from participants about their experiences in their own words rather than in the words of the researcher; and lastly, it gives the women an opportunity to direct the conversation to areas that they feel are most important to them. While direct questioning can give an expectative frame to both answers and thus to a discussion overall, a semistructured approach allows for participants to discuss relevant and important information that may not have necessarily been on the agenda, via their spontaneous responses and stories (Alston & Bowles, 2003). I found that the semistructured questions and probes helped the women to stay on-topic, whilst allowing them the respect and flexibility to discuss their experiences of depression in their own time and manner. Most of the time the
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 79 women stayed on-topic but when they did diverge it was to add relevant and salient stories that connected up to their experiences.
Before each interview, I contacted the participant to confirm the time and location of the interview. I tried to make the office interview setting as comfortable, informal, and nonthreatening as possible, and placed a lounge and coffee table in the room rather than a desk. I also ensured that all the seating was of equal height and value as I wanted to convey a message of equality and keep the environment as nonthreatening as possible.
Some of the women who chose to have the interview at my office appeared to be somewhat apprehensive on their arrival, but once the initial introductions, purpose of the interview, and relevant discussions and paperwork were completed and we entered the interview stage, most participants seemed to relax somewhat. Some of the participants were nervous when I turned on the audio recorder, despite having agreed to be recorded; however, after the first few minutes of the interview, I noticed it was less of a distraction.
For the eight women who I interviewed in their homes, the process was the same as the office procedure. The interviews often happened at their kitchen table or in their lounge room in a comfortable setting. At the time of these interviews, no other person was at home; the women made it clear to me that they wanted confidentiality and had arranged that their partners and children not be present while we were meeting.
Interview context. Each of the interviews had three stages: “warming up”, “telling the story”, and “winding down”. The “warming up” stage served as an icebreaker for the interview so I could get to know more about the participants, and they could become more comfortable with me. Most of the participants did not know me; some knew of me because of my association with the district, but overall, I was unknown to them. While this may have made them a little uncomfortable, it may also have been an advantage to tell their story to someone they did not know. But bearing in mind the emotional aspect of me being a stranger, I opened the interview with questions that were open-ended and that I hoped would be nonthreatening, such as, “Tell me about yourself, so I get a sense of you as a person—your likes and hobbies”, or perhaps, “Tell me something about your depression experience, if you feel comfortable”.
I was aware that it was important to proceed at a pace that ensured the participants felt comfortable, and these kinds of open-ended questions allowed the women to share on those topics they wanted to while also having the option of not sharing. Since I was aware of the power differentials involved in being the interviewer, I wanted the interview style to allow the
80 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW women to be empowered by the process itself and to feel safe and comfortable in making their own choices about what to say and what not to say within it. It appeared that most of the women were generally happy to share their depression journey, and gave rich accounts and stories of their lived experiences. Only the women themselves will know how much of their stories they kept back, but I was struck by how detailed some of the stories were.
In the second stage, “telling the story”, the women gave accounts of their depression experiences from the context of living in rural locations. Again, I used semistructured questions, with probes, for example, “Could you tell me about your depression experience please?” and/or, “What is your understanding of depression and its causes?” Most women wanted to tell their stories in the hope that they could help other rural women who were experiencing depression. Some of these women offered tips that they felt might be helpful to others, such as how to access services in their local towns. During this stage of the interview, I would use probes such as, “Would you be able to elaborate on that a little more please?” to help facilitate the conversation. In most cases, the women were happy to discuss the topic in more depth if asked.
The third stage was the “wind down” stage and most of the conversations generally came to a natural conclusion. Most of the interviews finished after 90 minutes, although some women felt ready to finish earlier, at around 60–70 minutes. In the wind down stage, I thanked the women, checked how they were feeling emotionally, and asked whether they were okay to drive home or if they needed assistance or some time to rest before they left my office. Most were comfortable to leave after the interview and the formalities were over. Most of the women said they felt good about giving up their time to share their experiences, and one woman said that she felt the interview was an empowering experience for her.
Data Analysis Techniques
After the interviews, I paid a transcriptionist to transcribe the audio files into written transcripts of the interviews. I applied a thematic analysis approach to data interpretation. Thematic analysis is a common type of analysis used in qualitative and feminist research that focuses on identifying themes emerging from the transcripts. The researcher engages with the data by examination and re-examination of the data, line by line, in order to obtain meaningful categories that then can be grouped to form a theme or a series of themes. I employed thematic analysis in my research as I was interested in the women’s voices and lived experiences of depression, and I wanted to create a lens for the study using the themes and patterns within the
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 81 women’s stories. The thematic analysis used an inductive critical feminist standpoint, which was balanced by being theoretically open to what the women brought to the interviews. This meant starting and finishing with the women’s voices and exploring these as a valid source of knowledge, including being open to new knowledge that may not have been anticipated.
In the thematic analysis process, I looked to identify patterns, themes, similarities, and differences among the participants’ stories, and to do this, I read and re-read the 27 transcripts of the participants’ interviews. Descriptive coding, which is considered the first run of data coding, aims to organise data and develop initial themes that are likely to be helpful in addressing the research objectives (King & Horrocks, 2010). In the descriptive coding stage, I read through the transcripts, highlighted any relevant sections/material, and made comments for myself on the transcripts. I then started defining descriptive themes, and I repeated this for each transcript, refining the descriptive themes as I progressed. I labelled the descriptive themes with a short phrase or single word at this stage. I then read through the whole transcript again to see if I could merge some themes together where there may have been a high level of overlap, which in some cases there was. Then the whole descriptive process commenced again with the next transcript, and so on. I would often refine the descriptive themes after reading many transcripts; however, after coding the 27 transcripts over and over I reached a point where no new themes were emerging. This confirmed to me that I had reached saturation point within the data.
After I had completed this initial organisation, the process continued with interpretative coding, the second stage. In this stage of the process, I was trying to go beyond describing the themes and to focus on interpreting the meaning of them. I did this by grouping together descriptive codes that had common meanings and themes within them. This involved identifying more rigorously the themes that had been developed, and I kept connecting back to the interview transcripts to clarify my thinking; I did this at all stages of the analysis (King & Horrocks, 2010; Liamputtong & Ezzy, 2005). I went back to the transcripts to help keep them in context; I did this over and over. I redefined and reapplied my interpretative codes as I proceeded from one transcript to the next and I finished this stage when I felt I had captured the meanings offered in the text. To help me judge this, I kept in mind my research objectives.
The third stage was defining overarching themes from the interpretative themes, and these overarching themes were those that defined key concepts in my analysis. I commenced a higher level of abstraction at this third stage as I began to draw on the underlying theoretical ideas of my study. In the end, I had seven overarching themes from this last stage of thematic
82 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW coding. As an example, one of the overarching themes was grief and loss which included various types of grief and loss events and experiences.
I used this model of data analysis to develop the main themes and subthemes from my data, coding for the themes of the individual women as well as coding for the overall group. It was very time consuming, particularly since I did the recursive process myself without any computer programs to assist me, but I did this intentionally as I wanted to immerse myself in the process and be as close to the data and analysis as possible. Developing a summary of the interview and grouping the data into beginning themes was very slow, as I needed to re-read the transcripts with each new theme that emerged. I also developed mind maps to help organise possible patterns and overarching themes within the data. Since the outcome of the first round of data analysis can potentially influence the questions that are subsequently asked of it, I used a constant comparative method, “reinterviewing” the data to check for accuracy and validation, and rechecking it for any new emerging themes that could inform the next iteration. I also shared some of the transcripts with my supervisors to check my understanding in interpreting the women’s interviews. Rich understandings and knowledge grew from this process; although it was time consuming, it was purposeful and useful and helped me to be as authentic and familiar with the data as possible.
As discussed, this study employed thematic analysis in the data analysis stage; however, it must be noted that some of the quotes in the next chapter from the women’s stories are long in presentation, despite this narrative style being a departure from the usual thematic approach. I wanted to keep the women’s voices intact, as their accounts were so powerful and salient to the themes they were discussing. A narrative approach is concerned with the wholeness in storytelling; thus, where I felt the whole story was needed in order to fully convey the richness of the meaning, I chose to keep such narrative elements as free from reduction as possible (Silverman, 2005). I believe that using thematic analysis with an appropriate mix of narrative style presentation of the women’s voices was authentic to the women’s voices and best captured their meanings.
Ethical Issues
Ethics is more than just formal requirements and I was determined to ensure that any ethical issues that could impact the participants and this study were explored in order that I could limit any potential for harm or exploitation. I was acutely aware that I would be interviewing women who could be vulnerable due to the topic I was discussing with them. I
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 83 sought out the QUT Human Research Ethics Committee (QUT HREC) for guidance and followed their procedure and guidelines, and my research was approved for 2011–2013 (Approval number: 1000000169 see Appendix F).
A variety of ethical issues, including those suggested by feminist research principles, were taken into consideration in the preparation and practice of this study. These were:
• ensuring voluntary participation and protection of participants;
• obtaining informed consent by giving complete and correct information at the outset;
• maintaining researcher and participant safety and appropriate boundaries (at the various interview locations);
• confirming participant anonymity and confidentiality (within the rural context);
• dealing carefully with participants to minimise distress, particularly potential emotional distress (given the nature of the topic) during the interviews, and by giving participants information about counselling services for further assistance in case that should be needed after the interviews;
• maintaining an awareness of power, and the abuse of power, within the research and during interviews with the participants; and
• describing to participants the final storage of the data and how to access the thesis once completed.
It was paramount that I fully explained the project to participants for the purpose of informed consent. Informed consent entails the participant first obtaining a full understanding of the project, and the participants were each given an information statement sheet and a consent form (see Appendix E). Further information about the study was explained and explored before the interview date, and, on the day, if the women had any other existing or new concerns, they were given the opportunity to resolve them, but if they could not they were assured that they were welcome to decline the interview. Issues such as what was expected of them (and of me) regarding anonymity and confidentiality, and a knowledge of my process of record keeping and the secure storage of their interview data were carefully presented; I also apprised them of the QUT HREC complaint procedures. After talking with the potential participants and answering their questions, no participant chose to withdraw from the research.
I was concerned about the issue of confidentially and privacy within the context of a shared rural location. Some of the women lived in the same rural town as myself and I wanted
84 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW to reassure them that their stories would be respected and honoured as well as kept private. I intentionally took some time in the initial stages to discuss the limits of confidentiality of the study and was clear about how the information would be used, stored, and secured. I wanted the women to feel safe to disclose their stories knowing that the information would not be disclosed in a public way to anyone. I also wanted to be clear that if I was to see the women later, in another setting, such as the local supermarket, I would not acknowledge them unless they acknowledged first that it was alright to do so; I did this to be rigorous about their ongoing safety, privacy, and confidentiality as I did not want to allow any unspoken ambiguity to give opportunity for the women to feel uncomfortable in other settings of their everyday lives. The women were appreciative of me taking the time to explore the confidentiality and privacy aspects of the study, and they were happy to proceed with the interview.
When I did visit participant’s homes, safety protocols were adhered to, such as taking a mobile phone with me and informing a third party about my field location (within the bounds of the confidentiality consent agreement) as well as my expected return time.
It was my intention as well as my obligation to participants to give clear information that would enable them to make informed decisions about their involvement in the study beforehand, in order to reduce any possible confusion, misunderstanding, or distress. In each case, there was a prior discussion with the participants individually about the research and the potential topics of the interview, as well as making referral service contact details available to them for after the interview if they should have need of them.
In feminist research, it is important to be fully aware of the use of power and to endeavour to ensure that all participants are protected from any exploitative behaviour. Sharing personal information can be upsetting; interviews had the potential to place participants in a vulnerable emotional situation (Alston & Bowles, 2003). I needed to be able to manage participant distress, and I did this by being aware of appropriate supportive practices, being respectful, being sensitive to the participants’ needs, being congruent, and having appropriate professional boundaries. I also discussed with the women that there were support and counselling services available to assist them further if they should need them afterwards, and I gave them applicable contact details at the end of the session. After-care support is important in situations where people have been vulnerable, and I was aware that these women had been discussing distressing life events. Ensuring that they both had and were aware of the support that they might require was an essential part of conducting my research in a nonexploitative manner.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 85 Some of the women wanted to know something about why I was conducting the study and how I fitted into it, and I was comfortable to answer any questions the women had. I believe I modelled respectful, equal relationship by sharing appropriate information about myself and about how I was located within the study.
Limitations of the Study
The study is limited mainly by the similarity of cultural background and ages of the participants. Most of the women were from Anglo-Australian backgrounds and none of the women was under the age of 30. There were no Indigenous women involved in the study that I was aware of or who self-identified. I would have preferred to have attracted both Indigenous women and women from culturally and linguistically diverse (CALD) backgrounds, however, the sample size was small and it became apparent to me that greater recruitment of Indigenous and CALD women would have required a specialised recruitment strategy which was beyond the scope of this study. In hindsight, I also believe the snowballing technique compounded the lack of participant diversity, as the participants suggested women for the study who they knew and who were often people with similar backgrounds to their own. So, the lack of diversity of participants could be seen as a limitation of this study that emerged because of the difficulty of recruitment and the size and scope of the research.
Even though women could self-define as depressed, using the term “depression” could have potentially discouraged some women from being involved in the study, as they may have seen themselves as distressed rather than depressed. Therefore, by potentially discounting some women from participating in the study, I may have created another limit on the scope and diversity of the women I was able to recruit.
Summary
This study was informed by feminist standpoint theory and used qualitative methods. To gather the data, I conducted semistructured interviews with 27 women participants from rural NSW who all identified as living with depression, whether biomedically diagnosed or self- diagnosed. This study was a journey of exploration. Its purpose was to create rich descriptions of women’s lived experiences of depression and to understand and find similarities and/or patterns within them, rather than to begin with and try to extract or explain a previously generated theory about them.
86 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW The data was gathered over a 12-month period between 2012 and 2013 in the Riverina area of NSW, in and around Wagga Wagga. The semistructured interviews were 60–100 minutes long and I interviewed all the participants personally. I had some challenges in recruiting 27 participants, but by 2013, the data collection was complete. The interviews were transcribed and I read and re-read and coded the data myself manually over a period of time. From the thematic analysis process, I found seven overall themes, each of which will be discussed in depth in the next chapter.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 87 Chapter 6: The Women’s Voices
Twenty-seven women shared their stories of living with distress and depression. The women gave rich accounts of their journey, and common themes subsequently evolved from their stories. Seven main themes were identified: women’s understandings and explanations of depression, how depression disrupts everyday life, living in rural NSW with depression, abusive childhood experiences, grief and loss, accessing professional help and services, and accessing informal help and support. This chapter will explore in detail these themes and findings from the women’s voices.
Women’s Understandings and Explanations of Depression
“I understand that it’s a chemical imbalance and all that sort of stuff . . .”
The women made sense of their depression experiences by drawing on a variety of explanations. Many of the women articulated genetics and heredity as the reason for their depression, or made reference to other medical understandings of depression, such as having a chemical imbalance. However, some of the women gave different explanations, such as personality and psychological factors and/or relational and social-environmental understandings. Moreover, interestingly, many of the women had multiple meanings or layered understandings as to the cause of their distress—for example, holding a social-environmental understanding while acknowledging at the same time a biological understanding.
Three subthemes emerged as the women discussed their understandings of the causes of their feelings of depression: biological understandings, social-environmental understandings, and multiple understandings of depression.
Biological understandings. At the time of the interview, Cin was 44 years old, working in welfare, and living with her two children and her husband in a regional town in the Riverina. Cin’s understanding of her distress was a clear snapshot of depression from a biomedical standpoint—one based on biology and genes/heredity. She said, “I had a good childhood, mother had it (depression), I think it is biological as medication works really well for me”. Cin clearly felt that her depression was biological and genetic, passed down from her mother; but later on, in her interview, she also talked about social-environmental issues and of her depression being triggered by a doctor criticising her parenting in an appointment.
88 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Moreover, another participant, Sam, held a similar view. Sam was 45 years old and self- employed in the Riverina district at the time of the interview. She and her husband farmed the land and enjoyed the outdoor life. Sam stated: “Yep we have a family history of, like on my mother’s side. . . . But as I’ve found out later, that my father had suffered from depression as well, so I’ve got genetic depression, as well as hormonal”. Both of these explanations are based in biomedical discourse; yet, later in the interview, Sam also discussed that she was not on antidepressants but was managing her depression through nutrition, vitamins, and other alternative methods.
Laura was 59 years old at the time of the interview, had one adult child, and was retired and living with her husband. She said, “It’s on all sides, like it goes back through all the lines of the heritage. So, the depression, I realise now that my father suffered from really, really low self-esteem which was very sad”. These women believed that their distress was caused by biological and genetic factors, yet Sam did not accept the biomedical treatment that she had been offered (medication), but instead used alternative methods of alleviating her experiences of distress such as improving her nutrition.
Social-environmental understandings. Some of the women had explanations of their depression experiences that were related to relational and social-environmental factors, such as violence and abuse in childhood or subsequent life stressors like difficult relationships—in particular, difficult partner relationships.
Mia appeared to understand her depression from an environmental and relational standpoint. At the time of the interview, Mia was 71 years old, a retired school teacher, married, and with two adult adopted children who were no longer living at home. About her depression, Mia said:
Well I think I had basically started 43 years ago—when I got married. Probably from the beginning of my marriage I just felt rather disappointed and I wasn’t able to have children, and I started from there and I gave up work to try and have children, and it didn’t happen, and so we adopted a child, and then I just was disappointed with my husband’s first reaction to our new child. Pretty soon after that, I mean these are all the key factors, pretty soon after that when we adopted our child, my father who I dearly loved collapsed, and died seven months later of a brain tumour. And I said goodbye to my father six weeks before he died and brought home a six month old baby and a blind father-in-law who had developed retinol blindness through alcoholism. So, I came home pretty bitter and my husband was a very aloof man, his way of surviving—he had
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 89 grown up in a very emotionally deprived home—he was an only child and he was more comfortable with books than with emotions and I had loved emotions. And through life I have learnt to distrust my emotions and I think it would be lack of emotion response from my husband.
Mia described a series of losses and disappointments in her intimate partner relationship: the disappointment of not having her own biological children, the death of her father, and the sadness of not feeling emotionally close to and unable to share her emotions with her husband. Mia believed all these disappointments had bearing on her depression experience.
Likewise, Rosie’s responses indicated that she believed the abuse she suffered in childhood, specifically, living with a violent father, had caused her depression. Rosie was 51 years old at the time of the interview, married, and with two adult sons—including one she had recently reconnected with who had been adopted out at birth. I interviewed Rosie at my office. She said, “I know what caused it . . . my father was psychotic. . . . He self-medicated with alcohol and he was violent”.
Moreover, Dira, also, believed her depression experience was caused by social factors such as growing up in a violent home. At the time of the interview, Dira was 65 years old, widowed, without children, and living alone. She said, “It [the depression] stemmed from my childhood. . . . I would feel bad because he would use mum as the punching bag . . . ”.
These women were able to give accounts that relational and social factors, and abusive childhood experiences such as violence, had all influenced their depression experience as adults. It became clear, also, that many of the women were able to simultaneously hold multiple understandings about the causes of their distress.
Multiple understandings. Some of the women concurrently held multiple understandings of the causes of their distress and depression experiences, such as holding both biological and social/relational understandings.
Paula, for example, was told by her doctor that her depression was due to a chemical imbalance, but she thought that social factors may have also caused it. Paula was 68 years old at the time of the interview and was living in social housing on her own. She was single, with adult children who were mostly estranged from her.
Well I was told I had a chemical imbalance. . . . I think it’s a learnt thing but it can come from upbringing as children or a child if the person is not nurtured or hasn’t got a role
90 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW model or a guide to help them in life. The depression is something to hide behind I suppose, a mask for help.
Kathy’s understanding of the causes of her depression was based on the medical explanation of a chemical imbalance, as well as feeling that environmental factors and heredity had played a part, particularly as other family members had had “nervous breakdowns” in the past. However, she also stated that her stepfather had caused her depression. Kathy was 36 years old at the time of the interview and was single; she had three children, but only one child living at home. She said,
Well I understand that it’s a chemical imbalance and all that sort of stuff—I wish they’d come up with a cure for it—seriously—but my Mum has suffered a fair bit as well and I don’t think she’s been diagnosed for—I know she had a nervous breakdown that was caused by my stepfather and he caused mine too—so we’re just going to blame him totally for all of that. But I’m pretty sure my Mum suffers it as well. I’m pretty sure my Pop has as well—he’s a bit of the same personality as us—it could just be an inherited thing.
Kathy’s understanding of what caused her depression was somewhat complex and appeared to be made up of multiple viewpoints. Although she expressed her view of a hereditary link to her depression, as she said that she thought it ran in her family, in her interview she also talked about her parents splitting up when she was 12 years old, and how her brother had committed suicide shortly afterwards. She explained how his suicide had profoundly affected her, and at other times in the interview she partly attributed her experiences of depression to this event and also to her stepfather.
Di understood that her depression was due to genetic causes, which she described as a gene that predisposes a person to be vulnerable to depression; she also talked about personality and about stressful circumstances. Di was 47 years old at the time of the interview, and a nurse; she was married, with two children, both living at home.
Yes, I think that everybody that suffers from depression it’s probably, it’s the same thing. There are certain people that are prone to it—I absolutely guarantee my husband would simply not, it simply wouldn’t—that’s not his makeup—he’s just not somebody who is prone to it. So, one, I think you’re already predisposed to it when you’re born— I think there’s a gene DNA that says that this person is going to be vulnerable. Then depending on the path that you grow up on, I think certain things can exacerbate it or ease it or I think a lot is caused by outside influences.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 91 Mona was 74 years old at the time of the interview, divorced, and living alone. She had one adult son, and was retired from working in the welfare sector. She thought the depression experience was a combination of heredity factors and life traumas, as she said, “I often wonder, because my sister was very depressed and I think my mother suffered from depression. And I think it could be a little bit hereditary. . . . I think it’s the life traumas. . . . And the isolation”.
For some of the women in this study, having a medical explanation for what they were going through was helpful as it reassured them that “at last there is a name for what I am experiencing”, and gave them a sense of relief and acknowledgement that it was not just “in their heads”. For others, this explanation was not as helpful, and some of the women preferred to understand their depression through a social-relational lens, or via a combination of understandings, including that violence and abuse affects wellbeing and therefore causes distress and disempowerment. Multiple understandings at first glance appear to show conflicting ideas within the women’s views, however, participants in this study seemed to be open to holding multiple understandings of the causes of their depression and distress, and consequently some of the women were also open to exploring diverse and alternative methods of help and support, some of which did not follow the biomedical model. The women also shared in the interview how disrupting and isolating their depression experience was for them.
How Depression Disrupts Everyday Life
“I just could not get out of bed, or eat. . . . I had safety pins holding up my jeans.”
In the interviews, the women shared how their experiences of depression tended to get in the way of their ability to cope with daily living and everyday activities. The women also talked about how their depression experience made it difficult to do activities that they had previously participated in and enjoyed. Some of the women described an inability to participate in social activities, make decisions, and enjoy everyday life, and for some, this meant preferring to live in isolation. In this theme of the disruption of depression, I included anything that the women described as getting in the way of or hindering their normal life and activities, and any inability to enjoy or participate in activities that they once found meaningful.
At the time of the interview, Jay was 54 years old, working as a part-time school teacher, and was married, with three adult children. Jay talked about her inability to do activities that she normally enjoyed doing.
92 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Probably irritable and just feeling anxious I suppose, about doing normal things, you know, not wanting to necessarily go places and just wanting to be at home. So when I’m depressed I have real trouble, I manage to usually exercise, I try and force myself to go for a walk because I’ve always exercised, so I’d make myself do that and then I’d come home and I’d just be sitting there and I’d try and read my Bible, which I did and that was a comfort but I would sit there and think what will I do now—which is really odd because now that I am well I can see so many things that need doing, it’s not funny. So, I did manage to do the washing and ironing and basic cleaning I guess, and cooking tea, but I wouldn’t cook slices and cakes or do anything interesting which is what I do if I’m well because I really like cooking, that is something I enjoy doing. And I wouldn’t really play the piano which is something I like to do when I’m well. And I really like doing sewing and knitting and stuff; I didn’t do that.
Other women discussed how their depressive experiences interfered with their ability to eat and sleep, such as Lin. At the time of the interview Lin was 45 years old, divorced, and had two children living at home with her. Lin described the disruption to her life this way:
Because I wasn’t sleeping, I wasn’t eating, I wasn’t functioning—going to work and stare out the window for hours, I just was a walking shell, I felt like the walking dead. Well I was not eating—some people eat when they’re stressed and I go the opposite way and I shut down—so I had people bringing me food that was palatable, so I was on a diet of pumpkin pie and apple puree because I couldn’t eat anything hard, I couldn’t even eat an apple for two years. . . . Just to shut those voices off and give some peace because the second I was awake, it would just be on and I’d almost feel like ripping my brain out, you know, leave me alone, just constant. So, yeah, drove me nuts really, having that constant noise in my head. I’m just trying to think—so my hair—my hair falling out—so the stress started getting, washed my hair and would find clumps coming out in my hands—So, I thought, yes, having an effect on my body, so I lost weight dramatically to the point where people were concerned—I had, I’ve still got some actually, to the point where I had safety pins holding my trousers up.
Lin experienced an inability to function in her everyday life due to her depression experiences; her sleeping and eating patterns were affected and she had difficulty continuing her normal everyday life activities, such as going to work. Lin’s story suggests a significant disruption to her everyday life for a consideration length of time.
Cin, also, talked about how her experiences interfered with her ability to make decisions and to move forward in situations.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 93 Shallow breathing, panicky breathing. A real anxiety about making any decision. A real ambivalence. Just this whole arresting of going forward, I couldn’t make a decision. Feeling very gloomy. I remember saying that to a nurse, she came in and asked how I was feeling and I said “gloomy”. And she walked out again! And I said, “Excuse me.” She had a particular attitude that lady (nurse) who was very unhelpful to me.
Di, too, discussed how incapacitating the depression experience was for her: “Like I couldn’t get out of bed, I just was feeling absolutely dreadful, alone”.
Ange was 41 years old at the time of the interview; a divorced mother of five children, Ange was running her own small retail business at the time. She struggled to go out socially due to her depression experiences. She said, “I feel robbed of social contact due to being embarrassed about the shaking of my hands, so I just didn’t go out socially”.
Maree was 55 years old at the time of the interview, was married with two adult children, and was a full-time teacher in her local town. She said, “I was losing it with the kids and not enjoying myself—getting so anxious and feeling like I couldn’t cope. Like I was a failure. I started not sleeping well . . . ”.
Another participant, Peta, was 52 years old at the time of the interview, married, and with three adult children. She worked in her own small business. Peta struggled with sadness and an inability to make decisions and concentrate. Peta said, “I cried for three days straight, I could not concentrate, couldn’t make decisions, so I went to my GP”.
Vera, also, gave clear descriptions of how her depression experience was getting “on top of her”. Vera was 59 years old at the time of the interview and was married without children. She was living in social housing and was receiving a disability pension. She, too, described a reduction in her ability to do daily activities because of her experiences of depression. She said, “I felt I have an unrealistic view on life, because of the depression, the depression gets me down, and I just can’t do much anymore”. Vera also talked about how her physical disability was often a struggle, and how, coupled with her depression experience, she felt like she was redundant and not much fun to be around. It appeared that she blamed herself for her experiences and internalised it as her fault.
Pam, also, had similar experiences to some of the other participants. She struggled to cope and felt very isolated in her depression experience. Pam was 70 years old at the time of the interview and was married with two adult children—one adult child with a disability living
94 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW at home. Pam was working as a nurse and living on a farm near Griffith. Pam said, “I couldn’t sleep, crying, I couldn’t cope, I felt isolated, didn’t speak to anyone about it . . . the depression”.
Mona also felt that her experiences of depression had affected her ability to function in everyday life. Mona said that she felt “extreme loneliness . . . I’d isolate myself a lot. I wasn’t painting. I wasn’t doing much . . . just go to work, come home. . . . I was having savage migraines”.
Gay, at the time of the interview, was 60 years old and divorced, with two adult children; she was receiving social security benefits and was living alone in social housing. Gay said, “I’m standing at the sink and I put my hands in the water and suddenly I look up at the clock and it was five hours later. I just lost five hours—I hadn’t washed up, hands still in the sink. I just broke down you know . . . I thought, I can’t do this”. Gay felt she was “losing it” and struggled to stay present in everyday activities during this period in her life.
These women’s stories highlight how living with depression had affected them and their ability to function and cope in their everyday lives. Some were not able to go to work or look after themselves for a period of time, such as Lin, who relied on help from her mother and father and friends to help her do daily chores and care for her children. Moreover, it was clear from the interviews that some of the participants felt that the feelings of depression had disrupted their ability to function in their everyday lives; for some of the women this had been going on for a considerable length of time.
Women’s ongoing depression experience. As the women told their stories of depression, it was particularly striking that for some of the women, the depression experience had been an ongoing disruption, sometimes over a considerable period of their lives. Most of the women who described their experiences as ongoing were over 50 years old at the time of the study, and several of these women stated that they had been living with depression since childhood. In this subtheme, women’s ongoing long-term depression experience, I included: women experiencing depression for long periods of time; and depression experiences that were ongoing and frequent, causing continual disruption to everyday life.
Dira described her experience of depression as “a feeling”. She stated that she “just [couldn’t] seem to get rid of it”, and identified her depression as being long-term and occurring since childhood. She said,
For some reason, this is my journey on this earth. So, I have to cope with it the best way I can [and] know that there is a reason and a purpose for it. I’ve asked God a few
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 95 times to tell me what it is but he hasn’t told me. And it’s the same sort of thing you know—lovely day, good time and you go back to an empty house and it all caves in on you again. I just can’t seem to get rid of that feeling (loneliness). I just get tired of it; I have had depression since childhood.
Deb, at the time of the interview, was 60 years old, married, working full-time in welfare, and had one adult daughter who had been adopted out at birth. She said, “I had been depressed all my life. I think the rejection of my mother, the anxiety and the depression. I think I was always a teary child, always sad-faced”.
Stevie, at the time of the interview, was 38 years old, in a relationship with no children, and was working in administration. Likewise, Stevie disclosed that she felt that she had had depression since she was a small child. She said, “I always felt that I had depression since I was small, not feeling worthy, disliked school, never fitted in, had a hard time at school, couldn’t wait to leave. I always felt like I didn’t belong”.
Stevie, Deb, and Dira all described their experiences as ongoing and commencing in childhood. All felt some sort of rejection early in life, and feelings of depression and unworthiness followed. Dira’s quote gives the sense that depression was a lonely experience, and not having ongoing companionship with another person appears to have exacerbated it. For all these women, the ongoing nature of depression was an experience of unworthiness, loneliness, and isolation, factors which appear to be more about the context of their lives rather than a medical condition.
Living in Rural NSW with Depression
“Being around the bush, the animals grounded me.”
The experience of living with depression in rural NSW was discussed in the interviews, and the women gave rich understandings of their experiences within these rural settings. Some of the women had mixed responses to living in rural NSW, others had positive experiences on the whole, while still others struggled with the perceived gossip and stigma of living with depression in a small rural town. Some held multiple views and stated that, at various times, the rural environment was both a hindrance and a help in their distress.
The first subtheme (rurality as an aid to coping) includes positive descriptions and experiences of how the rural (social and physical) environment, the lifestyle, and location helped women cope with their depression experiences. The second subtheme (rurality as a
96 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW hindrance to coping) includes negative descriptions and experiences of how the rural (social and physical) environment, the lifestyle, and location caused difficulties for the women. The third subtheme is a mixed view of how rurality was a hindrance, and, at times, also a help for some of the women.
Rurality as an aid to coping. Nine women gave accounts of how living in a rural environment was helpful for them in relation to their depression experience. Lin gave a particularly rich and vivid account of how living in a rural environment—the physical environment and her love of horse-riding—had helped in her recovery process. She said,
I had really lost my sense of self in all that. . . . When I was a girl I used to ride horses all the time, and so that’s when I started. Actually, a friend of mine is really into horses and she said right, I’m going to teach you to ride again. So, every Wednesday I’d go out, she lived just down the road, and she’d give me a riding lesson, and the first time— because I had no confidence, I hadn’t ridden a horse for years—I was just you know, a shell of a woman, trying to ride a horse, but she just took it gently every week and just built my confidence. . . . Just having that contact and trust with an animal was part of my therapy as well, so it was the horse therapy that got me back in the saddle literally and in life. . . . Well, I guess, living in a rural area we have access to that, so I guess, any type of animal therapy . . . particularly when I’d howl on her (the dog) and howl on the horse. But to get on the horse and go, you know, into the bush, and just feel everything around me. Start feeling again, that’s what I’d really missed, you know, the sense of what was around me, feeling the warmth, feeling the breeze, hearing, just hadn’t heard anything but those voices for such a long time gradually, it’s all come back and rebuilding so it was that sense of having to go back to a 12-year-old girl and build on that. . . . When I head out on the horse, because I live near a bush reserve, I would head up to the reserve and there would be no one but, there would be animals and the birdlife around, the bush, the smell of the gumtrees. I just love being in touch with the land and, you know, I’d ride my horse and often I’d just close my eyes when riding because he was such a safe horse anyway and just feel it, smell it, hear it, you know, all the other senses and take sight out of it . . . you know, to actually feel it on my face, the warmth of the sun, the breeze, and be up there and see kangaroos hop along. Or look at the sheep in the paddocks sort of stuff; stop to talk to the other horses over the fence. You don’t get that anywhere else, that’s why I love it here. . . . I think it helped living in a rural environment.
Lin’s account of her experience of living with depression in a rural setting gives a vivid example of how the rural space and atmosphere can be healing on many different levels. In her
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 97 detailed description of the physical environment of the horse-ride, Lin states how “smelling the gum trees” and “listening to animals” while riding her horse had a “grounding” effect on her, to which she attributes her healing process during this period in her life. As Lin’s account of how the natural environment and space was a place for healing for her indicates, the psychological and emotional effects of space and place on wellbeing cannot be underestimated.
Figure 4. Rural Landscape, Riverina, NSW. Photograph shows a landscape similar to where Lin went horse-riding.
Deb also identified that the rural environment was an aid in helping her cope with her depression experience. She shared that the lifestyle she enjoyed in the country helped to keep her stress levels down. She believed that being on a hobby farm and having a swimming pool was something that would be out of her reach in the city. She said,
Certainly, I get really stressed with city traffic—my anxieties come out in a city location. I need to manage my stress levels, living in a rural situation allows me to do that, living on five acres is wonderful—to afford a house of five acres with a heated pool is an essential for me to keep my stress levels under control. . . . So, lifestyle is wonderful here.
Dira also liked living in a rural setting and found the atmosphere and the sense of place was a comfort. She also liked the community atmosphere that her country town afforded her.
98 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW I like living in a rural setting, like to see the freight train go by each day, only walk a few steps from the house then you are in the bush, like the cattle crossings, the countryside, the turtle sign on the road and I like community atmosphere in the country.
Dira said that she received a sense of peace in her experience of country life, in the predictable rhythm of the freight train going by at the same time each day and in having the bush (trees and nature) at her doorstep.
Jay also liked the small community setting and thought that it had assisted her to cope with her depression experience. She said,
I think it’s probably helped actually. Because in the school or in a small community, in
the church we’re in a small community, even though this town is a big place there’s kind of, we still have the advantages of a small community. I haven’t lived close enough to my family to have that family contact so I guess church friends have been more like family. They’ve replaced family.
Lorrie described how she felt people were friendlier in the country compared to where she was living in Sydney. At the time of the interview, Lorrie was 59 years old, divorced, and living alone in social housing, estranged from her three adult children. Even though she did not directly suggest that her depression experience had improved since moving to the country, she was very positive in the interview when talking about her experiences of rural living. She said,
I was blessed the day I came to this town . . . this is the happiest I have been in years. . . . People talk to you and people will come up to you . . . friendliness, if I had known people were friendlier in the country, I would have left Sydney earlier than I did.
Dee also felt that the rural environment was helpful, and spoke of how she liked the isolation of living on a farm, despite the fact that at the time of the interview she was living in a rural town. She spoke about feeling comfortable around farm animals, such as watching the lambs in the surrounding countryside, and she said that she felt less stressed in a rural space. Dee was 45 years old at the time of the interview, with two children (who did not currently live with her), living alone in social housing, and receiving social security benefits. She said, “Yep, away from the hassles, away from the stress. Just out on the farm, play the computer or go for walks up the paddocks. Or ride up the paddocks . . . ”.
Paula also experienced the rural environment as being helpful to her depression experience, as she said, “Living in a small community . . . helped me with my depression
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 99 because I didn’t have to be anybody else, I could choose where I wanted to go and the help was available”.
These women felt that rurality and the rural space had helped them in coping with their depression experiences for a variety of reasons. Some appreciated their rural location for its lifestyle, some for the features of the physical environment and atmosphere, such as easy access to space, natural surroundings, and animals, while for others it was the local social connections and interactions that rural places can facilitate that helped them. In some cases, therefore, the rural space was helpful for the women’s recovery. For others, however, rurality was a place of despair.
Rurality as a hindrance to coping. Some of the women described how living in a rural location was at times a hindrance, often due to access to services, but more often than not because of the fear of a lack of confidentiality and of perceived gossip in their communities, and of how they would be received if the community found out they had depression.
Jenny discussed feelings of being isolated from her family, who lived a five hour drive away, and mentioned her fear of small-town gossip and stigma. Jenny was 36 years old at the time of the interview, separated, and living with her two children. She said,
For a start, I think being in a rural setting was a big trigger to my depression because I didn’t have my family and my close friends around me so I felt isolated in that respect. I think maybe, not in terms of the stigma but in terms of the sharing with people I probably had a tendency to keep it to myself just because of the way people talk in the country. And once, being in a small town it feels like once one person knows your business everyone knows your business and people can’t help but, you know, not in a nasty way, but there are always people who say, “have you heard she’s going through a break up?” And maybe with the best intentions and a good heart but it does, it spreads.
Pam travelled a four-hour round trip from her home town to Wagga Wagga to obtain assistance for her depression experience. She felt that she could not go to her GP in her local town because she was known there, particularly as she also worked in the health industry. She did not want to be gossiped about or have her personal situation known to the locals so she travelled the distance to Wagga Wagga to help ensure her confidentiality and privacy.
I travelled to Wagga to see a GP as I did not want to go to the local doctor in my town as the receptionist knows me there and she would be wondering why I am there and start asking me questions.
100 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Sam also felt that it was difficult living with depression in a rural location and was concerned about the “gossipers” in her local area; she felt that everyone knew everyone’s business, including what others were doing.
You cannot suffer privately; you have an obligation to turn up to community gatherings. . . . I worry about what others think of me. . . . I do not tell many people about my depression . . . I try to isolate myself . . . as I have seen how the community responds to people with depression and it is negative.
These women found that the fear of small-town gossip and the perceived lack of confidentiality in their social environment were drawbacks for them in living with depression in a rural environment; but they continued to live in their rural areas despite these concerns.
Rurality as both a hindrance and a help: Multiplicity of views. Some participants felt that living in a rural community was both a hindrance and a help at the same time. These women did not seem to have a black-and-white picture of rurality as either romantic or harsh, but were able to hold multiple views on rurality at the same time. Margaret, for example, discussed how living in the country was a conservative social experience in some respects; however, she also held the view that rural living in general was helpful to her in coping with her feelings of depression. At the time of the interview, Margaret was 53 years old and in a relationship, had three adult children, and was self-employed as a farmer on property near Wagga Wagga. She commented, “Yes people are very conservative in the country, but I think the country air and space also helped me with my depression as well”. Margaret appeared to enjoy the space and the unique environment and atmosphere that rurality provided for her.
Di gave an account that demonstrates this subtheme well; she had mixed feelings of how living rurally had been a hindrance as well as a help for coping with her depression experience, yet she was clear that “things being compact” in a rural setting had been helpful for her.
I suppose it’s helped and it was also a hindrance. It’s helped in the fact that, everything is a little more compact in that you don’t have the hustle and bustle of a place like Sydney so things can be kept—you can sort of keep to yourself a bit more. Whereas in Sydney I would imagine if you had a job to go to the pressures of travelling and doing all those sorts of . . . I think it would be harder—I don’t necessarily think there would have been any more services available in a city—although they have private clinics up there [in Sydney]—but I don’t know I just—it’s a really hard question to answer. I think it has its fors and againsts really. Like I said, having things on hand, family, everything being sort of compact here in this town, it is helpful, if that makes sense?
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 101 Vera also felt that the rural location was both a hindrance and a help and held multiple views on the subject. She said,
I don’t think we get good access to services here, if you don’t have a car, have to rely on public transport and public transport is not effective in the country, however, personally I am happy with the services I get living here, so it is both, really—good parts to living in the country and this town as well.
The diversity of opinions about how rural living affected the women’s experiences reinforces the idea put forward by this study that rurality is not just a single location with benefits and drawbacks, but instead is a complex, multidimensional space about which individuals can have conflicting and diverse views and opinions. While Lin gave a rich description about how living in a rural environment was one of the key positive influences on her ability to cope and heal, other women clearly discussed the negative impact of living rurally owing to ongoing difficulties with confidentiality and the fear of gossip—both of which did, at times, stop some women from accessing existing services in their locality, and meant that some women had to travel to other, larger rural towns to access help. These are some of the drawbacks of living in rural NSW; however, in keeping with the complex and multiple views people are capable of holding about their lives, the women could weigh up these drawbacks and still feel that they wanted to live in their rural location.
A strong theme that emerged from the interviews was of abusive childhood experiences and violence that the women had experienced. In the interviews, 11 of the 27 participants discussed how abusive childhood experiences had contributed to their depression experience as adults, at least in part.
Abusive Childhood Experiences
“Dad was a violent alcoholic.”
It is clear that some of the women felt that adverse experiences in childhood, such as childhood abuse, were a contributing factor to their depression experiences in adulthood. This theme emerged strongly and consistently from the interviews. The women were not asked directly about childhood experiences; however, they often made reference to their childhoods in the interviews. Of the 11 participants who reported that they had had abusive childhood experiences, many spoke of abuse—often at the hands of their alcoholic fathers—and how this had influenced their lives and contributed to their depression experiences as adults. Again,
102 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW there were no specific questions posed in the interviews regarding the women’s childhoods; however, when the women voluntarily talked about their families of origin, they often mentioned painful, ongoing abusive events from their childhoods, and some of the women linked these events to their depression experience as adults.
This theme included the following: direct child abuse (neglect; sexual, physical, emotional, or verbal abuse; and multiple types in combination), and indirect childhood abuse (high level conflict resulting in martial breakdown, witnessing domestic violence, parental substance or alcohol abuse, early childhood parentification, and exposure to significant violent and traumatic events). Some of the 11 participants who disclosed abusive childhood experiences attributed their adult depression to these early experiences.
Women had to have experienced at least one of these abusive childhood experiences to be included in this theme, but in fact many of the women had experienced several. For example, Dee had experienced child abuse (neglect) and family breakdown (witnessing domestic violence), and had been removed from her family by child protection services and placed into foster care. Dee talked frankly about her chaotic family life and abusive childhood, and attributed her depression as an adult to these early abusive childhood events.
Me dad bashed me mum when I was only five years old, and DOCS [NSW government child protection agency] took custody of us. . . . Dad was an alcoholic . . . and he tried to harass me when I was 16 years old. . . . I got tossed from probably the length of this room over the kitchen table—I got thrown ’cause I stood between Mum and me sister and Mum grabbed me sister by the throat and almost killed her . . . I’ve got bad nerves since I was young. . . . Raped at high school, moved from pillar to post in foster care when we were young.
Dee’s childhood experiences of abuse from her parents, being sexually assaulted in high school, the ongoing violence in the home, and the loss and disruption she experienced due to being taken into foster care had impacted her life overwhelmingly. Her story highlights the chaotic and abusive family lives that some children have to endure throughout their childhoods. The powerlessness, violence, and fear that Dee was subjected to as a child must have been overwhelming.
Mia disclosed that she had been sexually abused as a child and talked about how this abuse had impacted on her life and her choices in adulthood. She discussed how distressing this was for her.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 103 I had been abused carnally when I was four and that left a big impression on me all my life. And that was one of the reasons I married him ’cause he was the only person I told. . . . I felt all my life so unclean and that was troubled by relationships with my husband.
Mia’s pain and feelings of shame and being “unclean” due to the childhood abuse was evident in her demeanour and voice in the interview. Mia did not disclose who the perpetrator was or talk at length about this abuse in the interview but she was clearly bound by shame and had internalised that something was wrong with her. This highlights a theme that tends to recur often with women and children who suffer abuse—that they internalise the abuse as being somehow their own fault and live with the ongoing feelings of shame, instead of the perpetrator being seen as responsible (Bass & Davis, 1988).
A subtheme identified within the abusive childhood experiences theme was fear. Rosie talked about living in constant fear of her father even as an adult living hundreds of kilometres away from him. As she talked about the fear and violence in her childhood, she explained how it permeated everything she did.
I’ve got a, my father was psychotic, um so, he was an, he was psychotic, and of course he self-medicated with alcohol and he was violent, and you know, that, that figures. I grew up in a household that was very violent, um, there was, there wasn’t a lot of physical violence towards myself and my sister but there was a lot towards my brothers, and that was abusive you know, that was abusive for me to see my brothers abused. And it wasn’t, I don’t have, I actually don’t have visual memories of it but I know it happened, you know, you know, and as a consequence I can’t hit my son, and I can’t let my husband hit him. But you see, the thing was my father, my father threw me out of the house when I was 15 in one of his violent psychotic rages, you know, and that just led to more, you know, I mean, I wasn’t sleeping under bridges but I was homeless, and as a result, um, by the time I was 17 I was pregnant. . . . As a child, all you can see is the violence, and all you see is the fear, you know, and all of that sort of thing. You know, the fear, the fear was just an all-encompassing thing. It just was, it just permeated my life, you know, that was my whole life, was just controlled by fear and I’ve, I’ve been freed of that in the last, you know, probably 15 years, but you know, it just, even, even when my father wasn’t in the same city, that fear of him was just so oppressive. . . . Feeling afraid and it didn’t matter where my father was, I was afraid of him, like, I, I lived in Sydney and I was afraid of him. He moved to Nowra and I lived in Orange, I was afraid of him, you know. Like, I was still afraid of my father and yet he was so far away geographically. It was just, you know, it just stopped me. It stops you doing things.
104 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW The fear that Rosie felt, despite the geographical distance from her father, was overwhelming and had continued even into adulthood. She did not feel safe until she had a spiritual encounter that she attributes to God, which will be discussed later in the seventh theme.
Another common factor within the abusive childhood experiences theme was that of living with a violent father and not being allowed to express emotions within the home, which initially emerged from Dira’s story, and was found to be a common thread in other women’s accounts. Here is Dira’s account of the abuse and violence she experienced as a child, living with her father:
It stems from my childhood because my father was a violent alcoholic. And he was always negative. Putting down everyone. Had no emotion, ’cause you weren’t allowed to have emotions. He used to crush your spirit. And I used to feel bad for my Mum because she was his punching bag. He robbed me I suppose of a lot of happiness. Being able to get up and go out and enjoy things and not have this blanket over you all the time. I see other people go out and having a lot of fun—they’re happy, happy, happy. That takes me down because I never seem to get that, I’ve missed out on a lot of stuff because of him, destroyed our emotions. I very rarely get excited about anything—even today—all those years on. I don’t get excited because if it doesn’t come off, I don’t have far to fall.
The sense from Dira’s account is that her emotions were not valued or allowed to be expressed around her father and she felt she was not safe, a feeling that had remained with her into adulthood. She clearly articulated that her experience of depression, and the dullness of her emotions was directly related to the impact of her father crushing her spirit and invalidating her emotions in childhood. The fear and violence that Dira was subjected to in childhood had clearly traumatised and oppressed her throughout her life.
However, in Paula’s story, the violence within her home from her abusive father was interpreted and explained in a different way from many of the other women’s stories. Paula said,
He only beat Mum. He loved us kids but he was very violent—when something would go wrong—Mum was same she was a funny lady—I didn’t know her—she was a funny lady—her mum died [when she was] nine and I think that every time she [my mother] was depressed and when [her] child was a certain age she would up and run away again. ’Cause she couldn’t handle being in a violent relationship with her husband. But she
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 105 said she loved him and he said he loved her then they’d have another child and then she’d run away again. She used to run away a lot. She ran away with one bloke once— well two blokes—one bloke once she ran away and she come back pregnant and that was OK ’cause Dad loved that baby anyway and he never ever held that against her but was a very good point—and I could never understand why he never hated Mum for that and he actually helped the baby into the world on the back seat of a car. So maybe that’s the bond that he had so he was—something they did together that was lovely. Then he had—he used to get sick a lot—he had a lot of bronchitis and no money—he didn’t have an education either—he worked a lot—just to put a roof over his family’s head. I think I admired my father more than I admired my mother ’cause Dad was always there. . . . Later he got tangled up with a woman and she used to drink—her husband [had] died. So, they got together and she had six kids and he had five at home at the time so he started drinking then but I don’t think it ever made him violent towards her—except when she shut him out of the house once—she locked him out of the house so he got the chainsaw and cut the door down.
Despite the neglect, chaos, domestic violence, and disrupted attachment that were highlighted in Paula’s story, unlike Dira, Paula did not blame her father for her abusive childhood experiences. Paula was different in this respect to the other women who reported that they had had violent fathers. She did not see these experiences as abusive or blame either of her parents, although her language implied that her father’s violence was her mother’s responsibility, but she did not feel that these experiences had subsequently affected her negatively. She did not attribute her adult depression to her abusive childhood experiences because she did not see them as abusive. However, she did disclose that she thought her mother had had depression because of a disrupted maternal attachment (Paula’s grandmother died when Paula’s mother was only nine years old). Paula revealed in the interview that she herself had had an adversarial relationship with and periods of estrangement from her own adult daughter, yet she did not attribute this relational struggle to her own abusive childhood experiences or to her own poor attachment to her own mother. In fact, Paula did not acknowledge her childhood as being one that was traumatising or oppressive.
Claire, like Mia, was sexually abused as a child. Claire’s story of abuse, rejection, and of not feeling connected to her farming family—where she believed that males were highly valued and were afforded more power over women in the home—left her feeling unwanted at times; and, as in some of the other women’s stories, alcohol and violence were a negative part of
106 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW living with her father. At the time of the interview, Claire was 65 years old, single, and living alone; she had no children and was retired. She said,
Well I think my father right at the beginning, my father drank and my parents fought and I think I had great difficulty—I had twin brothers and then I had another brother who was older than me. And the older brother was devoted to my mother and then the moment I was born he hated me. He was very, very resentful of me. And it brought trauma into the house when I was born and being a girl because I believe my mother had issues and I believe that she—I was just seen as though I shouldn’t have been there. And then I thought she brought the wrong baby home from the hospital. In later years when I met my husband, I went and got the birth records to see who my parents were and she [my mother] said, Why did you do that? And I said well I just had to check and when I told her that I had been raped which [it] was probably in her 70s [when Claire told her]—she said I’m not surprised because the teacher was a boarder in our home and I was very affectionate towards him and so she said I’m not surprised—and then she said if your father had known he would have had him castrated.
It is clear from Claire’s story of how as an adult she felt she had to obtain her birth certificate to find out whether or not she had been adopted (she was not adopted) because she felt unwanted and rejected by her family and this had influenced her self-worth and identity into adulthood. Yet Claire did not believe that these abusive childhood experiences had necessarily contributed to her depression; she did not think her feeling of being “less than” or being treated as unworthy by her family had had any bearing on her sense of self and her feelings of distress. Instead, she thought that her depression was due to genetics rather than her childhood abuse.
Kathy, too, described traumatising childhood experiences, including experiencing bullying at school, her parents fighting and separating, and the sudden loss of her brother to suicide. Her themes are those of loss and disruption in her childhood.
Probably when I was about 13 or 14. I’ve pretty much had a fairly rough life. I was picked on a lot at school—used to hate school with a vengeance. Just after I turned 12, my parents split up, on Christmas Eve, of all days and then three months later my brother killed himself—he was older.
Kathy’s story, which included a description of her parent’s high-level conflict, is similar to those of the other women who had also had abusive childhood experiences. She also stated that her brother’s suicide still haunted her as an adult.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 107 Mona, too, had experienced abuse and trauma in her childhood, especially after her father died in a motorcycle accident that both Mona and her mother witnessed. Mona said,
I went through hell with Mum. . . . (Dad died in motorcycle accident around the time the violence started) and after that Mum became very mentally disturbed and she got violent and by the time I was 16, I was scared to go to sleep at night. My nerves were shredded.
Research into child abuse and depression by Bifulco and Moran (1988) found that abuse was linked to the survivor’s depression in adulthood, and that often the childhood abuse had been by a male caregiver in the family, a finding which seems to be supported by the findings of this research. Of the 11 participants who discussed their childhood stories, nine of the caregivers who were abusive or violent were male, and usually it was the participant’s father (except for Dee and Mona).
What is significant overall is that 11 of the 27 women disclosed abusive childhood experiences, that some of them considered that these experiences had disadvantaged them in adulthood, and some of those further believed that those negative childhood experiences had contributed directly to them having the experience of depression. The stories revealed a strong sense of loss, shame, rejection, abandonment, loneliness, and fear. These stories also highlighted that as children the women were not valued or protected by their caregivers. Yet many of the women kept referring back to the biomedical explanation of depression and an internalised view that “something is wrong with me”, not “I lived in violence and abuse and this has caused how I am feeling and relating to others now”. Many of the women were not aware that being subjected to violence and oppression in childhood could affect them throughout their life and into their adulthood.
Some of the women in this study also experienced ongoing grief, loss, and powerlessness, including those who were forced to give up their babies for adoption in the 1960s–1970s. Others experienced the grief and loss associated with loss of relationships or of expectations unfulfilled. The fifth theme explores how these losses contributed to the women’s depression experiences.
Grief and Loss
“I was told never to mention this again, otherwise no man would want me.”
108 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW This theme included grief and losses that significantly impacted on the participant’s life: losing someone or something significant, or the termination of a relationship. A loss in this theme could have been the loss of a child, or being unable to have children, the loss of a husband or of a significant relationship, or loss from a death, or the loss felt by a relinquishing mother giving up her child. I included relinquishing mother to include any woman who felt she was coerced into adopting out her child due to being unmarried in the 1960s–1970s, either by the medical system, the authorities, parents, and/or a combination of these.
Mia felt a tremendous loss when she could not have her own biological children. She also discussed in the interview the feelings of loss and distress of not having a husband that was emotionally available to her. She said, “ . . . I felt disappointed that I could not have children and it started from there and I gave up work to try and have children and it didn’t happen”. Throughout the interview, Mia shared her feelings of loss and shame from being sexually abused as a child. Mia felt that all this had had a significant impact on her and had added to her depression and distress.
Maria, also, had had a significant loss, as her first husband died in a car accident when their child was only 11 months old. Maria was 68 years old at the time of the interview, remarried, and with one adult daughter. She said,
When he died, I, I just went into a horrid depression. I was devastated, absolutely devastated . . . . world fell in. . . . He was in a coma for three days . . . It was awful. It was awful . . . I lost a heap of weight. I was skin and bone. I cried all the time . . . It feels your heart is aching because that’s literally what it did do. Yeah. The sadness is just so overwhelming.
Paula, too, had had significant losses in her life; she discussed having two failed marriages and of feeling inadequate, and also of having been estranged from her adult daughter for some periods of time. Her struggle to reconnect to her daughter had caused her to move to the same small town where her daughter lived in a bid to rekindle the relationship.
I have had two failed marriages. . . . I feel inadequate and not being able to cope with life in general. . . . One reason why I moved back to here—’cause family, family relationship here. My eldest daughter—and it has helped me moving back here to rekindle and rebuild a relationship with her that broke down years ago. She doesn’t hate me as much—which is horrible—to be hated by your own daughter. Now we work on the relationship . . . but I sometimes because I do feel isolated in my own body.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 109 Lin also disclosed in her interview her feelings of betrayal, loss, disempowerment, and anger when she found her husband in the car with another woman. Lin described:
He comes [my husband] the other way with the girlfriend in the car. And exactly that I thought oh my God, and I had my daughter next to me and I said to her, was that who I just thought it was, was that Dad with her? And she said yep. So, he was taking the girlfriend to Canberra. So, I saw red, the flick switched and I was just was in rage— how dare he do this again—chased him down the highway. Got out to the turn off— chased him—finally got off the highway and we caught up to them so he pulled over, had the altercation on the side of the road which wasn’t pleasant, I’ll admit that. It might have been the wrong thing to do at that time, but I was just furious . . . one week you’re with me the next week you’re with her—just going on—total confusion. He actually took off with me hanging onto the car door and then he stopped and then he sort of got out and I’m sort of what is going on. The kids are there, watching the whole thing. Can you imagine, as a child, there’s your mother screaming, your father in the car with the other woman? So, it was just a horrific ending and it just started all that again, you know those feelings of not feeling valued, rejected, abandoned, loss, what’s she got that I haven’t—that sort of thing—and just feeling like a total reject basically and spiralling downwards.
For Lin, finding her husband with another woman led to her having a flood of emotions— rejection, inadequacy, and subsequently, demoralisation—and it was this combination of event and response that she felt was her tipping point into a spiral of distress and depression.
Deb and Rosie discussed their experiences of being unmarried mothers in the 1960s– 1970s. They told how their experiences of being coerced into giving up their children for adoption had significantly impacted on their lives, their relationships, and their depression experiences.
Rosie discussed her experience as a young woman taken to Sydney to adopt out her newborn baby, and how that experience influenced her life.
I wasn’t sleeping under bridges but I was homeless, and as a result, um, by the time I was 17 I was pregnant. My mother organised, basically, you know, shuffled me off to Sydney, the baby was put up for adoption . . . and then, of course, in those days, you were told to give the baby up for adoption, go away and get on with your life, and never talk about it again, you know, and that was the thing. So, I’ve gone away, and basically, I wasn’t able to talk about it. By this stage, by the time I was, you know, um, you know, living in Orange, I got married, and I got married and hadn’t told my husband that I had
110 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW a son, you know, because, they [the nurses] had said to me, if any man ever finds out you’ve had a baby, he won’t, no man will ever marry you, you know. It was just all those, um, you know, lies, yeah. I felt the shame of it, so crushing, the shame of being pregnant and alone. So, then I, then I went and seen, so I finally told this male counsellor that I was talking to, I finally told him, and he was really good actually to talk to. Um, you know, I desperately wanted to have another child. I desperately wanted to not have to be, I don’t know if I really realised I didn’t want to have to keep this secret, but I think I realised at a subconscious level that I didn’t want to have to be keeping this secret, you know, it was lies, and every time someone asked me if I had children, I said “no”. You know. It was a lie. Every time I said that, it was a lie. And so, there was all this, you know, there’s, like there’s the depression but there’s this agitation, internal agitation and conflict. . . . Having a secret, and you know, I was married. I wanted to have more children and I couldn’t because I could not go through, I was so traumatised that I, I found it, I couldn’t even entertain the thought of going off contraception basically, and yet I wanted another child. So, and you know, we did want to have a child, you know, and also the conflict, the internal conflict of being married to someone and he didn’t know about this part of my life . . . I, you know, I’m thinking, you know, I’ve got to face this one day.
Rosie’s description of how living with the secret, feeling like she was not able to share it with her husband, and of having conflicting feelings in wanting another child but of being so traumatised by the past adoption experience that emotionally she could not go through being pregnant again, showed that these things had all influenced and negatively impacted on her life. Rosie believed that the crushing shame she experienced, the loneliness in her pregnancy, and how she struggled to come to terms with the loss of having to give up her son, as well as of the turmoil of it being unspoken due to the oppressive social mores of the day that shamed unwed mothers, had contributed to her depression experience. Her story speaks of a time when unmarried mothers had very little control over either their bodies or their babies through a gendered set of social expectations and requirements that gave rise to feelings of powerlessness. The sense of demoralisation and helplessness that these women were experiencing as they watched their babies been stolen from them by the medical establishment must have been overwhelming; calling it “grief and loss” hardly does justice to such experiences.
Deb described a similar experience of being an unmarried pregnant teenager in the 1960s, and how that had impacted on her depression experience.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 111 I’d fallen pregnant once I’d left that job and was then living on my own—then that left me with the dilemma of what do I do? I didn’t want to do anything. I couldn’t see that it was the child’s fault in any way. So, I avoided going to the doctor. So, I was probably about six months gone before I went to a doctor and said, “I’m pregnant, I’m putting on weight” and he said, “Well I’ll give you an internal examination”. He said, “There’s no doubt about it, you’re definitely a good six months pregnant” and he said, “How are you situated?” He sent me off to a hospital and linked me into things. They gave me addresses of places that I could go and stay, so I wrote off to them. I was 19 in Melbourne then, a naïve 19 year old. Then I went to my local church minister who rang my parents who were overseas at the time and told them. So, my parents sent me a ticket and said get on a plane—over to Scotland—which is why my daughter has the Scottish accent—because I had my baby in the UK system with their healthcare system and then she was adopted out over there. I was tired—then I knew I was depressed— but I was depressed before I got pregnant. So, I guess the guilt of giving up a child for adoption—that is really hard. I was told you just give it up and you forget about it, and you just move on, and you’ll have another family, and there was so much lies—there was nothing in the literature that I had read, and my body went into the same sort of grief as when I gave up the child for adoption. So, I’d had a lot of grief stuff that I’d had to deal with later with giving up my baby at 19, and then the abortion later on.
These women’s experiences of giving up their children for adoption had, and continued to have, a negative impact on their lives. Even though only two of the women brought up this issue voluntarily when interviewed about living with depression, the considerable impact of these experiences on their lives suggested that it was significant enough to mention in this study. The progressive impact of the loneliness of being unmarried and pregnant, the crushing shame, as the patriarchal society did not welcome unwed pregnant women, the grief, and the inner turmoil of not being allowed to grieve because of it being a shameful secret, and the feelings of loss and powerlessness of having to give up a child to a forced adoption arrangement or by abortion had culminated in a negative impact of distress for these women for many years. The above stories speak of loss, betrayal, powerlessness, shame, and demoralisation in the lives of these women.
For most of the women in the study, accessing some sort of assistance and help for what they were experiencing was important. Most of the women talked at length about their experiences of accessing assistance and support, and these are discussed in the sixth theme.
112 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Accessing Professional Help and Services
“I saw lots of counsellors, psychologists, psychiatrists along the way, was seeking answers.”
The women commented extensively on their experiences of accessing services for help for their experiences of depression. In this study, the theme of rural women’s experiences of accessing professional help included: the experiences of women seeking out help to alleviate their depression experiences through accessing GPs, hospitals, mental health services, health and community services and other nongovernment services, or other professional services, and the women’s subsequent experiences of the services and treatments they received.
The participants had had various experiences, both positive and negative, regarding access to services and the treatment they subsequently received. They had contacted a range of services; some approached services that were state funded, such as the local public hospital or regional mental health service, while other women had accessed private psychologists and psychiatrists or other private counselling services in their area. Nearly all of the women had contacted their GPs for help as their first port of call. Despite the biomedical model describing that depression tends to contribute to low motivation and energy, what emerged from these women’s stories was a keen desire and busyness in trying to find help.
Di discussed at length her experience of the services and treatment she had received, including the lack of choice of services that she had experienced in her local area. She felt she had needed a private psychiatric inpatient clinic but that this kind of service was not available in her area. She said she would have had to drive for three hours to obtain this type of service, and that at the time when she really needed it, it was not locally available to her.
But you know, if we had a private psych clinic in this town, I probably would have ended up in there; that is one thing this town is desperately short of. I mean we’ve got . . . [a public mental health hospital unit] and that’s not an option—I know what it’s like—I mean obviously it serves its purpose for some people . . . but in Canberra there’s a place called Highsen Green which is a private clinic—which is part of Calvary Hospital in Canberra. . . . They have psychologists, all the classes for your meditation, relaxation, and programmes, it’s phenomenal, it really is, I just don’t understand why Wagga doesn’t have the same setup—it [Highsen] only has about 20 beds—20 maybe 22 beds but it’s all very—it’s lovely. That’s one thing that I’d really like to campaign for because . . . you know you have to be privately insured to be there of course, but you know, we just don’t have that option for people that are privately insured in my area—there is nothing, there is no private inpatient facility. And if you were that bad
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 113 that you needed to go into Gissing House—and if it is full—they send you to Albury [128 km from Wagga Wagga] or Orange [306 km from Wagga Wagga] you know— you don’t even get a say. It’s—if they feel that you need to be scheduled and there’s no bed available here at this hospital—well it’s wherever the closest bed is—you could be [put] in Goulburn [265 km from Wagga Wagga]—that’s how poor the system is.
Di believed that the biomedical model would be able to help her with her distress, and indicated a felt need for a local private inpatient service. She felt she could not accept the local state inpatient service because she would not have a choice as to her treatment location, and might be allocated a bed in a facility that was potentially hundreds of kilometres away from the support of her family and friends.
Stevie, too, talked about the cost of accessing biomedical help when she needed specialist services in her rural area, and described how geographical distance and a lack of services in her rural location were a drawback for her.
Cost a lot of money paying for psychiatrists and psychologist and travelling three hours one way and then having to pay for accommodation overnight as I couldn’t face the long drive back to my town from Wagga, I did this for years, as the services were not available in our small rural town.
Jade was 34 years old at the time of the interview, married, and with five small children; a nurse by profession, she was not currently working at the time of the interview. Jade discussed her struggle to find appropriate help for her depression in a rural setting. She found the local state mental health service inadequate due to the “fly in, fly out” arrangement with the Sydney- based roster of psychiatrists. These specialists fly in and out once a week on a rotation agreement with Wagga Wagga Base Hospital. She felt there was no consistency of service provider and treatment, amongst other issues.
I think to some degree as far as finding professional help and professional help that is ongoing, because you have lots of “fly in and fly outs” in a rural setting, so I guess in that respect it is a hindrance to recovery in depression but then I think in a rural setting you are able to get down better on a personal level. Yeah well, I’ve had the close community support with the church and friends but then we did have a lot of trouble finding professional help that could actually help. Having to tell your story over and over again isn’t really conducive to fixing the problem. And before I found Dr J., my psychiatrist, I’d been through a number of different psychiatrists, psychologists, counsellors, and even Dr J. he finds it hard at times because I believe he does care for his clients and he’s always on-call so to speak—
114 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW but because of the workload and he being the only live-in psychiatrist here it’s hard for him to even juggle the patients he has, let alone having new patients. I wouldn’t like to think that people potentially don’t get along with Dr J.—where do they go? I’ve been lucky that yes, I’ve found a doctor that works but and that’s the thing, the doctors that you see at the local hospital here you don’t have contact with them once you’re out of there. They fly in and do your appointments for that week or that day and then they’re back to Sydney or wherever their practice is. And so, when you get out of a place like that, there really isn’t the follow up that I believe you really need.
Here again, this account from Jade reinforces the view that ongoing biomedical professional assistance can be difficult to find in some rural locations. Jade felt that one private psychiatrist servicing a large rural area was inadequate but she felt she was fortunate that it worked out for her because she felt assisted by the support of her psychiatrist. It was clear that these women had put their faith in the psy-professionals in the hope that they would alleviate their pain.
Deb felt that the cost of accessing counselling was prohibitive, and that there was only a small selection of qualified counsellors to choose from because she was living in a rural area. She said,
I’ve tried a few times to get a counsellor I could connect with but I’ve found the cost has been prohibitive and on a health-care plan trying to work out when I’m busy and have my values around my workplace—I don’t find—it doesn’t connect. And I think I need a really good Christian counsellor who understands the dynamics of what I’ve been through in some ways. . . . I’m glad to have the opportunity to speak into this. In rural communities, the services are only as good as their staff and the supervision of their staff—the quality that they can attract, so most people want to go where there is better money. Most people are money orientated—so it’s kind of silly to stay here when I can get two hundred dollars an hour in Sydney.
Lin discussed how she was desperate for help and sought out a whole range of treatment options in the hope of alleviating her pain.
I saw lots of counsellors, psychologists, psychiatrists along the way, was seeking answers—went to clairvoyants, got hypnotised, all that just desperate for relief from the pain. I couldn’t get medication from the doctor and there was no quick fix to stop what I was feeling.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 115 This expressive quote from Lin clearly demonstrates her desperation for answers and help as she sought out a diverse range of services and professionals, even pursuing alternatives such as consulting a clairvoyant.
Rosie was another participant who was very active in her own recovery. She travelled two hours each way every fortnight to get to see the same health professional of her choice and to have two hours of therapy. Rosie discussed how she had engaged a private psychologist from rural NSW and had invested one year of her time to intensive therapies including talk therapy (counselling) and eye movement desensitising and reprocessing treatment (EMDR— traumatic memories information reprocessing). She felt that the services she had had were extremely helpful in removing some of the “baggage” and trauma in her life.
I had so much baggage. I just had so much baggage, you know, by the time I’d got to that place in Sydney, so much damage was done, and it just takes years and years and years and years of work to unravel it all, you know, so, so I told him and then I, then I was seeing the psychologist in Central West NSW for about a year . . . and travelling to get the help.
Despite the hours of travelling, Rosie felt it was worth it to see the same practitioner and to obtain understanding for her distress.
Jay had also found psychologists and counsellors who were based in Sydney (five hours’ drive away from her town) helpful.
So, a few things have been helpful. . . . The psychologist gave me a couple of strategies . . . he talked about that every thought that comes into my head isn’t true. . . . If you have something in your mind that’s bothering you, you put it on a ship and send it out to sea . . . and he talked about doing breathing stuff and that’s been helpful when I’ve had panic.
Mona found both a private psychologist’s services and medication helpful for her experiences of depression. Mona said,
That lady was good . . . clinical psychologist and I see her and it was very helpful, very good. . . . And getting myself on medication because really, it’s hard to help yourself when you’ve got nothing left.
The women’s accounts of trying to find the right assistance for their experiences are stories of busyness. Most who did try to access biomedical help tried their GP first, and some were involved in ongoing psychological CBT interventions, counselling, or other therapies,
116 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW often concurrent with periods of treatment by biomedical interventions such as antidepressant medication. When this did not help their situations, these women kept trying, and spent enormous amounts of time, energy, and money on attempts to alleviate their experiences of depression. Depression is often thought of as low motivation and struggling to get out of bed, and for some of the women, such as Lin, there was a period of time that they struggled to function beyond the basics. Yet, what emerged from the women’s stories overall was that the low motivation and energy was only for a period of time and that seeking help was paramount to them.
Some of the women travelled for hours, like Rosie, Jay, and Stevie, to receive not just assistance but continuity of service. It was interesting that none of the women mentioned using online or phone services to get help or counselling, but rather evidently preferred to use services where delivery was face-to-face and with the same provider. These women could not get the help that they needed in their local area and instead travelled hundreds of kilometres each time in order to see their health provider, often a psychologist, and it appears from their stories that it was very important to the women to see the same health provider. The lack of service provider continuity was often due to the shortage of mental health professionals in their local town and/or due to the constant stream of different health professionals rotating in and out from the city. The women did not generally complain about the service delivery situation; they just accepted it as being part of living in a rural location. However, this acceptance of long-distance travel to obtain continuity of service delivery would not, perhaps, be common for their urban counterparts. The women’s acceptance of their need to travel to obtain the care they found useful was simply, “Well, this is what you have to do when you live in the bush”. Taken against the backdrop of inequitable health service delivery in Australia, it was astonishing that the women generally had just accepted the geographical discrimination in health services as being part of life in rural NSW.
The women spent considerable time and energy seeking out health professionals such as private psychiatrists and psychologists; they seemed to have accepted that these practitioners were the “experts” and so placed considerable faith in them. When their distress continued despite the medical interventions, however, some women then looked at alternative forms of assistance, such as faith and friends, in order to obtain help for their distress. So, some of the women found informal and nonprofessional assistance beyond the biomedical model, and some of the women only used nonprofessional means for help and support, such as Sam and Maria.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 117 Accessing Informal Help and Support
“Friends and family were so supportive.”
Some of the women described how they had used nonprofessional services, informal methods, and alternatives to biomedicine to help them with their depression experience. I included in this theme any informal assistance, event, or support—whether self-help groups or support from family and friends—that the women used to help them cope with or alleviate their depression experience. I also named spiritual faith as a specific subtheme, since it emerged from the interviews as a factor in assisting with a significant number of the women’s depression experiences.
In the interview, Rosie talked of being thrown out of her family home at the age of 15 by her father. Rosie disclosed that buying a house (as an adult) was a healing experience for her as it gave her the stability and security of feeling that no one would be able to throw her out again.
And then when we moved to Orange, I thought we can buy a house, and I said to Peter, I said we can save up and buy a house, and do you know, in three months, we had a deposit and we went and bought a house. That was really good, like that was a really healing thing. You know, because now, you know, I mean, we’ve bought and sold a couple of dwellings since, but I now live in a house, you know, since we bought that house, in 1992, 20 years ago, I live in a house that no one can throw me out of, you know, and, and that is a really healing thing and it’s, you know, it gives a lot of stability to your life, and a lot of security so, yeah, that’s been really good.
Rosie’s central theme from this quote is the high value she placed on feeling safe and secure in her adult life, something that had not been afforded to her as a child, and which she felt she had achieved by owning her own home. This event was instrumental in creating a physical sense of safety and security for her that had a flow-on effect to her feelings of psychological safety and security—as she put it, feeling like “no one could throw me out onto the streets again”.
Paula found that attending a weekly self-help group called “Grow” was helpful for her in coping with depression. She described:
It’s like a lot of people sitting around and talking and there was a program—just like AA program—they give you a blue book and a reading and everyone was so lovely and cuddly it’s become nice—it was nice to be accepted—to feel like someone cared—it
118 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW was lovely. And then I started to learn what acceptance was—I was so ignorant and naïve. . . . Ring someone up and if I had a problem I had someone to talk to and they would give me a practical thing to do . . . which might have been get out of bed. . . . I found that it helped me.
Jay felt that her husband was supportive, which was something that she felt really helped her—together with the assurance of knowing he was not going to leave her during this period of her illness.
I’ve just been blessed with a really great marriage and my husband has been amazing with how he coped and almost not noticed—you know, just gone on with life, not even really. Look I probably beat myself up more than what he did. He just realised that I’m not well, and I just can’t do some of the things that I normally do. So, he kind of did it. And I guess we just put up with the house being not quite how it should be, and so I think that’s how he coped. And you know, his comment is well, I put up with him studying and all that stuff for a long time—the least I [husband] can do is cope when Jay is sick. So that was really nice to have that assurance that he wasn’t going to walk out on me because I was depressed; that really helped me, he helps me with it. . . . Exercise as well, walking, I try to walk every day.
Jay discussed in her interview that she was initially worried her husband was going to leave her because of her depression, but was substantially assisted by his reassurance that this was not going to happen. This supports current thought in the literature that positive relationships with intimate partners are important to the wellbeing of women (Jack, 1991; Jack & Ali, 2010).
Jade, too, spoke of the value of exercise and of being with friends and said that these things were helping her deal with depression on an ongoing basis.
Yep spent a lot more, like put a lot more effort into being in touch with my friends and being with them. Exercise I’ve found has made a really big difference, and eating well. At first when I was really in the depths of it, I was just eating garbage, if I was eating at all. But once I was able to pull myself out of that, and try and improve things a bit— good nutritious food made a big difference. . . . The spiritual help has been helpful in keeping my thoughts on the right track.
Maria was one of the few women in the study who commented that she preferred alternative therapies, such as natural therapies (dietary supplements), and faith. She said, “Natural alternatives have helped, I didn’t like antidepressants. They made me groggy, but
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 119 natural alternatives have helped, as well as good counsellor and faith”. Sam, also, found self- help books and natural alternatives, such as healthy eating, fish oils, Vitamin B, and herbs, had helped in her recovery from depression. Maria and Sam were both committed to their belief that alternative therapies had helped them. Sam said,
Yeah, self-help . . . looking at self-help books, books on cognitive thinking . . . trying to retrain the brain. To think in a positive way . . . fish oil and Vitamin B are very important . . . and acupressure, massage—I’ve found that’s really good.
Other women, such as Lorrie, found that music, praying, and a connection with God were a help.
God and music . . . I love music, just praying and going into a big church . . . ’cause God is there . . . and there is someone there that will listen to you. . . . I like to help people too. That makes you concentrate on someone else.
Lorrie also stated that she had in the past gone to the RSL clubs to play the poker machines in order to distract herself from her depression experience, until it got too much and she decided to get herself barred from the RSL clubs in her local town. So, while this was a coping mechanism, Lorrie felt it was a negative part of her life and took steps to reduce this type of coping.
I started playing the poker machines and that because of the loneliness, and when you’re happy you don’t think you’re going to lose money. So, I am still having trouble with the poker machines. . . . I’ve excluded myself from the RSL clubs.
Dee felt that friends were what had kept her going through the difficult times she had had in her life. She felt that her friends were supportive through her depression experience, as she said, “Friends, that’s what’s keeping me going at the moment, their support”.
As the women described the various supports that had helped them cope with their distressing experiences, what stood out was that many of them found significant benefit from the support they received from their partners, family, and friends, from applying themselves to exercise and healthy eating, and through having a spiritual faith; they seemed to feel that these things helped their distress, outside of any professional biomedical intervention. This complexity of understanding appears to be consistent with the first theme, Women’s Understandings and Explanations of Depression, where many of the women held multiple understandings of depression. Similarly, they also seemed to hold that using multiple methods
120 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW of coping and accessing assistance—biomedical as well as informal—was the best way to help their experiences of depression.
Spiritual faith as an aid to coping. Faith in God was mentioned many times in the interviews as an aid to coping and assisting with recovery, to the point that this emerged from the data as a subtheme. Eight out of the 27 participants discussed in the interview how their faith in a higher power, such as God, was a help to them during their depression journey, and that it had helped them to cope. Spiritual faith was coded to include: spiritual belief in a power higher than one’s self; a belief in a higher power, or God, that had the ability to help and intervene in an individual’s life; and/or a spiritual encounter/experience that was attributed to God.
Some of the women described their personal encounters with God and the understanding and support of their church friends as significant parts of their recovery process. Lin said,
My increasing faith—having Christians around me and people who had been through it as well. So, even nonChristians—I’ve got some really great friends who were going through a similar thing at the same time. So, we had a kind of support group going. You know one day someone would cry on someone’s shoulder and the next day someone else would, and late night phone calls and friends that would come around, in the middle of the night in their pyjamas—so really great friends around and I can only thank God for that—for strategically placing them in my life. I couldn’t imagine if you didn’t have family, and didn’t have friends and your support people around you, how people do take their lives—they’re alone—they are so alone—and they have no one to reach out to and could be there in a flash. . . . So, finding the church, I would just go there and sob my heart out every week. I would be on the floor during the prayer each week and people would be hands on, and just that energy that would give me enough to keep me going for the next week, and then I’d fall in a heap again, and people even would just text to say praying for you or thinking of you. Knowing I had a support team around me was really what got me through it in the end.
From Lin’s story, it seems that support and prayer from a close-knit group of people was helpful for her through the rough times.
Rosie described an encounter with God that had helped her deal with the traumatising fear of her father—something she had experienced as a child but which up to that point was still affecting her as an adult.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 121 I went to a, like a, um, inter-Church thing one night and then, and then whoever was the guest speaker was saying, was talking about the Father, and that was really in my face because I found it very hard to relate to God as a father, and, I was just, I had my eyes closed, and I was saying to God, just silently, I was saying, “You’re not my father, you’re God”, and I said that about three times, and then God just showed me a vision of my father, and God said to me, “Ken”—which is my father’s name—“Ken is a crumpled shell”, and as God was speaking, this crumpled shell went from being in the front of my vision down beside my feet, but we were both, when it, when it finished, we were still both on the same plane, so he wasn’t below me, and that night, that, that experience wiped away the fear. I have never been afraid of my father since then. It was like that. And that was divine intervention. That was a miracle really. It was a divine intervention, and at that time, I was living in western NSW, and my father was living on the South Coast of NSW, but I was still afraid of him prior to that, that took away the fear, and that was God.
The fear that had paralysed Rosie for so many years was taken away in one night. She attributed this to divine intervention, and said that this helped in the healing process from the pain of the abuse she had suffered in childhood, and her subsequent depression.
Deb, like Rosie, described how she had had an encounter with God. However, for Deb, this encounter brought physical healing that she believed was from God.
But I became functional when I started being healed of a whole lot of things—I think I had a lot of improvement in my depression when I came into a relationship with God. . . . I had an experience once where I felt really warm or something, there was something really nice about it though—I feel like I’ve just had a massage. And then my mother dropped something on the floor, and I reached down to pick it up, and I had a deformity in my hand that meant I couldn’t operate my hand except for writing, but I couldn’t span at all but as I reached down I picked up the plate and my hand spanned out, and I said, “Look Mum, my hand’s working!” And she said, “What happened?” And I said, “I don’t know.” And she said, “Did you fall over and kick-start it or something?” and I said, “No, nobody’s touched it”—and I went to the doctor and he said, “You definitely got muscle wastage there, the muscles haven’t been operating there, but it is operating now, just be thankful” and I said, “Well you’ve got to give me an explanation as to why that has happened” and the doctor said, “I can’t, but why do you need an explanation, you’re fixed now, what’s the problem?”. And I said, “I need to understand what is going on.” And so, I left the doctor’s surgery and I heard the voice again and it was saying,
122 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW “It’s me that’s done that, it’s me that healed your hand” . . . and then I became, totally sold out to God.
It was clear in the interview that Deb believed that God had miraculously performed a physical healing in her deformed hand. That was the beginning of her belief in God, and she found that this faith had helped her with her depression experience throughout her life.
Jenny, too, attributed her recovery to the presence of God in her life, specifically through finding meaning from her spiritual connection to God.
Yep. I think knowing that even though I felt isolated—knowing that I haven’t been alone through the process was a big help. I think if I was not a person that had God in my life—I don’t know how you pull yourself out of it really. I don’t know how you’d find your meaning, without God to be there, or to turn to, I guess.
Cin also spoke of her faith in God. While she stated that she attributed her healing to medicine (medication), she believed, too, that science is a gift from God.
Definitely. I mean, for me, I mean, for me there are two comments there. For me, I felt pretty strongly that science and medicine is a gift from God. So, for me, God’s healing came from through this particular medication and me being diligent in taking it, and this was how it was, and this is what I had to do to be well. So, I’ve always been thankful for that. I suppose the other one was—see when you’re really screwed up in your mind, it doesn’t matter how you pray, it doesn’t necessarily change the dynamics of how you feel. It doesn’t always. I mean sometimes it does. I actually did one retreat once where I actually took some work and some scripture with me, and I did some meditation on that. And that particular week was amazing. I wrote the best essay I’ve ever written out of that particular meditation. But I guess I haven’t done that enough really. That’s only been an adhoc thing, but I know lots of people have been praying for me over that year and they would say that prayer is very important.
These women disclosed how spiritual faith, the support they received from the church and their friends, prayer, and spiritual encounters with God had provided help and comfort. They expressed how these interactions and encounters had helped them to cope and had given them hope, and for some it appeared to help, at least in part, in their healing journey. This was an unexpected finding in this research, and the fact that so many of the women discussed their spiritual faith in such an open, positive manner and linked it to helping them in their recovery was significant.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 123 Summary
This chapter has discussed the seven main themes that were identified in the women’s stories. Some of the women’s stories highlighted an overall sense of loss, rejection, loneliness, shame, fear, and abuse and trauma. Their experiences of depression had disrupted their everyday lives and had also affected their relationships with others and themselves. Child abuse and violence was a consistent theme in many of the women’s stories, which is a significant social justice issue; it was clear from the women’s stories that as children they were not safe in their own homes from people who were supposed to take care of them.
Despite the low motivation generally associated with depression, the women were proactive in trying to find help for what they were experiencing. Most of them went to their GP as their first means of accessing assistance; from the GP, they often received a medical diagnosis of depression and subsequently found psychological and medication assistance. The women often accepted the biological diagnosis and medical reasons for their depression, but some of the women still held dual understandings of depression that were both medical and social-environmental, and this in turn influenced how they accessed assistance and help. It stood out that some of the women held multiple understandings of the causes of their depression and consequently sought out multiple help options, including both professional and nonprofessional options, such as, for example, using a combination of medication, counselling, exercise, massage, and supportive relationships for their recovery.
Most of the women described their partner relationships as being important to them, and despite their depression feelings they wanted to be reassured that their partners were not going to leave them during their period of distress. For others, however, their partners leaving them was a trigger to their depression experience. For all the women who participated in this study, what stood out was that intimate partner relationships were very important to the women’s identity and self-worth. Unfortunately for some, intimate partner relationships were never fully realised or did not meet their expectations, and brought rejection and humiliation to them; disappointment, betrayal, and demoralisation were at times at the heart of some of the women’s depression experiences. For others, having a supportive partner was a source of joy, and helped them to cope with their experiences.
Recovery via time as a healer was not mentioned by the women specifically, but rather, some of the women stated that they felt that they had experienced depression for a considerable length of time and they did not feel it simply resolved itself over time.
124 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW In general, some of the women drew on biomedical services and found medication and psychological intervention helpful as part of their recovery journey, but they seemed to concurrently find nonprofessional and informal supports such as exercise, faith, family, and friends essential. Despite living rurally, formal assistance was not through online or phone services but occurred through face-to-face consultations with psy-professionals, and it appeared that the continuity of the face-to-face therapeutic relationship was very important to the women in these instances. Rurality and depression was not a neat-bounded entity: Rurality, for the women, held multiple understandings and meanings.
The next chapter will discuss at length how the women’s voices intersect with the current literature on depression and the main findings of the study.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 125 Chapter 7: Discussion
Despite the dominance of the biomedical discourse in mental health, in this study, the voices of women with experiences of depression suggest that there is a much wider field of consideration, both in terms of the meanings and understandings of depression, and the kinds of assistance that are needed for it. In this chapter, the central emphasis is on accurately naming the experiences of the women. Indeed, the term depression may not be the best description of what many of the women were experiencing. The analysis in Chapter 6 shows that their experiences are interwoven with many social issues, both contextual and structural. Underpinning the women’s stories are issues of multiple meanings of depression, a diversity of rural experiences, and active and creative help-seeking. Moreover, difficult relationships, loss, childhood abuse, powerlessness, and violence were a strong presence in many of the women’s lives.
1. Multiple Meanings of Depression
Biomedical discourse is influential when women access assistance for their distress, as often women contact their GP as the first port of call. The literature confirms that the biomedical model is the preferred model for the diagnosis and treatment of depression (and it is via this pathway that health-care funding is available from the Australian government); however, the biomedical model does not tell the whole story because it does not address the social, cultural, and environmental factors in women’s lives (Gammell & Stoppard, 1999; Stoppard, 2000). The biomedical model implies that women are fragile, that something is wrong within them, and that medicine will help or correct the deficit (Gammell & Stoppard, 1999; Stoppard, 2000). However, when women feel powerless, are subjected to violence and abuse, live in poverty, and have limited resources, often the only viable (affordable) option is accessing help from their bulking-billing GP, and usually this means a medical diagnosis of what they are experiencing, and often this comes with a prescription for medication. There seems little difference between this and the Australian model of the 1960s and 1970s—when women went to the doctor with their experiences of distress and oppression and were often told to have a “cup of tea, a Bex (tablet), and a good lie down” (Hennessey, 1993). The biomedical
126 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW model is still minimising women’s experiences of suffering and oppression by glossing over and individualising cultural and social injustices that affect women and children.
Some of the women had accepted the medical explanations offered to them by their doctors because that was the only explanation on offer and had gone along with the treatment suggested, usually medication, in the form of antidepressants. Some of the women may not have questioned the doctor’s suggestions given their positional authority. Thus Paula had accepted her distress as a result of a chemical imbalance, as that is what her doctor had told her. This supports the work of feminist researchers Gammell and Stoppard (1999), who observed in their study that once women were given a diagnosis by their GP they then accepted the biological conceptualisation of their experiences. However, not all the women in this study accepted the biomedical explanation as the “only truth”.
Some of the women discussed and understood that their depression experiences had been influenced by social, relational, and environmental factors, such as childhood experiences of abuse or relationship breakdowns. Many of the women also felt that by experiencing depression they were in some way letting their families and partners down, and this was a source of anguish for the women, who wanted to be able to maintain and preserve gendered societal expectations of themselves as “good mothers and wives”. A richer understanding of the ways in which women construct their experiences of depression could more clearly inform the ways in which service delivery providers address women and their wellbeing. Yet, often women themselves may not see the gendered aspects of their day-to-day lives as a legitimate source of distress, since these factors are often underestimated by them and those around them. When the everyday demands of domestic and caring work become overwhelming, a woman may be more likely to blame herself for not keeping up with what society expects from a wife/mother than she would be to view male privilege and the discourses of femininity as the problem.
Responses to and understandings of depression have increasingly become corralled into a “tightly-policed” biomedical domain. However, as the findings of this study suggest, a diagnosis of depression may not be the best way to comprehensively conceptualise women’s experiences. Rather than seeing the various oppressions women have experienced or are currently experiencing—whether poverty, acts of violence, past traumatic childhood events, or other adverse experiences—as simply triggers for depression, perhaps these elements of women’s overall social situations need to remain central when women present for help.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 127 2. Diversity of Rural Experiences and Help-Seeking
Despite many stereotypes of rural people and ideas of what rurality is, the women in the study gave diverse accounts of their experiences of rurality and had multiple understandings of it and its impact on their experiences of depression. There was no neat or homogeneous view, despite my preexisting ideas of poor access to services and support in rural NSW. Nor was there any evidence to support either the romantic views of the country or the deficit view that things are tough and harsh in the bush; these polarised positions were not reflective of the diversity of understandings that the women gave of their lives within rural settings.
Differing access and help experiences in rural NSW. It was clear from the interviews that many of the women found living in a rural community had some drawbacks and posed some difficulties in terms of trying to access private, in-patient mental health centres, psychologists, social workers, and psychiatrists. Those who did want to see the same health professional often had to travel to access a private service, as the public system in parts of rural NSW has a “fly in and fly out” rotation of mental health professionals, and some areas also have high staff turnover—all of which often means little hope of delivering continuity of service relationships. The women often just accepted that they had to travel to ensure continuity of service with a health professional they could see regularly and on a consistent basis, and they were resigned to the fact that travelling to access health professionals of their choice was simply part of living in rural NSW—just something they had to accept and endure. This acceptance of service inequity in rural NSW is an aspect of rurality which in fact enables the status quo to remain entrenched and invisible so that there is neither challenge nor impetus for change to the geographical discrimination that some rural women experience in health service delivery. This added layer of geographical discrimination intersects with the existing levels of discrimination, and increases rural women’s level of difficulty in accessing help. The women in this study had many levels of oppression that intersected, such as rural disadvantage, gender inequity, and the traditional, patriarchal values of their sociocultural spaces, which ultimately serve to oppress women. The intersectionality of rural space and its dominant patriarchal values has not been adequately accounted for, and this study highlights the need for a greater awareness of how rurality intersects with women’s daily lives, and, together with issues of gender, violence and discrimination, causes oppression. The women were not necessarily aware that the patriarchal values they lived under had influenced their connection to self, others, and their intimate partners; however, many of the women were aware that within the rural culture, men are more valued and have more authority (e.g., make most of the economic
128 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW decisions for the family). It appeared from the women’s understandings that gender inequity was just accepted as a part of rural life.
It is important to also see that taking an across-the-board “lack of service/deficit approach” to rural health care limits the full story about women’s experiences of health services in the bush, as it fails to recognise that some areas may be adequately serviced for their clients’ needs, and that, in addition, rurality at times allows for more flexibility in practice, which suits some women’s needs. Some of the women felt that their rural locations had appropriate health services for them; for others, such as Lin, this was not as important to them as the greater access they felt they had in their rural environment to support from their church, family, and friends. Moreover, this “lack of service/deficit approach” argument also fails to consider that some of the women were not reliant on professional health services at all. In fact, it seems that while most of the women may have initially accessed their GP and health professionals, after a while some of the women self-managed their experiences of distress through nonprofessional means, making access to professional health services less important to them. It would seem that the stereotypical view of the role that rural health services play in a community—especially for people living with depression—is not entirely reflective of these women’s experiences.
In addition, an emotional attachment to place as a factor for women’s wellbeing was evocatively highlighted by Lin, who drew strength and healing from her natural environment through connecting with the bush surroundings by horse-riding and spending time in nature. Attachment to the natural environment and place is often overlooked when understanding women’s experiences of healing (Smith, 2007). Yet, connection to place and the physical environment, such as being close to nature and animals, seemed to be a particularly important part of recovery for some of the women, such as Lin, Dira, and Dee.
It appears that recovery is more than just about access to services; it is about finding support, help, and understanding that suits each individual woman. This seems to look different for each woman, and does not necessarily mean accessing professional help all the time; instead it is more about women feeling acknowledged and validated, and reassessing their views and gendered social expectations about themselves and their relationships in what they consider to be a supportive environment. This finding is similar to those found by other studies, such as Jack (1991), Scattolon (1999), Schreiber (2001), and Wilson (2007). Formal services and health professionals may not necessarily always play a part in recovery for rural women.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 129 Social factors impacting on help-seeking in rural NSW. Some of the women’s accounts indicated that they struggled with their own and others’ perceptions of the stigma of having depression. Some of the women, such as Sam, Pam, and Jenny, felt that there was a lack of confidentiality in their rural environment, and a fear of gossip hindered these women from getting help and being opened to sharing with others what was going on for them. It is well documented that help-seeking behaviours are affected by a perception of lack of confidentiality in a community (Hogg & Carrington, 2006; Jackson et al., 2007). But, apart from these three women, the rest of the women in the study did not highlight these issues as being significant for them, and most of the women happily accessed help within their own community.
The responses of the women interviewed for this study suggest that rural women are a diverse group, and that broad or stereotypical statements are not necessarily reflective of the actual residents of rural locations—even documented ideas of bush social culture may be too homogenous in expectation. While stoicism may still possibly play a role in rural women not accessing services as much as their urban counterparts, this study suggests that being stoic about their mental health was not the women’s main concern when seeking assistance. Overall, most of the women were comfortable about family and friends knowing about their lived experiences of depression, and found these support networks were vital. In one sense, however, stoicism may be indicated in that despite difficulties with service delivery or struggles with recovery, the women had adapted their endurance to their requirements, and, having done so, made little complaint about their choices in the interviews. While the concern regarding stoicism was that they would not get help due to self-reliance—the belief “I can do it on my own”—findings seem to show that the women were determined to get help and “soldiered on” despite service issues and despite their own distress. Although perhaps invisible to them (enmeshed in their cultural selves), stoicism (self-reliance and determination) may actually have been an ally in their recovery.
None of the women mentioned using telephone services for counselling assistance, which may suggest the importance of face-to-face interactions; in fact, women went to lengths to ensure continuity of professional relationships that were face-to-face. Moreover, informal relationship support was particularly important to many of the women, and feeling supported and valued by their intimate partner was also vital and linked to their recovery journey. It seemed that if the women felt supported by their partner, things looked up; conversely, however, intimate partner relational difficulties (such as marriage breakdown or betrayal) were
130 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW a trigger for some of the women’s depression experiences, perhaps where their sense of self meshed with their ability to keep and maintain a relationship.
Help-seeking and spirituality. An unanticipated form of coping and assistance appeared from the interviews in that eight of the women indicated that faith and having a connection to God were helpful in their recovery. Some of the women gave an account of how an experience with a higher power was a turning point in their depression experience—such as Rosie. All the women who mentioned spirituality found it to be a positive and a healing factor in their recovery. It appeared to give the women a sense of hope and a feeling of not being alone, since they had a “higher power”, they could turn to in their need. Other studies have found similar themes regarding spirituality and how it has helped women to cope with life stressors (Brown, 2002; Koenig, 2009). An Australian study by Bennett and Shepherd (2012) found that social supports and spirituality played a role in depression levels in Australian women such that those who reported higher levels of spirituality corresponded to having lower levels of depression.
However, spirituality is generally not given any significant weight or thought in the treatment of depression, and does not interface easily with the biomedical model. Women may keep their faith stories to themselves in case their GP disbelieves them or denigrates their experiences. Consequently, in the domain of medical treatment, spirituality is perhaps not considered a legitimate assistance for women’s distress. Ultimately, spirituality is unlikely to be considered or discussed widely by health practitioners. However, listening to the women’s voices, it would appear that spirituality had the potential to offer meaning and hope to some experiencing distress, and despite historical evidence that women have been oppressed and controlled by traditional patriarchal religions, most of these women had had a one-on-one supernatural encounter that they ascribed to God and which they had found empowering. The experiences that the women described occurred mostly outside of their churches and were apart from any particular religious denomination. Perhaps further understanding of how spirituality might play a part in recovery for women needs to be considered.
To summarise, the women in this study had used diverse and creative means to obtain assistance for what they were experiencing, often based in relational help, and were very active in seeking out assistance from a variety of sources, including some unexpected ones, such as spiritual faith and encounters with God. It seems that it is unwise to assume that all women who are depressed fit the stereotype of being bed-ridden and passive; in fact, this study has shown something quite different: women who were determined and very active in their recovery journeys in many creative and unique ways, and at times without biomedical help.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 131 3. Difficult Relationships, Loss, and Childhood Abuse
Women in the study shared about experiencing difficulty in their relationships with others, often with their intimate partners; some had a strong sense of loss and powerlessness, often owing to the loss of significant relationships, while others had an overwhelming sense of how childhood abuse, violence, and trauma had left a legacy of destruction in their lives.
Self-worth, identity, and relationships. Some of the women in this study suffered from low self-worth and poor self-acceptance, often because of trauma or abuse they had experienced in their family-of-origin. It appeared also that many of the participants had been socially conditioned into a cultural heritage of gendered stereotypes, which they were unconsciously using as a reference point for their sense of self. As evidence of this, some of the women did not feel as if they were living up to societal expectations of what a “good wife” should be and so somehow, they felt “less than”; Jay, for example, expressed this belief. These kinds of beliefs, often internalised as “I am inadequate”, leave women caught up in negative self-talk that is unseen by others around them. Often these women live tyrannised by thoughts such as, “I must be less than because I cannot keep a partner”, or simply, “What is wrong with me?” These thoughts can compound negative self-talk and self-image, and the subsequent self- beliefs remain unchallenged. As an example, often these women internalised their relationship difficulties with their partners as being their fault (a legacy of the social conditioning of women to be the caretakers in relationships) and just accepted this as a fact without questioning it; this hidden self-blaming further compounded their already poor sense of self and their distress.
This is also evidenced in the research of Fullagar and O’Brien (2009), Hurst (2003), Jack (1991), Scattolon (1999), and Schreiber (2001), that women’s self-talk and cultural and gendered role expectations were oppressive and difficult to live up to, and were a contributing factor to their depression and distress; it was clear from the interviews that these issues had been a cause of great anguish amongst the participants, particularly Jay, Paula, and Lin.
However, in most cases, the women did not appear to connect their depression experiences to their negative relationship to themselves (their beliefs about themselves and how they viewed themselves), or to the unrealistic gender stereotypes they were trying to live up to. They did not indicate that they were conscious of the gendered society of male privilege that they lived in or the social conditioning they had undergone as women. This study suggests that relationships were often a double-edged sword for the women: if they were going well, the women found the relationship a source of stability, but if relationships/connections to others
132 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW were difficult and hurtful, this was a source of internalised pain for the women and compounded their distress. In accepting that it was their fault that the relationship was difficult, the women struggling with these issues seemed to have inherently accepted that somehow, they were responsible to maintain the relationship. They did not seem to have the reference point or awareness from which to challenge the patriarchal system of male privilege that they lived in or the gendered cultural notions that they had accepted about themselves as women, and yet this cultural heritage of gendered stereotypes was a source of internal tyranny. In general, psy- professionals are not trained to place importance on the contextual issues of women’s distress, so when the women went to obtain help from professionals, the biopsychosocial discourse would likely have glossed over the gendered nature of their depression, reinforcing these layers of oppression and potentially compounding the women’s distress.
It must be considered that the women in this study were mostly over the age of 40, and even though social expectations have changed, as have many of the stereotypes which were oppressing them, there are certainly others that women still unwittingly take on without realising where they come from, which does not give them a place from which to question if they want those gendered ideals, or even why the ideals exist. In the biomedical treatment of women’s depression, an awareness of these silent, internalised models that can create multiple layers of oppression is missing. This leaves women’s socially-constructed selves as complicit in their suffering, since their ideals are both imposed and unattainable. Research with younger women that explores gendered stereotypes and depression might be an important future direction for research so that more deliberate attention can be paid to this issue in practice.
Loss and powerlessness. Another significant finding was of profound loss, a factor that had affected several of the women during their lives. Some identified this as contributing to their depression experience. Losses that the women discussed were: loss of significant family members, loss of relationships with intimate partners, losses of children to forced adoptions, and losses of expectations (e.g., being unable to conceive children).
In particular, the grief and loss of having to give up a baby for adoption was profound and was compounded by the fact that the women affected took on board societal messages that they were “soiled goods” and that “no one will ever want me now”. The enforcement by medical professionals, who colluded in the practice of forced adoptions to keep the “incident” a shameful secret, further enhanced the maintenance of the status quo and the control of women who were perceived to go outside the accepted cultural sexual norms of the day. The masculine dominant discourse of that time often rendered women powerless and marginalised and put
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 133 them into categories of “good” or “bad” and therefore deserving of “punishment” (Jack, 1991; Ussher, 1991). The women who told of forced adoptions had silently taken on the stigma and shame society directed towards unmarried mothers, and had no reference point from which to stand up against male privilege or to challenge the patriarchal values of that time.
Other women described different types of losses, such as Mia, who discussed the loss of not having a close emotional bond with her husband and the loss and disappointment of not being able to conceive children. Other women had had losses through the death of a husband, while still others had had loss and rejection from their partners and some from their adult children. Significant losses, coupled with poverty, abusive childhood experiences, and poor intimate partner relationships have been identified in the literature as social-environmental factors that can contribute to women’s distress and depression (Belle & Doucet, 2003; Bifulco & Moran, 1998; Brown & Harris, 1978; Jack, 1991; McGrath et al., 1990; Mirowsky, 1996; Nolen-Hoeksema, 2001; Stoppard, 2000). This brings this discussion back to the same key issue. A diagnosis of depression may not be the right fit for all women who are identifying grief, loss, and powerlessness as their primary concern. Perhaps the biomedical domain cannot really offer appropriate “treatment” for loss and grief and oppression, since it is not possible to medicate for emotional pain, abandonment, and powerlessness. Health professionals need to consider, however, that the social, cultural, and historical events in women’s lives have significant impact on their mental wellbeing and how they view themselves. These stories may not be of depression necessarily but of loss, grief, shame, and being demoralised, as Hurst (2003) suggests in her research.
Childhood abuse and violence in women’s lives. Many of the women described their depression as being influenced by events in childhood and adolescence. Their stories were not of symptoms, but of experiences of trauma and abuse at the hands of family, often their fathers. The strong presence of violence in the childhoods of these women was overwhelming. The effects of childhood abuse on adult mental wellbeing have been well documented in the literature (Astbury, 2010; Bifulco & Moran, 1998; Brown & Harris, 1978; Felitti et al., 1998). Other research supports the feminist view that the proportionally high depression rate among women is more likely to be due to social class, poverty, abuse, and oppression than it is to biological factors (Astbury, 2010; Bifulco & Moran, 1998; Nolen-Hoeksema, 2001; Stoppard, 2000). In the group of participants, Dee, Paula, Dira, Mia, Rosie, Mona, Kathy, and Claire had all experienced some form of abuse in childhood, often at the hands of their caregivers, and,
134 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW except for Paula and Claire, all of these women discussed how the childhood abuse had caused their distress and depression to some extent.
It was clear that some of these participants felt their early life experiences of abuse had contributed to their depression as adults. They often felt unloved, vulnerable, rejected, and unsafe in their homes—factors that can undermine a child’s sense of self-worth and are often carried into adulthood as a profound sense of unworthiness and difficulty in trusting people (Bifulco & Moran, 1998; Hurst, 2003). Dee, Dira, and Rosie all struggled in their adulthood with issues of trust and with the legacy of abuse and betrayal by their caregivers. The women stated that their identity and how they viewed themselves was tied up in their abuse experiences from childhood, and that feelings of unworthiness and shame often haunted them. It appeared from the women’s stories that they took on board that the abuse was somehow their fault and internalised the shame of the event/s as belonging to them, instead of the perpetrator being seen as shameful (Mia is an example). Women are often conditioned to feel shame at an early age and this serves to keep them quiet about exposing the perpetrator; if a woman does disclose a sexual assault, she is often not believed (Bass & Davis, 1988). The patriarchal culture oppresses women via the vehicle of sexual violence, which conditions women to be “less than” in society; this oppression and sexual violence is used at an early age to dominate, control, and to “program” women into being subservient to the male and his authority, a strategy that disempowers women and maintains the status quo, making it even more difficult for change to occur in society (Chesler, 1972; Ussher, 1991).
The level of oppression and fear that some of the women were living under impacted on their sense of self and safety in the world, affected who they could be in the world, and thus their identity; this, also, has been well documented by existing literature (Astbury, 2010; Bifulco & Moran, 1998). Rosie, for example, stated that she had a fear of her father even years later, living hundreds of kilometres away from him; she still felt the terror and did not feel safe even as an adult.
Some of the women who had had abusive childhood experiences were not in a relationship with their adult children at the time of the interview. These women described how difficult relationships were within their own families, both with adult children and with partners, and said they had challenges to maintain any sort of relationship; due to these struggles, some had isolated themselves, such as Dira and Paula, and had remained cut off from their families and their adult children. Some of the women did not directly see their abusive childhood experiences or their poor attachments with their own parents as having any bearing
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 135 on their ability to have positive attachments and relationships themselves as parents. Yet current research supports the view that experiences of disrupted attachments (namely with parents or primary caregivers) early in life have a significant effect on the ability of individuals to parent as adults themselves (Bifulco & Moran, 1998; van der Kolk, 2005).
Childhood abuse and its associated personal, social, and financial outcomes are intertwined, but what is particularly striking is how these experiences of violence and oppression were tied to the women’s sense of self—and yet only a few of the women said that their psychologist or social worker had addressed issues of past trauma, abuse, and disconnection to self during therapy sessions. These traumatic experiences had left the women with a profound sense of loss, shame, fear, abandonment, and rejection, and yet they talked of their diagnosis of depression and the process of seeking treatment with little mention of professionals such as psychologists and social workers having worked with them about their childhood abuse experiences, let alone structural issues of power and oppression and how these may have intersected to create multiple levels of oppression in the women’s lives.
In this study, depression for some of the women might be better understood in the context of trauma, violence, and oppression. One could suggest that in fact the women are traumatised and that some of the “knock-on effects” of this appear to be outward symptoms of depression. If the trauma experiences and other social and structural issues were addressed, this could be more helpful than a medical diagnosis. In fact, many of these women did not just have one trauma experience, but had had multiple experiences of violence and abuse over numerous years. Childhood abuse is well understood to affect physical and mental health, but it also affects how one sees the world and how one views oneself. For example, “I am being hurt and no one has protected me; this must mean I am worthless”, captures the potential for life-long pain regarding childhood violence and abuse. Negative self-beliefs of this kind can often be held unchallenged for many years—as in the case of many of the women in this study.
One of the participants, Rosie, did have some of her traumatic childhood experiences addressed through EMDR, counselling, and a spiritual healing experience. However, she was one of the few participants in the study that recognised on her own that her traumatic experiences in childhood were negatively influencing her as an adult, and consequently got help in that framework.
In fairness, when discussing appropriate help for trauma experiences for the women in this study it is important to recognise that these women were already mostly over the age of 40
136 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW and some of the women had received professional help during a much earlier time period. Bruce Perry (Perry, 2006; Perry & Dobson, 2013) and Bessel van de Kolk (2005) have spent more than twenty years bringing awareness of the effects of adverse childhood experiences and childhood developmental trauma to the professional and public domain; however, in the 1980s and 1990s when these women received assistance, this research was still in process, and clinical practice gave minimal attention to the ongoing effects of trauma and violence. It is therefore not surprising that many of the women and their practitioners were not as informed about the connections between mental health and childhood abuse and trauma as health practitioners are today.
However, while professional knowledge of how trauma affects children later in life is important, as is acknowledging the importance of offering informed trauma counselling to women and children, this approach still individualises an issue that is structural in its roots. How abuse and violence is allowed to continue towards women and children even though society recognises it as a “social ill” (on the surface) is a significant justice issue that needs to be addressed. Since the late 1970s, through consciousness-raising and direct action from feminists and supporters, laws have come into effect to criminalise violence and abuse against women and children (Wendt, 2009); unfortunately, however, gendered violence and abuse still continue at alarming rates and it seems that the ongoing effects are often medicalised as depression, perhaps because there is no mechanism through which to observe that the women may be oppressed (Wendt, 2009; Western, 2009, 2013).
Feminist contributions to trauma theory have been considerable over the years, bringing sociopolitical context to the trauma discourse (Burstow, 2003). Indeed, feminist theory may offer an alternative to the traditional, individualistic, psychological CBT and trauma counselling that is currently offered through the Medicare system. Feminist therapy sees trauma within the context of gendered violence and aims to empower women to reclaim their voices within such contexts; it validates women’s experiences, and encourages their voices to be heard in all domains (Tseris, 2013). Understanding the narratives of women this way means that assessment of their distress is no longer confined to medical and psychological models that de- politicise the nature of violence against women (Tseris, 2018). In the psy-domain, a medical diagnosis of trauma is often viewed as depression or post-traumatic stress disorder, which merely individualises the issues of violence and abuse and pathologises women and children who have been subjected to violence and degradation (Burstow, 2003).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 137 Listening to the voices of women and avoiding a reliance on a diagnostic deficit approach may enable long-held biomedical beliefs and values to be challenged (Tseris, 2013). Feminist therapy understands the gendered, oppressive contexts that women live in, and this understanding allows trauma to be seen not just as an individual experience but as the result of an act of criminal violence, removing the “trauma recovery” framework from the woman and placing it onto society (Tseris, 2013, 2018). Feminist therapists often work with women on a one-to-one basis, but rather than seeing the woman in a reductionist perspective, they see her within the broader context of how culture, class, race, place, and gender intersects within the woman’s daily life and her experiences. This is a departure from the individualistic frameworks of traditional psy-approaches, and, in shifting blame from the self, may lift the load of shame, responsibility, and oppression from women’s shoulders and onto the patriarchal system.
There is a tension, however, that exists when a woman experiencing distress accesses a practitioner. As a counsellor myself, this tension lies in helping the woman in her distress in the “here and now” of her pain, while still keeping in mind the macro and structural levels of discrimination and oppression that led the woman to be in distress in the first place. Practitioners on a day-to-day, grassroots level cannot change the political climate they work in, such as the prescriptive, biomedical Medicare system; however, they can be involved in advocacy for system change by educating and empowering women to understand what led them to experience distress in the first place. Raising awareness that depression and distress are not located solely within the rural woman herself but have come about through the intersections of rural culture, gender inequity, unrealistic role expectations, social conditioning, and violence is a central place from which to commence empowerment. Despite the challenges involved in addressing the structural contexts of women’s experiences, simply continuing the usual biopsychosocial interventions for women living with depression without attending to the social forces that contribute to it will only reinforce the status quo—just as labelling women’s life experiences as depression de-politicises the issue of power and control of women and children and makes the oppression of women and children into an individualised problem within the woman herself (Stoppard, 1998, 2000; Taft, 2003).
There is an ongoing debate in social work regarding the acceptance by social workers of biomedical discourses as “truth”, and their subsequent participation in the continuation of oppression of men and women who find themselves within the mental health system. Many social workers are employed within the mental health system and may feel that they have to “go along” with the dominant biomedical framework within that environment, but this does
138 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW nothing to challenge the psy-disciplines and their individualistic, reductionist practices that intentionally and unintentionally disempower men and women (Cresswell & Spandler, 2016). Social work as a discipline could be seen as increasingly becoming more individualised in its service delivery rather than a focusing on community and social action.
Women need to be empowered to challenge the social conditions and the patriarchal system that they live in. Raising awareness is vital for change at all levels of society so that women who feel that they cannot live up to the discourses of femininity are able to identify and challenge these discourses. Women’s own views of themselves that accept narrow “domestic ideals” and unrealistic gendered role expectations need to be considered and challenged, otherwise accepting a label of depression becomes harder to resist at all levels. In addition, change will come when direct action takes place to challenge the social issues of male privilege and power imbalance, and when the private sphere of violence and abuse is exposed in the public domain.
The literature is clear that childhood trauma and abuse can set women up for poor social, mental, and physical health outcomes in adult life (Bifulco & Moran, 1998; Felitti et al., 1998; Perry, 2006; van der Kolk, 2005); however, this known literature does not appear to be well acknowledged or actioned at the primary level of health care in Australia today. Since a diagnosis of depression is made by a GP, instead of merely having a conversation with the woman about her symptomology of depression and offering medication, perhaps involving her current and past lived experience of, for example, traumatic childhood experiences, poverty, oppression, violence, and loss could be a more relevant and comprehensive approach. If health professionals were able to fully embrace a more holistic and intersectional understanding of women’s everyday lives and context, the reductionist biomedical diagnosis for depression would be further challenged. Alternative avenues to appropriately address the pain and disempowerment of women, such as feminist therapy, may then become necessary and accessible. Challenging the status quo and destabilising the assumptions of the medical model could, in turn, open up ways to understand those issues at a broader structural level; this would, however, have to be recognised at policy levels for change to occur.
Summary
The biomedical model appears to have “blinkered” health professionals into a limited range of standpoints and paradigms of the lived experience of their clients, and has therefore narrowed the way women receive help in the funded Australian health-care system. This study
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 139 calls for a paradigm shift in thinking, since for some of the women the term depression was not an “appropriate fit”; rather, their distress seems better understood in the light of trauma, abuse, and loss. Some of the women in this study had also internalised narratives and beliefs that supported a biomedical response, rather than finding a social/structural understanding of themselves or of their experiences of depression. Change will occur when women themselves review their biomedical understandings and gendered cultural stereotypes and begin to challenge and reshape these for themselves.
This study found that women were very active agents in seeking help for what they were experiencing and used a diverse range of formal and informal supports and services in their rural communities. In addition, despite traditional notions of rural life, it appears that rural women are a diverse range of people, and professionals need to view women as individuals rather than accepting stereotypical views of rural residents and rurality. In this study, limited access to health services, gossip, and a perceived lack of confidentiality were not the main concerns for most of the women. Research has shown that factors such as poverty, unemployment, violence, and adverse childhood experiences have a profound influence on the prevalence of depression for Australian women in both urban and rural environments (Rich, Byrne, Curryer, Byles, & Loxton, 2013). While the rural environment played a role in the women’s experiences, many of them were most affected not by the lack of rural health services but by the legacy of violence, oppression, and disempowerment in their lives.
140 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Chapter 8: Conclusion
This study commenced as a feminist investigation into the lived experience of women living with depression in rural NSW. I was interested in understanding how women’s experiences of depression (however they defined depression) might be affected or influenced by living in a rural environment, and I wanted to hear from women who were seemingly voiceless in the literature. When this study began, I was curious as to how some women had managed to stand up to depression and I wanted to learn more. I was also interested in understanding whether the environment and space that the women came from and were living in had any influence on their experiences of living with depression, and whether, as context, the elements of place had an impact on their experiences. I was particularly concerned about rural women, as the literature describes rural spaces as places of disadvantage owing to some concerning health statistics, geographical disadvantages, and issues of limited access to services. So, with this in mind, I embarked on interviewing 27 women from the Riverina area of NSW, and some of the findings from what I heard in the women’s voices were unexpected and powerful.
Reflections
As a practitioner, being a PhD student was a new experience. I began this project in mid- 2009, not really understanding the scope and implications of what I was about to embark on. I worked on it on a part-time basis over many years and the thesis evolved over that time. I learned about the world of research methods and about how to conduct research interviews and data analysis, all of which was new to me. I really enjoyed meeting and interviewing the women and listening to their stories.
Through the interviews, I got to know the women’s stories and their life challenges, and through their lived experiences I got a real sense of each participant in a meaningful way. Reading and rereading the transcripts was time-consuming, but it was worth it, as I found the women’s stories interesting and powerful, even on paper, and uncovering themes and messages that they had conveyed about their everyday lives was extraordinary. I found that I, personally, had some notions about rurality and rural people—even though I am one myself—that were not necessarily reflective of the women in this study.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 141 I commenced this thesis from a practitioner perspective and I end it the same way, as a practitioner. Some of the findings from this study will now directly influence my approach in my own rural practice. One area in particular is my new awareness of how much male privilege influences women’s acceptance that everything is their fault, and how gendered, unrealistic role expectations make women miserable. Assisting women to be aware of the influence of male privilege and the prevailing devaluing societal attitudes, and how these impact women’s views of self and relationships will now be important in my own professional practice. I feel strongly that encouraging consciousness-raising is vital if women are to be empowered to stand up against the tyranny of the discourses of femininity and male privilege in their own lives. Although I was aware of these issues before the commencement of this study, working closely with the women’s stories has certainly highlighted them for me as an extremely relevant part of rendering assistance to women living with distress and oppression. Another part of the study that has come to be very salient to me is the fact that as rural women, we just accept that we have to travel to get the right help—in some cases, to secure continuity of service delivery with the same practitioner—and this could mean hours of travel, expense, and some stoic determination. From this study, it seems that the current structure of the public health system struggles at times to ensure continuity of service provision for rural women, and it has become apparent to me that this is really not equitable or just. As a rural woman living in the Riverina, I myself had just accepted this, but it is geographical discrimination.
In this, I was able also to recognise that relationships, in particular, with the self, others, and practitioners are vital to women’s recovery. As a practitioner, I knew from my training that the quality of the therapeutic relationship is important, but after completing this study it has become very clear to me that if women are prepared to travel long distances time and again to ensure that they get to see the same service provider, continuation of the service provider relationship is imperative. It became obvious, too, that this theme of relationships occurred across the research, as most of the women were and wanted to be very relational, and placed high value on relationships, particularly intimate partner relationships. At the beginning of this study, literature indications had reinforced my preconceived notion that women wanted to be relational, and indeed, after listening to the women’s stories, I believe that women do seek out relationships and are generally seeking social contact for themselves and others. In fact, some of the women’s “yard sticks” that they were “okay” were if their relationships were doing okay, which is perhaps, too, a legacy of women’s social conditioning as children. It has become clearer to me since embarking on this journey that women want to be in relationships, however,
142 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW and despite their personal relationships being very difficult, at times many were still prepared to have intimate relationships in their personal lives. Others chose not to, as it was too painful to have close connections; however, some may have substituted intimate relationships in their own lives for having a relationship with health professionals, as this was possibly a safer option where they were less likely to get emotionally hurt.
Moreover, as I reflect on my journey as a PhD student while being a practitioner and social worker in private practice, I am acutely aware that I am working at the micro level; however, within this one-on-one context, I am now more intentional about bringing the structural, cultural, social, and political issues that affect women into the counselling context, and I am mindful to discuss with the women how these issues intersect to create and maintain structural inequities and oppression in their lives. Social justice is and will continue to be important to how I render assistance to women who are experiencing distress and oppression.
The women in this study were mostly over the age of 40 and were Anglo-Australian, which was not as diverse a population as I would have liked. I did not have any women from different cultural backgrounds that I was aware of, although two of the women were born in England but had moved to Australia over 30 years prior to the time of the study. Moreover, none of the women self-defined as Indigenous. Women who were under the age of 30 did not respond to any of the recruitment methods I used. The eventual use of the snowballing technique, whereby women already recruited into the study contacted other local women who they thought might also have been interested in participating and then some of these women contacted me, often meant that the new participants were of similar backgrounds and ages to the friends who had told them about the study. Therefore, the snowballing technique, also, did not help to attract participants of diverse backgrounds or ages.
I was therefore not able to recruit culturally diverse groups of women, and this could be seen as a limitation of the study, as seeking and obtaining the views of diverse populations could possibly provide a wider range of experiences than I obtained with a group of women who had similar demographic profiles. Moreover, there were no women under the age of 30 who participated in the study, and I think in hindsight if another study was to be conducted, specific and culturally appropriate recruitment strategies would need to be considered to recruit a more diverse and younger group of women. Despite these limitations, I learnt so much from the women who did participate in the study and heard so many intense and vivid stories of pain, loss, and recovery. The determination and courage of the women was infectious, too much
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 143 feminine wisdom to record here, and this brief summary is just a portion of some of the important life lessons I learnt from the women during my time with them and their stories.
I found writing this thesis difficult and taxing, as academic writing did not come easily to me after my life in clinical practice as a social worker and counsellor. I spent considerable time on draft after draft in order to refine my thinking, to critically reflect, and to analyse themes. It was an endeavour that impacted my life, my family, and my worldview. My critical and reflective thinking evolved along the course of this study and became clearer. Overall, it was important to me in this endeavour to accurately reflect the voices of the women’s experiences in a way that was authentic and respectful to their lived experiences. I wanted this research to capture the essence of the women’s life experiences for a wider audience so that it could help other women in similar situations. I was committed from the outset to telling the women’s stories so authentically that if the women themselves read the thesis, they will feel I have done justice to their lived experiences, and that giving up their time was worth it. I wanted this thesis to be a public testimony of the women and their lives.
Main Findings, Recommendations, and Implications for Practice
This review of the collateral aspects of depression suggests that it is not just an individual issue but also a societal one. As a society, we need to review how both the social structures and the social and cultural context allow for abuse and oppression to continue—including how male privilege and an imbalance of power between the genders creates a climate for devaluing women and children that is the status quo. The dominant culture’s tolerance and support of demeaning attitudes and values towards women and children plays a pivotal role in allowing and perpetrating violence against women and children. Criminal penalties can help to deter men from private violence in the home, but underreporting through fear of the perpetrator and lack of faith in the legal system are difficult to overcome, and reporting itself is still a burden on the victims.
It is important to note that help for women living with depression which does not attend to the social forces that contribute to it will simply uphold and reinforce the cycles of the status quo: Labelling women’s life experiences as depression depoliticises the issue of violence, power, and control and turns it into an individualised problem that is left up to the woman herself to solve, which in turn leaves the real issue invisible. In tension with this, women themselves need to challenge the social conditions that they live in, and not accept attitudes of sexism and male privilege as the norm. Consciousness-raising is vital for change at all levels
144 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW so that women who feel that they cannot live up to the discourses of femininity are able to recognise and challenge these discourses and resist the label of depression.
In this study, I found that women were active and empowered in their own assistance, and some did not necessarily only accept a biomedical explanation for what they were experiencing. However, it was clear that the women were often depressed and distressed because they were betrayed, abandoned, grieving, and abused. The outflow of these experiences is constructed and viewed by the biomedical profession as depression, but the limitation of this framework is that it then goes on to label and “treat” trauma, grief, and oppression with antidepressants without an imperative for gaining a contextual viewpoint. It is clear that the term depression could be challenged and a different framework of understanding should be applied.
Health professionals need to be enlightened to take a broader approach and consider the complex social, structural, cultural, and economic contexts that women come from, and be aware that continuity of same health professional is important to women in their recovery journey. Government, policy makers, and health practitioners, including GPs, need to consider the lasting and generational effects of oppression, violence, and abuse on women and children.
I call for an accurate naming of women’s experiences for what they are, and a challenge to the medicalisation of social injustice issues, such as the ongoing labelling of surviving violence as “depression”. This study suggests that medical and health professionals need to take into account alternate understandings of the lived experience of women’s realities, including feminist understandings, that will address the complexity of the cultural, structural, social, and gendered contexts in which women’s lives, past and present, exist in order to better inform their service to rural women. Women’s social and material experiences need to be central in any understanding of their distress.
I also recommend that a joined-up policy and service approach needs to occur, as traditionally, services have often operated using a “silo approach”. Domestic violence, child protection, and mental health services are often fragmented in their delivery approach to women. Health service providers need a more inclusive, holistic, and integrated approach to women’s lived experiences of violence and oppression, as mental health, violence, and poverty are not discrete entities but all concurrently affect and intersect in women’s lives. Encouraging services to work together in a contextualised and collaborative way for their clients could provide more appropriate service delivery and be in the best interests of the women.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 145 I call for a rethinking of government values surrounding the frameworks of help for women. The Australian government currently only funds biomedical forms of psychological treatment under the Medicare rebate system. Given this study’s findings on the ways women find and obtain help, often through nonbiomedical frameworks, review and change to this singular focus for funding would be beneficial. Opening up allied health professionals to provide broader, better informed psychological and social interventions by valuing and including other alternative frameworks of approach and understanding, including feminist and social constructionist frameworks, could help health providers to better identify and cater for what some women are experiencing—not depression necessarily, but oppression. Without a broader systems approach that takes social and cultural contexts into consideration, health providers will continue to miss what is really going on for women. The government-funded Medicare system needs to endorse this kind of broader framework of practices if health professionals providing free or subsided services are to be of real assistance to women in distress.
In tandem with this, changes on the structural level to destabilise the biomedical “truth” as a perceived complete entity need to occur alongside challenging the patriarchal values that still permeate our society. Acceptance that the biomedical domain has the “answers” for all women’s suffering is unacceptable, and an awareness of other, alternative, perhaps lesser known, help and support systems may be more useful to women living in distress and oppression in rural Australia.
Rural differences in service provision exist, but these may just be a distraction from the issues of male privilege and masculine dominant culture that rural women are subjected to in their daily lives. The pressing issue is not necessarily a lack of services (however concerning that it is) but is that women and children are not safe in their own homes and are subjected to violence and oppression within their own spaces. Rural health practitioners such as psychologists and social workers need to consider obtaining training and education in feminist understandings so that when women come for assistance, instead of simply applying the usual individualistic psychological interventions, they are able to help women gain an understanding of the contexts of their lives and the factors of oppression and disempowerment that intersect for them daily. Of central focus is the commencement of education in feminist and intersectional understandings of how gender, culture, and rurality interrelate to create multiple levels of discrimination and oppression in rural women’s lives, something which has been overlooked in the main by the psy-disciplines, that place and culture can impact and
146 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW disempower women. Such understandings of women’s oppression will better serve women than the standard type of individualistic, CBT psychological treatment currently employed by most services.
Moreover, social workers have been increasingly recruited into the micro level of practice over recent years, rather than working at the macro level of community work or direct action. With this in mind, I, as a practitioner and social worker, need to be aware not to individualise women’s concerns when they come for help, and to maintain a feminist framework that situates women’s distress and abuse as being a result of the structural inequalities and the prevailing devaluing attitudes towards women in society. My role as a social worker and practitioner is to facilitate empowerment and to assist women in the contexts of their daily lives.
The study’s findings show that the women themselves were unaware of the structures of patriarchal values and male privilege that were the source of their unrealistic self-expectation and oppression, and, without a platform from which to challenge the patriarchal system that they lived in, had just accepted that something was wrong with their ability to perform their roles. Consciousness-raising around issues of male privilege and gendered role expectations needs to occur for the women themselves to be able to identify these silent, internal models, become aware that the inherent ideals may not actually be their own, and so stand up to the oppressive systems that they live in.
Considering the low profile of feminist understandings in the field generally, it is perhaps not surprising that the formal supports available to the women did not include any group work, community work, or conscious-raising on any sociopolitical level to attempt to raise awareness about women’s wellbeing in tandem with women’s distress and oppression. This study calls for implementation of community development and action at the grassroots level, in order to bring about an increase in public awareness of how power and control in the patriarchal society impact women’s wellbeing because of intersections of oppression on both micro and macro levels. Consciousness-raising can empower women with the awareness to understand that these issues are not simply located within the individual woman herself, but are a social product. In addition, feminist education and empowerment group work programs implemented in rural areas could help facilitate understanding for both men and women so that they are able to recognise the oppressive attitudes and structures that they participate and relate in. This, in turn, could help women to stand up to oppression, and reject the diagnosis of depression (if they so choose); it is essential to begin to create an accessible framework for women to use so
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 147 that they can challenge the notion, “something wrong with me”, so that it can become “something is wrong with our culture”.
This study rejects the notion that a biomedical understanding of depression is appropriate for all women, because it does not attend to the gendered nature of depression and the social and cultural injustices at play in rural women’s lives. It is all too easy to locate the problem in the individual woman; this needs to change if health professions are to be relevant and helpful to rural women. There is also a need to challenge the gender-blindness of mental health policy in Australia that serves to make women’s experiences of distress and oppression invisible. Policies that ignore the social, cultural, environmental and political spheres that are shaping the gendered nature of our relations with ourselves, others, and our community are just reinforcing the status quo, and do nothing to address the gendered aspects of women’s distress in rural Australia.
In conclusion, this study has found that the depression experience that the women described in their stories was more about the complexity of a legacy of violence, abuse, and demoralisation than it was actually an individualised medical condition. In fact, for some, depression could be better termed oppression. The women were not passive in their rural situations or depression experiences, but were active and creative in sourcing help, and it is this proactive agency that has highlighted the complexity of the requirements for the genuine assistance of women who are experiencing distress; the biomedical model on its own will not do.
Health professionals need to be encouraged to be aware and to consider the complexity of social, structural, cultural, and economic contexts that women come from when they present for assistance. Society needs to be intentional about addressing gender inequality, promoting zero tolerance of violence against women and children and addressing social injustice affecting women and children. These rural women were a testimony to the human spirit: despite significant challenges, betrayals, violence, and oppression they were determined to seek ways to heal and to “talk back” to “depression”.
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Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 159 Chapter 9: Appendices
Appendix A: Social Demographics Information and an Overview of the Women
(Names have been changed to ensure confidentiality) Ange: 41 years, Anglo-Australian, single, divorced, five children (four younger children living at home), owns a small business (full-time), struggling financially. Cin: 44 years, Anglo-Australian, married, two children (living at home), welfare worker (part-time). Claire: 65 years, Anglo-Australian, not in a relationship, divorced, no children, lives on own, retired. Reports having depression for a long period of time. Deb: 60 years, Anglo-Australian, married, one adult child (adopted out at birth), welfare worker. Reports having depression since a child. Dee: 45 years, Anglo-Australian, not in a relationship, mostly estranged from her two children who live with their father, lives on own, not working, on social security benefits, struggling financially. Di: 47 years, Anglo-Australian, married, two children, nurse (part-time). Has had periods of depression over the last 15 years. Dira: 65 years, Anglo-Australian, not in a relationship, widow, no children, lives alone, retired. Had depression for a long period of time, since teenage years. Gay: 60 years, Anglo-Australian, married, divorced, two adult children mostly estranged from her, lives on own in social housing, on social security benefits, retired. Jade: 34 years, Anglo-Australian, married, five small children (living at home), nurse (currently not working). Had depression since teenage years. Jay: 54 years, Anglo-Australian, married, three adult children, teacher (part-time). Had depression on and off over many years. Jenny: 36 years, Anglo-Australian, separated from husband, two children (living at home), teacher (full time). Kathy: 36 years, Anglo-Australian, not in a relationship, divorced, three children (one child living with her), self-employed. Laura: 59 years, Anglo-Australian, married, one adult child, retired. Lin: 45 years, Anglo-Australian, not in a relationship, divorced, two children (living at home), accountant (full-time). Lorry: 59 years, Anglo-Australian, divorced, three adult children (estranged), lives on own, retired office worker, on social security benefits, in social housing. Maree: 55 years, Anglo-Australian, married, two adult children, teacher (full-time).
160 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Margaret: 53 years, Anglo-Australian, currently partnered, divorced, three adult children, self-employed on own farm. Maria: 68 years, Anglo-Australian, married, one adult child (living at home), retired. Mia: 71 years, Anglo-Australian, married, two adult adopted children, retired teacher. Mona: 74 years, Anglo-Australian, divorced, one adult child, lives on own, retired. Pam: 70 years, Anglo-Australian, married, two adult children (one adult child with a disability), nurse. Paula: 68 years, Anglo-Australian, not in a relationship, mostly estranged from her two adult children, not working, living on social security benefits. Peta: 52 years, Anglo-Australian, married, three children, self-employed in administration. Rosie: 51 years, Anglo-Australian, married, two children (one child adopted out at birth), currently employed (part-time). Sam: 45 years, Anglo-Australian, married, no children, self-employed on own farm. Stevie: 38 years, Anglo-Australian, currently in a heterosexual relationship (identified as bisexual), no children, admin worker. Had depression since a child. Vera: 59 years, Anglo-Australian, married, no children, lives in social housing, on social security benefits (has a physical disability).
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 161 Appendix B: Social Demographics Questionnaire
1. How old are you? 2. What ethnic background do you come from? 3. What is your educational background? 4. How would you describe your current marital status? 5. Do you have any children? (Include children who do/do not reside with you in the home.) 6. If you are currently employed, how would you describe your role/profession?
162 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Appendix C: Selection Criteria Interview Schedule
• Are you over 18 years old? • Do you identify as female? • Do you reside in rural NSW? • Are you currently in an acute mental health crisis or suicidal? (If so, refer immediately to appropriate services.) • Do you feel comfortable discussing your experience of depression with the researcher? • Are you comfortable to be interviewed to discuss your experiences of depression for appropriately 60–100 minutes? • Are you comfortable with the interview being audio recorded and transcribed? • Are you comfortable meeting either in your own home, my office or local hired rooms?
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 163 Appendix D: Interview Question Guide
• Tell me about your experience of depression. • How would you describe your experience of depression to others? • How do you understand the causes of your depression? • Can you discuss how depression has influenced your life? • How has living in a rural environment shaped or influenced your depression experience, if at all? • How have you managed and coped with your depression experience so far? What has helped or not helped? • Have you tried any alternative or informal supports?
164 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Appendix E: Participant Information and Consent Form
PARTICIPANT INFORMATION for QUT RESEARCH
PROJECT
Down and Out in the Bush: Women's Experiences of Depression in Rural Australia
Research Team Contacts Stephanie Johnson Professor Robert Lonne Dr Mark Brough BSW, MSW, MAASW, Principal Supervisor Associate Supervisor EMDRIM Social Work and Human Social Work and Human Principal researcher Services, QUT Services, QUT
Phone 0402371448 Phone 07 3138 4620(BH) Phone 07 3138 4664 (BH)
Email Email [email protected] Email [email protected] [email protected]
Description and Participation The principal researcher is a Doctoral student of Queensland University of Technology, with an interest in mental health and women’s experiences of depression in rural and remote areas of Australia. The principal researcher has had an interest in mental health and women’s issues for the last 18 years, and has been a social worker and counsellor during this period. This research is being conducted with the aim of exploring such experiences and honouring the voices and wisdom of women, who are often not heard. You have been given this letter in order to gauge interest for participation in one semi-structured interview that will occur in 2012. This will also include a short selection criteria to determine the appropriateness of the interview for you and answer any further questions you may have. Please note that your participation is entirely voluntary and you are able to withdraw at any time without penalty. The following is a sample of potential questions which will be asked of you: Tell me about your experience of depression. How would you describe your experience of depression to others? How do you understand the causes of the depression? Can you discuss how depression has influenced your life? Family, social events, work, etc. How have you managed depression so far? Have you tried any treatment? If so, what type—formal or informal? You can refuse to answer any question. Also, to maintain confidentiality, any identifying details provided will be changed. Confidentiality will also be explained in more detail in the selection criteria meeting. Please feel free to ask any questions through the whole process or contact the researcher with any questions you might have. The information gathered will be collated and written up as part of completing Doctoral requirements and being possibly
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 165 published in relevant academic journals. This will allow for your knowledge to be shared with social workers, mental health workers and students. If you wish to participate please complete the enclosed consent form. It can be returned to the principal researcher in the reply-paid envelope provided. Upon return you will be contacted to arrange an appropriate time and place for the interview. It should take approximately 1-1 ½ hours, depending on your responses. Expected benefits This knowledge could impact on better outcomes for mental health service delivery in rural and remote Australia. Discussing your experience of depression may also be beneficial to you.
166 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Risks Participation in this study may cause discomfort in the relation to the possible questions you may be asked. At any time the interview can be stopped immediately at your request. If you require further support the principal researcher will assist you to access local services. In addition, the following services can be accessed: • LIFELINE 13 11 14 (24 hour telephone counselling service) • GSAHS ACCESSLINE 1800 80 09 44 (24 hour crisis service) • SALVO CARE LINE 1300 36 36 22 (24 hour crisis service) Confidentiality To maintain confidentiality, any identifying details provided will be changed. Confidentiality will also be explained in more detail in the selection criteria meeting. Please feel free to ask any questions through the whole process or contact the researcher with any questions you might have. The information gathered will be collated and written up as part of completing a Doctoral requirements and being possibly published in relevant academic journals. This will allow for your knowledge to be shared with social workers, mental health workers and students. If you wish to have a copy of the findings please indicate this to the researcher. This project is based on one semi-structured interview. Your information will be stored in a secured filing cabinet with the principal researcher only having access to your identifying information. Identifying information will not be published at any stage. The interviews will be audio taped and the contents of this information destroyed once the contents have been transcribed. The interviewer may wish at a later stage to verify with you your comments prior to final inclusion into the document. Please indicate if you are happy to be contacted by the researcher outside of the interview. In this project unfortunately it is not possible to participate in the project without being recorded. The researcher and transcriber will have access to the audio recordings (the transcriber will also sign a confidentiality statement). However the audio recordings will be destroyed once transcribed. Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate. Questions / further information about the project Please contact the researcher team members named above to have any questions answered or if you require further information about the project. Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Coordinator on 07 3138 2091 or [email protected]. The Research Ethics Coordinator is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 167 CONSENT FORM for QUT RESEARCH PROJECT
Down and Out in the Bush: Women's experiences of depression in rural Australia
Research Team Contacts
Stephanie Johnson Professor Robert Lonne Dr Mark Brough BSW, MSW, MAASW, Supervisor EMDRIM Supervisor Social Work and Human Principal researcher Social Work and Human Services, QUT Services, QUT
Phone 0402371448 Phone 07 3138 4620(BH) Phone 07 3138 4664 (BH)
Email Email [email protected] Email [email protected] [email protected]
The purpose of this research is to gather information regarding your experiences of living with depression. It is envisaged that your knowledge will add to the information base of mental health services and relevant professionals in this area. If you wish to participate please read the participant statement and sign below. The completed form and interview transcript will be kept in a locked filing cabinet, until such time as no longer needed. At this time all information will be shredded and destroyed. Participant statement I am willing to participate in this research project. I understand that I am free to withdraw my participation in the research at any time, and if I do I will not be subjected to any penalty or discriminatory treatment. The purpose of the research has been explained to me and I have read and understood the information sheet given to me, including the potential discomfort associated with the research. Also, I have been given the opportunity to ask questions about the research and received satisfactory answers. I understand that any information or personal details gathered in the course of this research about me is confidential and that neither my name nor any other identifying information will be used or published without my written permission. Statement of consent
By signing below, you are indicating that you: • have read and understood the information document regarding this project • have had any questions answered to your satisfaction • understand that if you have any additional questions you can contact the research team • understand that you are free to withdraw at any time, without comment or penalty
168 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW • understand that you can contact the Research Ethics Coordinator on 07 3138 2091 or [email protected] if you have concerns about the ethical conduct of the project • agree to participate in the project • understand that the project will include audio recording • understand that I may be contacted outside of the interview times for verification on comments • understand confidentiality and security measures in regards to my information.
Name
Signature
Date / /
I would like to have a copy of the findings of this research once published. YES NO
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 169 Appendix F: Ethics Approval
Date of Issue: 30/4/10 (supersedes all previously issued certificates)
Dear Ms Stephanie Johnson A UHREC should clearly communicate its decisions about a research proposal to the researcher and the final decision to approve or reject a proposal should be communicated to the researcher in writing. This Approval Certificate serves as your written notice that the proposal has met the requirements of the National Statement on Research involving Human Participation and has been approved on that basis. You are therefore authorised to commence activities as outlined in your proposal application, subject to any specific and standard conditions detailed in this document. Within this Approval Certificate are: Project Details Participant Details *Conditions of Approval (Specific and Standard) Researchers should report to the UHREC, via the Research Ethics Coordinator, events that might affect continued ethical acceptability of the project, including, but not limited to:
(a) serious or unexpected adverse effects on participants; and (b) proposed significant changes in the conduct, the participant profile or the risks of the proposed research. Further information regarding your ongoing obligations regarding human based research can be found via the Research Ethics website http://www.research.qut.edu.au/ethics/ or by contacting the Research Ethics Coordinator on 07 3138 2091 or [email protected]
If any details within this Approval Certificate are incorrect please advise the Research Ethics Unit within 10 days of receipt of this certificate.
Category of Approval: Human—Committee Approved From: 30/04/2010 Approved Until: 30/04/2013 (subject to annual reports) Approval Number: 1000000169 Project Title: Down and out in the bush: Women's experiences of major depression and accessing services and treatment in rural and remote Australia Chief Investigator: Ms Stephanie Johnson Other Staff/Students: Prof Robert Lonne, Dr Mark Brough
170 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW Experiment Summary: Examine rural women's understanding of depression
Participants: Approximately 25 Location/s of the Work: Narrandera and Broken Hill region, New South Wales
Date of Issue: 30/4/10 (supersedes all previously issued certificates)
Specific Conditions of Approval: No special conditions placed on approval by the UHREC. Standard conditions apply.
Standard Conditions of Approval: The University's standard conditions of approval require the research team to:
1. Conduct the project in accordance with University policy, NHMRC / AVCC guidelines and regulations, and the provisions of any relevant State / Territory or Commonwealth regulations or legislation;
2. Respond to the requests and instructions of the University Human Research Ethics Committee (UHREC);
3. Advise the Research Ethics Coordinator immediately if any complaints are made, or expressions of concern are raised, in relation to the project;
4. Suspend or modify the project if the risks to participants are found to be disproportionate to the benefits, and immediately advise the Research Ethics Coordinator of this action; 5. Stop any involvement of any participant if continuation of the research may be harmful to that person, and immediately advise the Research Ethics Coordinator of this action;
6. Advise the Research Ethics Coordinator of any unforeseen development or events that might affect the continued ethical acceptability of the project;
7. Report on the progress of the approved project at least annually, or at intervals determined by the Committee; 8. (Where the research is publicly or privately funded) publish the results of the project is such a way to permit scrutiny and contribute to public knowledge; and
9. Ensure that the results of the research are made available to the participants.
Modifying your Ethical Clearance:
Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW 171 Requests for variations must be made via submission of a Request for Variation to Existing Clearance Form (http://www.research.qut.edu.au/ethics/forms/hum/var/var.jsp) to the Research Ethics Coordinator. Minor changes will be assessed on a case by case basis. It generally takes 7–14 days to process and notify the Chief Investigator of the outcome of a request for a variation. Major changes, depending upon the nature of your request, may require submission of a new application.
Audits: All active ethical clearances are subject to random audit by the UHREC, which will include the review of the signed consent forms for participants, whether any modifications / variations to the project have been approved, and the data storage arrangements.
End of Document
172 Down But Not Out in the Bush: Women’s Experiences of Depression in Rural NSW