Therapeutic itineraries of ‘depressed’ women in Greece: power relationships and agency in therapeutic pluralism

Abstract

This paper explores the treatment quests followed by women diagnosed with depression at the local centre for mental health. The data resulting from this investigation were collected during ethnographic research conducted in 1998 and 2001 from an urban context in north-western Greece. ‘Depression’ was analysed as a medicalized form of female suffering in a Greek context, and three aspects of therapeutic pluralism were examined. The criteria through which patients prioritise certain practitioners over others, the role exerted by relatives in treatment research and manners of reconciliation of contradictory and heteroclite types of therapy were all investigated. In encounters with male practitioners (psychiatrists, priests and mediums) and close relatives attempting to help find a remedy in order to avoid stigmatization of mental disorder, female patients appear to oscillate between gender and healing powers. The field of therapeutic itineraries interacts with gender power relations to produce various technologies of discipline and practices of resistance as female patients are subjected to the bipolar power of male healers and their male relatives. These gender dynamics are interfaced in the broader competition for therapeutic authority between institutional psychiatry, the Orthodox Church and other alternative healers.

Keywords:

• depression
• therapeutic pluralism
• agency
• women
• Greece

Acknowledgements

This work draws on fieldwork research carried out for the purposes of the author's doctoral thesis, which was supported by a fellowship from K.E.TH.I. (Research Center for Equality Issues). The development of an earlier draft benefited from fruitful comments and suggestions of the author's supervisors, M.E. Handman, M. Padolfi, R. Rechtman and A. Ehrenberg. All interpretations are, of course, the author's sole responsibility. Additional thanks to Philippa Currie who proofread the text. Ethical permission to conduct the research was gained from the Centre of Mental Health and the Ministry of Health [Greece]. The author would like to thank the participants together with their relatives without whose positive assistance this study could never have been realized. However, fictitious informants’ names have been assigned in the interests of confidentiality.

Conflict of interest: none.

Notes

1. During the 1990s, Greek psychiatry underwent a period of institutional changes promulgated as ‘psychiatric reform’ following the reorganization of the National Health System (E.S.Y.) which the socialist government introduced in 1983 with the financial support of the E.C. Nevertheless, the revelation of the inhuman hospital conditions at the psychiatric hospital of Leros and the shocking photos of internees that the European and Greek press made public accelerated the plan of shrinkage and occlusion of psychiatric asylums. The reform concerned the limitation and occlusion of psychiatric asylums and the implantation of small psychiatric services in the community (centres of mental health, professional rehabilitation centres, protected apartments, foyers of convalescence), training programmes for employees in the domain of mental health and evaluation programmes. Moreover, the division of the resident neurologist/psychiatrist into two separate specialisations with the six year degree programme in 1982 and the professionalization of psychologists (the first pan-Hellenic congress of psychology was held in 1978, in 1979 psychologists were granted legal rights and in 1989 the first school of psychology was established at the University of Crete in Rethymno) promoted community health services and non-pharmaceutical treatment. The region of Ioannina was not excluded from this ‘new institutional spatialisation of mental illness’ as described by Foucault (1963, 19). The Centre of Mental Health was born within this context in 1990 and functions in the morning (from 07.00 to 14.30) like all public services. It employs a psychiatrist, child psychiatrist, psychologist, social worker, and three nurses, on loan from the university hospital.

2. The conceptualization of gender as performative rather than expressive suggests a dramaturgical approach to gender identity as well as to the self (Butler 1990). Social life can be compared to a theatre (Dubisch 1995) where masculinities and femininities are substantiated ‘not through acts but rehearsals of a norm or a set of norms that acquires an act-like status’ (Butler 1997, 538).

3. Dubisch (1995, 214) notes that ‘suffering may also serve as a basis for a woman's identification with other women. This can be seen in the concept of ponos (pain) especially as it is applied in the experience of death and mourning […] Women's performances of mourning laments speak of a “community of pain” that unites women […]. The laments themselves are a major form of female performance, created by women from traditional forms and the painful materials of their own lived experience, and they serve as vehicles to express their sufferings and those of others and to protest against injustice on behalf of the weak and the downtrodden of the world […] Thus being a woman in this case means not only identifying with other women but also with others who share women's experiences of marginality’.

4. The relation between suffering and womanhood/motherhood is also explicated by Goddard (1996, 188–92).

5. Analysis of therapeutic itineraries is part of a larger project that investigates the representation and treatment of female depression in a provincial Greek town. The fieldwork upon which this study is based was conducted between 1998 and 2001 in Ioannina and in the frame of the author's PhD thesis, which was submitted at L’Ecole des Hautes Etudes en Sciences Sociales of Paris in 2004. Ioannina, the author's field site, is a town large enough to have a multitudinous university, two hospitals and an active commercial centre. In all, the author conducted 20 interviews in the Centre of Mental Health, a branch of the Psychiatric clinic of the University Hospital, with women that had been diagnosed as depressed. With ten of them the author formed close relationships that could be epitomized in practice to informal meetings outside the service, visits to their homes, periodic phone conversations, interviews with their healers and finally attendance of their therapeutic ventures. Although it was clear that the author's intention was not to offer them any therapeutic help, only at the end of this project did the author become aware of the therapeutic implication, which was a mere fulfilment of their expectations to express a diagnostic and a therapeutic discourse.

6. This recourse to the term ‘nerves’ as a synonym for ‘depression’ or distress is not unique to Greece. The meaning of nerves in different cultural contexts as embodied metaphors of social, psychological and economic distress has been discussed in many studies (Low 1994). In the context of Greek women immigrants to Montreal, Lock (1990) describes nevra as a feeling of ‘bursting out’, ‘breaking out’ or ‘boiling over’ and suggests that they permit immigrant Greek women to relate their suffering not only to the gendered inequalities emanating from their traditional Greek values but to the economic deficiency emanating from their immigrant situation. So, by resorting to medical services and by expressing their distress in terms of nerves, Greek women immigrants negotiate their ethnic identity, reinforcing their difference. In this sense, nevra, according to Lock (1990, 238), is a form of resistance to cultural expectations, ‘an experience, therefore, of crossing the “natural” boundaries between the inside and out’.

7. In the latter two cases, soul (psychi) is represented as a sacred locus which the forces of God (Virgin Mary and the saints) and those of Satan (evil spirits) seek to dominate (Handman 1996; Stewart 1991).

8. Gender has always been a central subject in the ethnographies of Greece, mainly examined in the context of marriage and kinship (Loizos and Papataxiarchis 1991; Cowan 1990) and initially explained in terms of the honour and shame code (Peristiany 1965; Campbell 1964). In the light of these values, the position of a family in the social sphere depends on the effective preservation of the reputation of its members (Dubisch 1995, 196). Men's reputation, flaunted mostly in the public arena, is based on the protection of their family's interests as well of the chastity of their wives, sisters and mothers. Women's social value, namely their honour, is related to shame, namely their shyness and their existence in the domestic sphere, thus avoiding gossip and fulfilling their ‘natural’ virtue of procreation. The honour/shame and public/domestic schemas were particularly criticised for considering masculinity and femininity as fixed set of representations (Cowan 1990, 9). Although the ethnographies of Greece since the 1980s have theorised gender identity and gender power relations beyond the honour and shame frame, gender was still studied in its realisation through kinship and, especially for women, through the domestic sphere and procreation (Loizos and Papataxiarchis 1991). Furthermore, in the context of the association of men with the public and of women with the domestic, some studies privileged the complementarity of gender roles in achieving a successful household (noikokyrio) (du Boulay 1974; Salamone and Stanton 1986). However, as Kirtsoglou (2004, 22) points out examining the majority of the Greek ethnographies it is women who are regarded as complement to men and complementarity does not simply imply equality (Cowan 1990, 11). Recent essays acknowledge the diversity of Greek gender representations and focus on the contextual and performative aspects of gender identity and power relations (Herzfeld 1985; Danforth 1989, 1991; Cowan 1990; Loizos and Papataxiarchis 1991; Dubisch 1995). On this basis, the present work illuminates the male/female performativity and authority within the therapeutic encounter.

9. The witness at an Orthodox wedding.

10. Thrace, in north-eastern Greece, is home to the Muslim minority (116,000 people according to the 2001 census) which consists of 56,000 Turks, 36,000 Pomaks and 24,000 Roms (Markou 2004).

11. Women's relationships have been described in ethnographies concerning Greece as highly significant in their lives given the male domination context (Kennedy 1986; Handman 1995; Kirtsoglou 2004), however in the fieldwork the author did not meet any women who had been accompanied in their therapeutic itineraries by female friends or relatives. Even though patients would often hear about a renowned practitioner or a healer from another woman, and so it would be her who decided on the next type of therapy, in most cases it would be a male family member who would attend and supervise her therapeutic quest. Such an absence of a female companion adds to the argument that in the therapeutic arena women are subjected in a dyadic gendered power relation: one emanating from the family and the other from the male care providers.

12. With reference to same-sex asexual relationships in the Greek context, Loizos and Papataxiarchis (1991, 22) have noted that remarkably influential friendships – either among men or women – are developed in contexts where the actors share a common predicament.

13. In her case study of a Sri Lankan woman affected by ‘Pissu’, Amarasingham (1980) notes that the patient and her family did not seem to integrate the different exegesis of illness during their journey through multiple medical systems. The diagnosis remained fluid, in an ongoing process of definition and redefinition of her pathology. In this sense, the patient did not attempt to obtain an over-arching synthesis. The woman's family was not engaged in drawing up an explanatory model that would endure as their single understanding, but were content to draw on a network of possible therapies at different times. A study of Indians in Britain reveals a similar conjunction of multiple interpretations and practices (Bhopal 1986). Barry (2002), in contrast, suggests that some western patients resorting to homeopathic treatment together with other healing practices, appear (at one point in time) to hold a single consistent ideology – rather than multiple ideologies – of health, illness and healing that informs their interactions with these different treatment systems. These differences suggest that there may be a greater openness within societies of pluralistic cosmologies such as those of India and Sri Lanka to combining multiple ideologies than in western, dualistic, monotheistic and Christian societies.

14. Kleinman (1977), who introduced the notion of explanatory models, has stressed that explanatory models are not fixed entities but are often a state of dynamic interaction created in part by the movement of patients from one system of explanation to another.

15. This explains why Theodora asked not to reveal to her doctor what she had narrated to the ethnographer: she was sure that he was going to prescribe more tablets for her.

16. Within the Orthodox Church, sin is not a stain on the soul, but rather a mistake that needs to correction through confession. This ‘missing target’, which is the literal meaning of the sin (amartia) in Greek, is represented as an intrusion of the evil in the originally pure soul (Plexoussaki 1992). All sinful acts are potentially venial as there is no formal distinction amongst different types of sin (original, venial, mortal) as in the Catholic Church (Ware 1963).

17. In general practice, the Orthodox Christian chooses an individual to trust as his or her spiritual guide. In most cases, this is the parish priest but it could also be someone monastic well-known for his advancement in spiritual life, and usually called gerondas (elder). This person is often referred to as their ‘spiritual father’, pnevmatikos. Once chosen, the individual turns to his spiritual guide for advice and confession of their sins. Confession does not take place in a confessional but in the church, usually before the analogio, the lectern, set up near the iconostasio. After confession, the priest covers the head of the person with his stole and reads the Prayer of Absolution, asking God to forgive him. It is believed that confession is not made to the priest but to Christ and the priest stands only as witness and guide. Confession is required before receiving Holy Communion and at the end of the fasting periods.