Life stories of depressed adult women in peri-urban Namibia

The problems women in peri-urban Namibia are faced with are multi-dimensional. Like women in other communities they face the pressure of having a number of responsibilities, namely working, being a wife and mother, taking care of their families and perhaps caring for aging parents. Sometimes the pressure can be too overwhelming to manage. As a result, many women become depressed. Studies on depression among black African women in Namibia could not be traced. It was therefore considered to find out how women suffering from depression from this part of the world tell their life stories. The purpose of the study was two-fold: Firstly, to explore and describe the life stories of depressed adult women in peri-urban Namibia, and secondly to use the information obtained to describe guidelines for psychiatric nurses working with these patients at psychiatric outpatient clinics as well as in the community. A qualitative phenomenological research design of an explorative, descriptive and contextual nature was used. The researcher approached the subjects and their experiences with an open mind. Ten depressed adult women between 21-55 years were involved in the research. The researcher strived to adhere to the principles of trustworthiness. To ensure this Guba's model (in Krefting, 1991: 217) of trustworthiness was adopted. All the interviews were analysed following Tesch's method (Creswell, 1994: 154-55). The services of an independent coder were obtained. The results indicated that impaired interpersonal interactions and stressful life events have a negative influence on the daily life of women leading to the development of depressive symptoms. Guidelines to support psychiatric nurses working with depressed women were drawn up.

Die doel van h ierd ie studie was tweeledig: Eerstens om die lewensverhale van depressiew e volw asse vroue in buitestedelike gebiede in Namibië te verken en te beskryf en tweedens om die inligting wat verkry is te gebruik om rig ly n e te b esk ry f vir p sig ia trie se v erp leeg k u n d ig es wat m et hierdie pasiënte werk by klinieke vir psigiatriese buitepasiënte asook in die gemeenskap.

Introduction
During 1996 (January-December) a total of 403 female psychiatric patients were admitted to Oshakati Hospital Psychiatric Unit in Namibia (Female Admissions' Register, Oshakati Psychiatric Unit, 1996-1997).Health workers at this unit reported that the problem was more common among females between 21 and 55 years of age.During the same period a high su icid e rate w as com m on in this population although the latter affected both males and females.Depression was often reported being the outstanding clinical manifestation among patients with suicidal tendencies.Community members expressed their concern about the suicide rates.Little was being done locally to elicit answers to their questions regarding the disorder.
The state of mental health problems in the region was ch a rac te rised by inadequate m ental health facilities, insufficient mental health personnel like psychiatrists, psychiatric nurses, social workers and clinical psychologists, as well as a lack o f interest and a negative attitude towards mental illness among some of the health personnel.
The focus o f this study w as on depressed adult women between 21-55 years.T his age g ro u p was chosen because of a number of major life changes taking place during this period.Some of these major changes include: experience of a m ajor cri sis related to m arital problems, job changes, assumptions of major social roles and the evolution of an adult self during early and middle adulthood.During m iddle adulthood important gender changes occur.As the women approach the age o f 50, they clearly define what they want from their work, fam ily and leisure.However, sometimes a lack of freedom in life-style, rigidly established social rules and a sense o f entrapm ent m ay lead to depression and a loss of confidence.
The following questions arose: • What a_re the life stories of depressed adult women?• How do they write and rewrite the stories of their life?• How can the obtained information be utilised to describe guidelines to develop a mental health education program to support these women?
The purpose of this study was twofold: • Exploration and description of the life stories o f depressed adult women.• Description of guidelines for the compilation of a mental health education support program for psychiatric nurses to assist depressed adult women in mobilising their resources to facilitate the promotion, maintenance and restoration of their mental health as an integral part of health.

Research design
A qualitative, explorative, descriptive and contextual research design (Mouton & Marais, 1989:45;Mouton, 1996:103-169) was utilised to conduct this research.The aim was to explore the life stories of adult depressed women that would enhance the understanding of how these women tell their life stories.This understanding formed the basis of the description of guidelines to develop a mental health education program to support these women.

Research method
This research was conducted in two phases: P hase One: The ex p lo ra tio n and description of the patterns in the life stories of depressed adult women.A nonp ro b ab ility , p u rposive, co n v en ien t m ethod was used to select ten participants (Creswell, 1994:15).Data g ath erin g included in -d ep th p h en o m en o lo g ical a u d io tap e d interviews, field notes and the use of communication techniques (Kvale, 1983: 171-196;Omery, 1983: 49-63).The interviews focused on the life stories of the specific participants.One central question was posed namely: "Tell me your life story".The interviewer created a context were the participants could speak freely and openly by utilising com m unication techniqu es such as c la rify in g , p ro b in g , p arap h ra sin g , summarising, reflecting as well as minimal response.During the interview s the interview er used bracketing (putting preconceived ideas aside and intuiting (focusing on the life stories o f the particip an ts regarding dep ressio n ).Interviews were conducted until the data w ere saturated as dem onstrated by repeating themes.The interviewer wrote field notes based on observations during the interviews.Data were analysed using Tesch's descriptive method (Creswell, 1994:154-155).
After a consensus discussion between the in d ep en d en t co d er and the researcher, the identified themes were presented.A literature control was done to verify the results.
Phase Two: Guidelines were drawn up to develop a mental health education support program for psychiatric nurses to assist depressed adult wom en in mobilising their resources to facilitate the promotion, maintenance and restoration of their mental health as an integral part of health.
The data collected from participants were used as a basis for d e sc rib in g the guidelines.A literature control was done and the guidelines were discussed with p sy chiatric nurses to ascertain the practical applicability thereof in practice.
A c tiv ities in achieving credibility were prolonged and varied field experience, time sampling, reflexivity, member checking, peer examination, interview technique, establishing the authority of the researcher and structural coh eren ce w ere em ployed.Transferability was obtained by using a purposeful sample working contextually and using dense d escrip tio n s.Dependability was achieved by doing a dependability audit, providing a dense description of research methods (data g ath erin g , data an aly sis and interpretation).C onfirm ability was achieved by ensuring an audit of the entire research process, reflexive analysis and triangulation.

Ethical measures
Ethical measures were adhered to during the research process.These include inform ed co n sen t o f p artic ip a n ts ensuring confidentiality and anonymity and competence of the researcher and the researcher-interviewee relationship (South African Nursing Association, 1998:5).

Results
The tw o m ajor them es as w ell as categories and sub-categories were id en tified from the life stories as verbalised by the participants:

Impaired interpersonal interactions
Poor interpersonal relationships related to impaired communication as evidenced by the following relationships: Marital Partnerships Family, friends and others.

Stressful life events
L ack o f perso n al w orth related to disempowerment as evidenced by: Deprivation of personal freedom Inability to bear children Inadequate emotional, financial and material support Emotional, spiritual and physical distress Loosing control.
These themes will now be discussed and supported by direct quotes from the depressed women and the literature control (Shifiona, 1998:39-67).

Impaired interpersonal interaction
Impaired interpersonal interaction made the daily lifestyle of depressed women difficult and at times intolerable.These wom en suffered varying degrees of impaired feelings in their daily lives, including unhappiness, w ithdraw al, loneliness, uselessness, hopelessness, emotional pain, anger and frustration (Moreau, 2004:187-190).

Poor interpersonal relationships related to im paired com m unication with a spouse
Participants indicated severe relationship problems experienced during married life.
Im paired com m unication had been observed as a stumbling block between them and their spouses.This is evident from the following statements: "...my own husband is the source o f my problems, we d o n 't understand each other at a l l ... ".
Another participant experienced it as follows: " When I came back home I found another woman in the house.What came to my mind was that probably she is visiting because I did not know her.To my greatest shock and disappointment I was told that she will be a second wife whether I like it or n o t".
H eifner (1996:5) describes wom en's depression in relation to ordinary, daily life issues like the burdens of marriage and child rearing which falls much more heavily on w om en.This type o f re la tio n sh ip co n trib u tes to wom en becoming more submissive to a dominant other, especially the spouse, leading to increased feelings of helplessness and h o p elessn ess.In the absence o f a positive or more promising relationship between two partners, it becomes very difficult for spouses, families and friends to understand depression and to realise its impact on an individual.
In relationships, often attending to the needs of others at their own expense.In unequal dom estic relationships, the women's attempts to grow, succeed and excel are perceived by the man as an attempt to demean him, and ultimately leave him.In order to protect and nurture the man she loves, the woman must ignore, deny and even acts against her own needs.This eventually results in anger and frustration which is again suppressed by the particular woman (Weingourt, 1996: 17) Obviously all these women were alone in their fragile relationships.Any strain in this kind of relationship may result in inability to care for a person's physical and emotional needs resulting in stress.Feelings of neglect, hurt, bitterness and unfairness were common among these w om en.P ro lo nged d isru p tiv e relationships lead to anxiety, and if it remains unsolved, it will eventually result in depressive episodes.
Poor interpersonal relationships related to impaired com m unication with the fam ily, friends and others Some p articip an ts attrib u ted th eir problems to a poor understanding of their condition by the people whom they live with.The latter is supported by the following extract: "... my brothers-andsisters-in-law kept on gossiping about me, laughing and swearing at me ... ".One participant's parents refused to offer support to further her studies, because they believed that paying her school fees w ill be a w aste o f m oney.As this participant put it: " ... fees will not be paid, because I will not manage at school, being mad .... " The participant felt demoralised by her parents' negative attitude.Her uniqueness and capabilities were not considered at all.This made her feel small and worthless with a low self esteem.Warren (1997:109) explains it further by saying that persons with low self-esteem view themselves as deficient and inadequate, although it is unclear if low self-esteem is a causal factor or a symptom of depression.It should be noted that in relationships that are d isin te g ratin g , there is usually a mounting level of anxiety that is shared by the person and significant othersfam ily m em bers, friends and others (Beeber, 1996:154-155).
As in terp erso n al re la tio n sh ip s are regarded as co n n ections betw een people, its absence leads to poor interpersonal relations as experienced by almost all the women in this study.

Stressful life events
All the participants have gone through one or more stressful life event.Warren (1997: 109) describes how continued bom bardm ent o f stress may alter a woman's cognitive appraisal ability so that she view each life event as being harmful or threatening and not a challenge she can manage.Categories discussed here are: L a ck o f p e rso n a l w orth related to disempowerment as evidenced in the deprivation o f personal freedom Powerlessness, a universal symptom experienced by depressed women, is related to the disruption o f the self system and -control in the face of external or internal stressors.Loss of personal power is usually a precursor to feelings of hopelessness, helplessness and despair experienced by a depressed woman.Some women felt that being sick had evoked in them feelings of being stripped of their own dignity, autonomy and personal worth.One woman described it as follows: "Lining up forfood and medications was an extremely humiliating and painful experience fo r me ".
Another participant commented on the labelling process: "..

. mad/crazy people
The participants felt that this attitude was humiliating and deprived them from their perso nal freedom and value as individuals.They believed their personal worth was not respected at all.

L a c k o f p e rso n a l w orth rela ted to disempowerment as evidenced in the inability to bear children One participant revealed how she was suffering the hum iliation because of inferiority. " I could unfortunately not bear my own children, culturally as soon as you fa il to fa ll pregnant, then you are nothing ... I live under p re ssu re fro m my husband, in-laws and neighbours. My husband has now extra-marital affairs and I am not allowed to utter a word on his behaviour".
Another woman stated: " I 'm told without a child I 'm nothing".This is supported in the literature.Atwood and Dobkin (1992:389) state that the major emotional toll is a deep sense of loss.Some women related the loss o f self-esteem and personal worth to failure in becoming pregnant.The participant further stated that the future looked bleak and she saw no reason to continue w ith such a relationship or to be alive.

L ack o f personal worth as related to d ise m p o w e rm e n t as ev id e n ced in inadequate emotional, fin a n cia l and material support
The absence of emotional as well as financial support was raised by most participants during the interview.One woman said: ".. .hewas not just there f o r us, we n eeded his su p p o rt so much... ".Another woman said: '7 struggle alone with my child, but I did not have courage to report him fo r support...".These wom en were sim ultaneously burdened by suffering and tim econstrained by the activities of their daily lives.The resources to support them were curtailed or non-existent.Absence of support had led to an insecure lifestyle as most of them expressed uncertainty about their own personal worth and future.

Lack o f personal worth as related to d ise m p o w e rm e n t as e v id e n c e d in em o tio n a l, sp iritu a l a n d p h y s ic a l distress
P a rticip an ts rep o rted a v arie ty o f emotional and spiritual experiences as they went through depressive episodes.They lived their lives with a sense of dissatisfaction, little understanding and a degree of chronic unhappiness.One woman expressed it as follows: "..

. I did not know what was wrong with me, my relatives told me that I 'm sick, uuh! I fe lt bad, you know! "
Depressed women share a sense of being incomplete and unintegrated as though something of them was missing.They live in conflicting relationships and are in conflict with themselves as they try to live out the expectations they perceive o th ers have o f them .O ne w om an described it as follows: "Our relationship was heartbreaking, was m arked by unhappiness everyday, but because I love this man, I did not want to leave him." This is supported in literature by Schreiber (1996:166) that the women's d ecisio n s w ere based on a narrow understanding of their lives and their relationships.The following feelings were common: o bitterness and blame They blamed them selves about their inability to fall pregnant and their inability to bring about changes w ith in the relationship from a negative to a positive and acceptable one.(1995:61) an experience of shame is isolating, highly personal and results in feelings of loss of control, inferiority, abandonment and rejection.What is exposed in shame is oneself, namely "I am ashamed of what I am".Participants were also complaining about a number of physical distress symptoms such as dizziness, loss of appetite, headache and lack of energy.These sym ptom s w ere a reflection o f the condition they were suffering from.

Lack o f personal worth as related to d ise m p o w e rm e n t as ev id e n ced in loosing control
A woman in this phase of her depressive exp erien ce is in a crisis situation, confronting her depression.Many of them spoke about being in a "dark cloud".One woman said: '7 have been covered by dark shadow, I did not know where I was and one day I decided to hang myself because my future was just dark".At this stage the woman may feel that she has got no future.It is a terrifying experience for the woman and the fear she experiences when thinking about these heavy clouds leaves her in despair and apprehension.Jambunathan (1996:28) concludes that depressed women at this stage have no confidence, no feelings of self-esteem, pride or personal worth.This is the time when they develop suicidal thoughts.According to Moreau (2004:187) nearly " 15% o f p atien ts w ith un treated depression commit suicide".Guidelines fo r p sy ch iatric nurses assistin g depressed women are thus a necessity.

Guidelines for psychiatric nurses
The guidelines are based on the themes identified from the phenomenological interviews and observations of depressed adult women.Impaired interaction and stressfu l life events w hich are experienced by depressed women, form the basis of these guidelines.
The following guidelines are suggested for use by psychiatric nurses in assisting depressed wom en in their quest for mental health and wholeness.
The appropriate strategy for improving the situation is for psychiatric nurses to make use of the psycho-educational approach when addressing the problem.The term "psycho-education" refers to the train in g o f in d iv id u als in psychological know ledge or skills, therefore a psycho-educational program will be useful to depressed women.
A ccording to M aynard (1993:9) a psycho-educational group program p rovides a m ore com prehensive intervention framework for women who are depressed.The emphasis is placed on addressing issues such as changing co g n itiv e p attern s, im proving interpersonal communication as well as increasing self-esteem.Knowledge and skills are taught through this program that can prevent depressive symptoms from becom ing severe enough to require hospitalisation.For those who have been in hospital the group provides outpatient support and assistance to help prevent or reduce recidivism.In the psychoeducational model, providing information and skills training are the major helping functions.The aim is to assist depressed women towards autonomous functions.

Framework of a psychoeducational program
This program includes the following: group form at; psychiatric nurse and psycho-education groups and psychoeducational content.

Group format
The group format entails a small group consisting o f eight to ten depressed women.This group will allow discussion of issues such as anger, abandonment, rejection and dependency as experienced within relationships.The group provides positive identification with other women, increased realistic self-assessment and feelings of empowerment, and ultimately improved heterogeneous relationships.W ithin the group, depressed women provide feedback to each other leading to a built-in support system.

Psychiatric nurse and psycho-educational groups
The objectives of the group includes the following: to emphasise the importance of social factors in the development of depression; to supply information related to the development and symptoms of depression; to help depressed women identify self-defeating thoughts and replace them with positive ones; to help women develop assertiveness and coping skills; and to teach methods to increase self-esteem in depressed women.

Psycho-educational content (see figure 1)
Participation by depressed women in this intervention strategy will therefore improve feelings of security, self-reliance, self-esteem , independence and selfrespect.Psychiatric nurses should make themselves available after the termination of the last session should the group req u ire fu rth er d iscu ssio n s on an individual basis.Group members can share co n flic t m anagem ent, stress management and assertive skills with the psychiatric nurse, which will ultimately help them deal with difficulties in their relationships.

• Provide strategies to deal with stressful life events
The focus should be on empowering depressed women to maintain patterns that would support growth and to change patterns that would create problems in their daily lives.Empowerment will enable depressed women to make choices in their lives.Women should be assisted to establish support groups which will provide a venue for them to explore their feelings and to learn what others consider as normal.Patient education brochures on various topics related to depression should be m ade available to them .Psychiatric nurses should assist women in build in g co n fid en ce through counselling on an individual or group basis.
Financial and material distress could be

Conclusions, limitations and recommendations
In conclusion the study revealed factors within women's daily lives which were regarded as core to the main problems.
These predisposing factors include, among others, unfaithful partners, poor understanding of the woman's condition, disappointing relationships, unsympa thetic family members, neighbours and friends as well as disconnected family relationships.High demands are imposed on the women with little recognition.
It is therefore incum bent upon the psy ch iatric nurse to bew are o f the presence of the negative factors and its impact on the mental health of women and to assist women in mobilising their resources in promoting, maintaining and restoring their mental health as an integral part of health.The guidelines suggested here are intended to empower psychiatric nurses and others who come into contact w ith this target group, w ith the necessary knowledge and skills.
Limitations of this study include that interviews could not be conducted in participants' homes as planned because of transport problems and long distances between the clinic and p articipants' homes.Member checking with all the participants was also impossible because all of them could not be reached because of the problem stated above.With the exception of two interviews, all other in terv iew s w ere co n d u cted in the vernacular (O shiw am bo).Since this study was conducted in the vernacular it was necessary to translate the data into English.This translation might have resulted in loosing or distorting the originality of the participants' everyday liv es as expressed in the o rig in al Recommendations are made with specific reference to psychiatric nursing practice, p sy c h ia tric nu rsin g ed u catio n and further nursing research.

• Psychiatric nursing practice
It is clear from the research results that d ep ressed ad u lt w om en re q u ire professional help and support in dealing with their experiences of depression.Psychiatric nurses should be involved in co u n se llin g sessions to assist d ep ressed w om en.C om m unity resources such as churches need to be m o b ilised so th at they could o ffer a ssista n c e th rough co u n se llin g depressed women.

• Psychiatric nursing education
The g u id elin es generated from the findings can be considered in designing in-service education programs for all health workers and curricula for the training of psychiatric nurses at under and post-graduate level.

Psychiatric nursing research
The results o f the research conducted should be disseminated to all psychiatric nurses.F u rther research need to be co n d u cted to assess w h eth er the guidelines provided in this study were effective in improving the patterns of interactions between the internal and ex ternal en v iro n m en t o f depressed women.
an o th er study on abusive relatio n sh ip s W eingourt (1996:16) concludes that wom en assum e full re sp o n sib ility for the caring in 7 Curationis May 2006

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sadness and hurt One woman said: " I felt hurt and very angry.I was betrayed and being used by this man ". o defeat and helplessness One participant said: " / tried to confront him about his behaviour, but he does not want to listen to me, instead he beats me up severely o anxiety and worry Depressed women experience anxiety about their condition as well as what the future held for them.One woman stated: "Now I am sick, I am not employed, the support I am getting is not sufficient, my future looks dark o shame and being stigmatised Depressed women feel ashamed about themselves and the stigma attached to them as individuals.One woman explained it as follow s: '7 did not w ant m y co llea g u es to know that I am d ep re sse d ".A ccording to Younger only the main themes, c a te g o ries and su b categ o ries w ere translated.

Poor interpersonal relationships related to im paired com m unication with a partner
A nother p artic ip a n t describ ed the relationship as disappointing: " ... he dissociate himself from us, was not just there, I was very unhappy, frustration and anger were my main problems... ".