Women and Depression

Antecedents, Consequences, and Interventions

Peter Horvath

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317993957
• Edition: 1
• Topic: Medicina
• Subtopic: Prestazione di assistenza sanitaria

The purpose of this book is to present a spectrum of women's experiences with depression. The book is unique in presenting both qualitative and quantitative studies on various stages of women's experiences with depression including its psychological and social antecedents, its adverse consequences, and the impact of psychological and community interventions. Our aim has been to present some of the recurrent themes and vital links in this chain of experiences. One such common theme has to do with the importance of acquiring and maintaining control over the evaluation of self-worth by the individual. Stressful circumstances and negative social encounters may produce the greatest harm and consequent depression by depriving individuals' control over the processes involved in the evaluation of self-worth.

This book will be of interest to clinical psychologists, counsellors, psychiatrists, mental health practitioners and community service providers.

This book was published as a special issue of the Journal of Prevention and Intervention in the Community.

Self-Silencing, Anger and Depressive Symptoms in Women: Implications for Prevention and Intervention

Josephine Tan, PhD

Brooke Carfagnini, MA

INTRODUCTION

The predominance of women among the depressed (Bebbington, 1996; Benazzi, 2000) has generated several explanations to account for the sex differential. One of the more recent explanations is the silencing the self theory (STS; Jack, 1991) which postulates that more women than men are depressed because of their greater tendency to self-silence in intimate relationships in order to preserve harmony and the relationship and to adhere to the traditional female role. Self-silencing, which involves the concealment of one's true feelings from others, can lead to a sense of divided self wherein the compliant self that is presented on the outside is incongruent with the personal feelings on the inside. The sense of divided self might be accompanied by feelings of anger and self-condemnation that can lead to heightened vulnerability for depression in some women (Jack, 1999). Self-silencing is undertaken to decrease interpersonal conflict in the relationship out of fear of retaliation and to adhere to idealized images of women as loving and responsible for the emotional climate of the relationship (Jack, 1991; Jack & Dill, 1992).

Gender-specific prohibitions against displays of anger and aggression in females further discourage the expression of such feelings (Jack, 1999). Women are socialized to place a strong emphasis on relationships as they are a central component of the female sex role identity and emotional activity. Failure to attain and maintain intimate ties can result in feelings of shame, guilt, and depression (Gilligan, 1993; Jack,1991; Kaplan,1986).

Jack (1991) noted that despite the depressed woman's tendency towards active self-silencing and anger suppression, rage and frustration would sometimes erupt, often inappropriately expressed or displaced towards innocent others such as children. The consequences of such anger expression, including negating responses from a spouse and increased self-condemnation, would tend to further erase hopes for relationship improvement and provide additional impetus for continued self-silencing behaviours, in turn predicting depression vulnerability.

Although research on Jack's model is relatively limited, the results show some support. Greater self-silencing in women has been found to relate to greater depression (Cramer, Gallant, & Langlois, 2005; Jack & Dill,1992; Page, Stevens, & Galvin, 1996; Thompson, Whiffen, & Aube, 2001), less marital satisfaction (Thompson, 1995), and greater perception of marital partner as critical or intolerant (Thompson et al., 2001). A mixed-sex study reported that greater self-silencing was correlated with greater fear of anger expression and with greater anger suppression and that previously-depressed individuals self-silenced more than the never-depressed (Brody, Hagga, Kirk, & Solomon, 1999). Self-concealment which reflects a tendency to hide distressing personal information from others (Kelly & Achter, 1995) was shown to mediate the link between self-silencing and depression (Cramer et al., 2005). Finally, feminine sex role type was found to be positively correlated with anger suppression, which in turn was reported to be the best predictor of high depressive symptoms (Kopper & Epperson, 1996).

Furthering our understanding of the psychological factors that are associated with depression in women has implications for addressing a wide-spread health problem in the community. Depression is the most common mental disorder (Desjarlais, Eisenberg, Good, & Kleinman, 1995) and strikes1out of every 5 women (Kessler et al., 1994). It occurs more frequently in women than in men, regardless whether it is indexed by elevated depressive symptoms or diagnosed clinical disorder (Nolen-Hoeksema, 1995). Le, MuZoz, Ippen, and Stoddard (2003) noted the importance for mental health initiatives to go beyond treatment and argued for a national priority to be placed on the prevention of depression in women. Others have called for prevention efforts to focus on subclinical depression or elevated depressive symptoms (Clarke, DeBar, Lynch, & Wisdom, 2003; Gillam, 2003; Parks & Herman, 2003) because it presents a risk factor for major depression (Clarke et al., 1995, 2001). As well, the psychosocial impairment associated with elevated depressive symptoms has been reported to be nearly comparable to that associated with clinical depression (Gotlib, Lewinsohn, & Seeley, 1995).

Following the same argument that subclinical depression warrants attention, the present study examined Jack's silencing the self theory with a group of women who presented with varying severity of depressive symptoms in order to determine the role of self-silencing in intimate relationships, anger expression and anger suppression in predicting the severity of depressive symptoms. In addition, the presence of strong social and cultural components in self-silencing would lend itself to community prevention and intervention approaches. It was expected that higher depression severity would be predicted by greater self-silencing, anger expression and anger suppression. Additional analyses were also performed on two sub-samples, high depression and low depression groups that were derived from the full sample to assess for differences in self-silencing, anger expression and anger suppression between women with no depression and those with elevated depressive symptoms.

METHOD

Participants

Out of the 60 questionnaires that were mailed to women who responded to recruitment efforts, 57 were completed and returned, yielding a 95% response rate. Responses from one woman were excluded from the data analysis because she suffered from a neurological medical condition that might contribute to her depressive symptoms. The final sample for the study consisted of 56 women (age M = 36.34 years, SD = 11.09) who were currently living with an intimate partner, and were free of chronic physical or neuropsychological problems that could contribute to their depression symptoms. Seventeen women were in treatment for depression. With the exception of three Asian women, all participants were Caucasians which approximates the ethnic ratio of Asian: Caucasian residents in the community from which the sample was drawn. The depression severity, as measured with the Beck Depression Inventory-II (BDI-II, Beck, Steer, & Brown, 1996), ranged from 0 to 39 (M = 12.93, SD = 10.19) in the sample.

Measures

Beck Depression Inventory-II (BDI-II; Beck et al., 1996). The BDI-II is a widely used measure of current depression severity. Its 21 items reflect the DSM-IV-TR (American Psychiatric Association, 2000) criteria of behavioural, cognitive, and somatic-vegetative symptoms that are responded to on a severity scale ranging from 0 to 3. The range of possible scores is 0 to 63 with higher numbers indicating greater severity of depressive symptoms. The interpretive guidelines for the BDI-II for patients with major depression are 0–13 (minimal depression), 14–19 (mild depression), 20–28 (moderate depression), and 29–63 (severe depression). Lower cut-off threshold is recommended to detect depression and minimize the number of false negatives (Beck et al., 1996). The BDI-II has been shown to have excellent psychometric properties in research with psychiatric and nonpsychiatric populations (Beck, Steer, & Garbin, 1988). The internal consistency of the BDI-II in the present study was .92.

Silencing the Self Scale (STSS; Jack, 1991).This 31-item scale uses a 5-pointresponsescale (1 = strongly disagree, 5 = strongly agree) tomeasure beliefs and behaviours about self-expression within one's intimate relationship. It yields a global self-silencing score that ranges from 31 to 155 with higher scores indicating greater self-silencing. The STSS has good internal consistency ranging from .86 to .94 (Jack & Dill, 1992; Smolak & Munstertieger, 2002; Thompson, 1995) and good construct validity and test-retest reliability (Jack & Dill, 1992). It has four subscales that are based on the themes of self-silencing derived from Jack's (1991) work with depressed women. The Externalized Self-Perception subscale which contains six items reflects the degree to which one judges the self by external standards. The Care as Self-Sacrifice subscale has nine items and assesses the degree to which one puts the needs of others before the self. The Silencing the Self subscale is composed of nine items and looks at the degree to which one inhibits self-expression and action to avoid conflict, possible loss, and retaliation from others. Finally, the Divided Self subscale has seven items and examines the degree to which one presents an outer compliant self that does not express internal authentic thoughts and feelings. In the present study, the Cronbach's alpha was .92 for the STSS full scale, .77 for the Externalized Self-Perception subscale, .73 for the Care as Self-Sacrifice subscale, .89 for the Silencing the Self subscale, and .86 for the Divided Self subscale.

State-Trait Anger Expression Inventory-2 (STAXI-2; Spielberger, 1999). The STAXI-2 was designed to provide a measurement of the experience, control, and expression of anger. It yields a total of six scales of which two are relevant to the present study. The Anger Expression-Out scale (AX-O) has eight items with possible scores ranging from 8 to 32 and assesses the frequency that angry feelings are expressed in verbally or physically aggressive behaviour. The Anger Expression-In scale (AX-I) similarly is composed of eight items with possible scores ranging from 8 to 32 and measures how often angry feelings are felt but not expressed. Items on both the AX-O and AX-I scales are responded to on a 4-point scale that ranges from 1 (almost never) to 4 (almost always). In the present study, the Cronbach's alpha was computed to be .83 for AX-O and .75 for AX-I.

Procedure

Recruitment for this study was conducted as part of the recruitment efforts for a larger project that looked at the meanings that men and women ascribe to the act of self-silencing. Participants were recruited from several health care sources and the general community through advertisements in the media (newspapers, television), and posters posted in public areas and health care facilities. The present study was promoted as a research project that examines psychological functioning and perception of selves within intimate relationships. Those who responded to the recruitments efforts were given information about the study and its procedure. A copy of the research questionnaire was then mailed out to each of them with instructions to complete and return it with in one week of receipt. The study was conducted in strict adherence to the Tri-Council Research Ethics guidelines.

Design and Analysis

The main analyses conducted on the full sample consisted of correlational analysis to determine associations among the measures, and stepwise regression techniqu...