The busy provider, hustling through a day packed
with sick patients and interspersed with physicals on
well children and adults, has her doubts about all this.
For many, taking care of ill people and performing
well care with the requisite attention to preventive
counseling and screening, and doing this well, is
more than a day’s work. Nonetheless, it is also true
that when practitioners enter the exam room and ask
“how are you?” they begin the process of providing
good psychosocial care.
The principles of good psychosocial care are both
simple and complex. A caring, attentive ear that
remains alert to the woman’s own understanding of
her life in relation to self, to others, and to the systems
and institutions that comprise her life is a beginning.
Fueled by genuine interest and curiosity, good psychosocial
care has, at its heart, a deep and abiding respect
for women and their enormous strengths and vulnerabilities.
It is dependent upon relationship; that exists
and is developing each moment of an encounter. For
most providers, this is knowledge acquired over time,
both in the general sense and in the specific.
The broader culture has not inculcated providers with
a sense of deep respect for women.
The broader culture has not inculcated providers
with a sense of deep respect for women. Many come
to the practice of medicine with biases and stereotypes
about the roles and capabilities of women. Even if providers are raised in families with positive messages
about women, popular culture has muddled that
message to some extent.
Good psychosocial care of women respects relationships
as fundamental and is capable of viewing
the world through relational lenses. It avoids judgment
and labeling and is willing to accept a world
view different from one’s own. It demands some
fearlessness about feeling and asks for, at times,
reconsideration of the more traditional medical rules
about boundaries. It may, at times, call for emotional
investment on a provider’s part and remains open to
that possibility. Nonetheless, thoughtful psychosocial
care fully respects appropriate boundaries.
Good psychosocial care is sensitive to the
dilemmas faced by women in the culture and does
not trivialize them. Respect for the burdens placed by
assumptions and prescribed roles that have oppressed
women is critical.
Good psychosocial care does not fail to acknowledge
these hard realities and appreciate the power
of them, and it does not shirk from addressing
them. It respects the enormous diversity of women’s
lives and does not make assumptions of normalcy.
It remains sensitive to the dilemmas faced by
women within the medical culture and seeks to
improve upon them.
If the relational model is used to consider health
care, the major risk factors threatening psychosocial
health become more apparent. Those events and
influences that lead to major disconnection will be
the most likely to disturb the well-being of an individual
woman. The potential dislocations that occur
as a result of social change, coupled with the significant
mobility of the culture provide enormous opportunity
and potential for major disconnection.
Disconnections such as death (particularly of a
child), job loss, divorce, partnership dissolutions,
domestic violence, trauma, or illness may seriously
threaten a woman’s sense of her self and her world.
Women remain particularly at risk for economic
dislocation, whether by earning less then men for
equivalent work, or through divorce, partnership dissolution,
or spousal death. Psychological and biological
health are all at substantial risk during such times when
a woman’s sense of control over her environment and
life is seriously threatened. Her ability to process, grieve,
and ultimately grow through such events is predicated
upon her own internal and external support systems
that may facilitate, or may threaten, her survival.
The potential dislocations that occur as a result of
social change, coupled with the significant mobility
of the culture provide enormous opportunity and
potential for major disconnection. Women remain
particularly at risk for economic dislocation, whether
by earning less then men for equivalent work, or
through divorce, partnership dissolution, or spousal
death.
A helpful model for considering the coping styles
of women facing major disconnections is that of
resiliency, the ability to rebound from adversity.
Wolin and Wolin have described seven features of
the resilient individual from their work with survivors
of troubled families (Table 5.2).6 These features will
cluster in varied fashion depending on the personality
and circumstances of the loss or disconnection faced,
and a given woman may utilize one or several of these
qualities in coping. For the provider, assessment of
the ability and diversity of such strategies may highlight
risks and illuminate strengths, while suggesting
other potential strategies for improved coping.
Knowledge of the individual, her experience with
previous coping strategies that were successful or not,
and awareness of the presence or absence of support
may all serve to help the provider care for and work
with an ill woman. A past experience of acceptance by
a provider is very powerful. Knowledge that she will
be accepted for her coping strategy and heard
empathically rather than lectured to about what she
“should” do is powerful.
Well-meaning friends and cultural mores often
dictate to women how they should cope or grieve.
Mores about acceptable grief, whether temporal
or topical, often tyrannize women. A climate of acceptance, a sense that she is right to do it her way, in
her own time is very powerful. Avoiding a tendency
to immediately medicate signs and symptoms of psychological
distress may also be valuable and appropriate.
Many women will benefit from a steadying hand
from their provider rather than a prescription.
Avoiding a tendency to immediately medicate signs
and symptoms of psychological distress may also be
valuable and appropriate. Yet, the provider need also
exercise caution about minimizing and downplaying
distress.
Yet, the provider should exercise caution about
minimizing and downplaying distress. Supporting
women through periods of reactive depression, overwhelming
grief, and intense feeling without judging
or pathologizing can be among the most important
and powerful clinical interventions practitioners will
ever perform.
Nonetheless, there are circumstances when prescriptions,
active interventions, and referrals are absolutely
necessary. The clinical judgment of the provider
must always be alert for the signs and symptoms of
major depression, suicidality, and life threatening
behaviors. In fact, an environment of trust and relationship
improves the likelihood that dangerous disconnections
will be more readily identified by the
provider and interventions more readily accepted.
Many women have had their feelings and concerns
minimized in the medical setting. Some arrive
to these environments primed to be ignored or to
have their feelings discounted. Lesbian women and
women of color have often been the victims of
insensitive and irrelevant care. Women are much
more likely than men to have had their behavior
and symptoms labeled. Providers who are inclined
toward curiosity rather than judgment, understanding
instead of diagnosis, and mutuality rather than
strict doctor–patient roles may find they are more
successful at providing good psychosocial care.
