Dukas and Lou-Marié.

Int J Womens Health Wellness 2016, 2:014

Volume 2 | Issue 1

International Journal of
Women’s Health and Wellness
Original Article: Open Access

A Feminist Phenomenological Description of Depression in Low-

income South African Women
Carla Dukas and Lou-Marié Kruger*
Department of Psychology, Stellenbosch University, South Africa

*Corresponding author: Prof. Lou-Marié Kruger, Department of Psychology, Stellenbosch University, Private Bag
X1 Matieland Stellenbosch, 7602 South Africa, Tel: 27-82-4456534, E-mail: [email protected], [email protected]

income, coloured1, blackand Indian mothers are particularly at risk

Abstract
for developing depression [29].
In this feminist phenomenological study rich descriptions of the
subjectively lived experience of depression, as recounted by ten Despite the fact that low-income South African women are
low-income rural women themselves, were provided. Analysis of deemed to be severely at risk for developing mental disorders such
the data obtained through semi-structured interviews, highlighted as depression, they, like low-income women elsewhere, have been
that the depressed women in this community often articulated their largely “shut up and shut out” [31] of mainstream psychological
psychological distress as bodily symptoms. Emotions of anger, research [12,17,32,33]. In particular, qualitative studies in which the
anxiety and hopelessness were also more commonly experienced
subjective experiences of low-income women themselves are fore
and expressed than sadness. The implication is that depression in
some low-income South African women might not always resemble
grounded, are scarce [26,34]. In this feminist phenomenological
traditional, mainstream depictions of the condition, and further, study, the aim was to obtain descriptions of the subjectively lived
that a diagnosis of depression may serve to obscure women’s experience of depression, as recounted by low-income rural women
feelings of anger and anxiety that are intrinsically linked to their themselves.
disadvantageous social and living conditions.
Method
Keywords
Depression, Low-income women, Interpretative phenomenological Feminist phenomenology
analysis Feminism and phenomenology have divergent social and
theoretical roots. However, they are compatible and are thought to
Introduction complement each other in important ways [35,36]. Concerned with
elucidating the purely subjective aspects of conscious experience,
Major depressive disorder is the single most commonly occurring the phenomenological researcher endeavours to provide a rich and
mood disorder in the world [1,2]. It exacts considerable personal and nuanced description of a particular lived experience [37-40]. In
social costs [3,4] and has become one of the largest social and health its broadest sense, feminism can be considered an intellectual and
problems of our time [5]. The burden of depressive disorders (years political movement that is committed to challenging the socially
of good health lost because of disability) has been ranked third in and politically entrenched positions of gender inequality which
the list of mental and physical diseases [6], and it has been projected disempower and subordinate women via traditional practices and
that by 2030, depression will be the number one cause of disability, attitudes [41,42]. While the feminist perspective acknowledges power
ahead of HIV/AIDS, traffic accidents, cardiovascular and chronic differentials and pays close attention to culture, context and language,
pulmonary diseases [7]. the phenomenological perspective is focused on individuals’
The fact that there is a twofold greater prevalence of depressive unique lived experiences. Because feminist phenomenology
illnesses in women than in men is similarly one of the most widely concerns itself with starting from women’s lived experiences while
documented findings in psychiatric epidemiology [8-14]. This gender offering contextually sensitive analyses, it is deemed by some to be
difference is typical of South African populations too [11,15-18]. particularly appropriate for the study of psychological disorders such
as depression [40].
Further, women in low-income communities are more likely
to develop depression than women in middle- and high-income 1 We are mindful of the fact that the use of racial categories in South African
communities [19-22]. Poverty is thought to contribute to depression scholarship is controversial. However, such categories are socially constructed
via its association with low self-esteem and agency, an increased and carry important social meanings. Thus, we believe that it is impossible
to conduct a meaningful analysis of study findings within the context of post-
number of stressful life events and chronic social adversity [11,23]. In apartheid South Africa without making reference to previous racial classifications,
addition, psychological literature suggests that factors such as gender, since these still inform existing power relations. In this paper, then, the category
race, class and motherhood may also increase the risk of depression of “black” will be used to refer to those designated as black under apartheid
racial classification, and the category “coloured” will refer to persons said to be
[16,18,22-30]. In the South African context this means that low- of mixed racial origins.

Citation: Dukas C, Lou-Marié K (2016) A Feminist Phenomenological Description of

Depression in Low-income South African Women. Int J Womens Health Wellness 2:014
ClinMed Received: January 15, 2016: Accepted: February 27, 2016: Published: February 29, 2016
Copyright: © 2016 Dukas C, et al. This is an open-access article distributed under the terms
International Library of the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.
 Table 1: Participants’ demographic information.
Pseudonym Age Ethnicity Relationship status Children (age in years) Persons Rooms in house Highest Employment Income
in house school level status p/m
Anna 27 Coloured Boyfriend of 3 years 1 (9) 8 3 Gr. 11 Sales clerk R2945

(Shares a room with 3

other people)
Chenille 47 Coloured Boyfriend of 6 2 (27 & son, deceased 2 2 Gr. 10 Cashier R1200
months 2005)
(RDP house. Shares a
room with her daughter.)
Christine 27 Coloured Boyfriend of 7 years 3 (11, 6, 9-months) and 8 2 Gr. 8 Farm-labourer R1900
foster child/nephew (5)
(RDP house. Shares
a room with 5 other
people.)
Elizabeth 69 White Single (widower of 3 (33, 36 & son, 1 3 Matric Unemployed R2000
30 years) deceased 1978)
Twela 38 Coloured Boyfriend of 2 years 1 (13) 10 4 Matric Shop R2500
attendant
(Shares a room with her
son.)
Nina 34 Coloured Marital separation 3 (13, 10, 8) 5 3 Gr. 8 Unemployed R0 – +/-
for past 9 months R400
(Sleeps on a couch in
the living room/kitchen.)
Evergreen 51 Coloured Second husband of 2 (24, 30) 2 2 Matric Unemployed R1140
8 years (Disability
(RDP house. Shares a grant)
room with her husband.)
Linkie 27 Coloured Girlfriend of 10 1 (3) 7 4 Matric Unemployed R260 (Child
months support
(Shares a room with 3 grant)
other people.)
Tracey 32 Coloured Single 1 (9), Tracey was 8 8 3 Gr.11 Farm labourer R1200
months pregnant at time
of interview (Shares a room with 4
other people.)
Melissa 36 Black Husband of 15 years 3 (15, 10, 6) 4 2 Gr. 7 Unemployed R800 (of
which R400
(Shares a room with 3 given to her
other people.) mother)
“Rooms in house” indicates the total number of rooms in the house (kitchen, living-room, bedrooms) but excludes the bathroom. All participants had either one
bathroom or an out-house which functioned as such.
All participants had at least one electricity/power point in their home.
All participants cited “Christian” as their religious affiliation. All but three claimed that they were “actively involved” in their local church.

Participant selection The first author of this paper conducted individual, semi-
structured, in-depth interviews with each participant. Each interview
Phenomenological studies usually employ purposive and
lasted between 60 and 180 minutes. The interview schedule was
convenience sampling techniques in order to recruit a closely defined
developed with open-ended questions that allowed participants to
group for whom the research questions will be significant [43]. For
flexibly explore their past and present experiences of depression [46].
the purposes of this research, female patients at a health clinic in a
All interviews were audio recorded and transcribed verbatim.
rural area in the Western Cape of South Africa, who were over the
age of twenty and met the diagnostic criteria for major depression Ethical considerations
[44], and were of low socio-economic status (as defined by the Living
Standards Measure [45], were invited to participate in the study. The This study was approved by the Psychology Department at
first ten women who fulfilled these criteria became participants in Stellenbosch University, the Stellenbosch University Research Ethics
the study after giving informed consent. Potential participants were Committee, and the Health Research Ethics Committee at Tygerberg
assured that they could withdraw from or refuse to participate in the Hospital. All participants gave their informed consent both verbally
study without jeopardizing their routine care and treatment at the and in writing. All location names, participants and persons revealed
clinic. There were no refusals to participate and no one withdrew in their narratives were given pseudonyms, in respect of the ethical
from the study (Table 1). mandates for privacy, anonymity and confidentiality.
Most of the participants were between the ages of twenty-seven Data analysis
and thirty-eight, with the exception of Elizabeth, who was sixty-nine.
One participant was white, one was black, and the other eight were Data were analysed using Interpretative Phenomenological
coloured. Educational levels ranged from the completion of junior Analysis (IPA) as described by Smith and Osborn (2008) [47] and
school to achieving a high school diploma. Four of the women had Smith et al. (2009) [46]. Each transcript was read and reread for
completed high school. Half of the participants were unemployed at familiarization before initial annotations were made. Emerging
the time of the interviews, while the other half were involved in low- themes were then grouped into superordinate themes and
paying and mostly temporary or seasonal employment. Participants corresponding theme clusters before writing up the findings. IPA is
lived in small and simple dwellings. Most of them, like many low- consistent with the feminist phenomenological underpinnings of this
income South Africans, were sharing their homes with as many as study as it considers people as embodied and embedded in specific
ten other people, often including members of their extended families social contexts that have been powerfully influenced by both history
and/or friends. All the women were mothers; each had between one and culture [48].
and three children in her care. Two of the women had lost a son to
illness. All participants cited “Christian” as their religious affiliation, Results and Discussion
and only three were not actively involved in their local church. Five superordinate theme headings emerged from the data:
Interviews 1) Bodily experiences of depression; 2) Emotional experiences of

Dukas and Lou-Marié. Int J Womens Health Wellness 2016, 2:014 • Page 2 of 8 •
depression; 3) Complex processes of coping with depression; 4) It was interesting to observe that having begun talking about their
Subjective beliefs about the factors that cause or exacerbate depression, emotional experiences, the women would often suddenly switch to a
and; 5) Subjective beliefs about the factors that alleviate depression. discussion of their physical maladies.
A number of theme clusters nestled under each superordinate
Interviewer: Can you tell the clinic sisters that you’re sad?
theme and are discussed in the following summary and discussion
of findings. While in our analysis the emphasis was on how ten Christine: No. I just come with a headache problem.
individual women experienced depression, in this paper we focus
Some participants explained that they preferred to report a
on the how the experiences of participants were convergent. Where
physical problem rather than an emotional one:
appropriate, we have commented on divergences of experiences.
Evergreen: Ja. So at times I cry and then he sees and “What’s
Superordinate theme 1: Bodily experiences of depression
wrong with you?”, “No, it’s my knee. My knee pains” - and it’s not
One of the most prominent findings in the study was that all the my knee, you know?
participants experienced and expressed their depressive symptoms
Interviewer: You just pretend it’s something physical?
in bodily (i.e. somatic) terms. When asked questions such as “Do
you think that you are depressed?” or “What does it feel like to be Evergreen: Ja.
depressed?” participants typically first spoke about bodily experiences
Pertinent to the South African context, researchers have
that caused them immense physical and psychological discomfort.
recognized that different population groups experience emotional
Those experiences included disturbed sleeping patterns, fatigue
distress in different ways [12,17,18,49,]. These authors explain that
and bodily pain. Sleep disturbance was immediately and repeatedly
in the context of depression, bodily pain can be considered a physical
equated with depression. Moreover, it was usually the first experience
expression of emotional pain. Thus, pain may symbolically represent
participants chose to speak about.
one’s emotional status, and emotional distress and depression can be
Interviewer: When was the first time that you started to feel experienced and expressed as physical pain [51-53]. Of course, having
depressed? bodily pain might also legitimize a person’s help-seeking behaviour
in a context where many needs compete for limited resources. Also,
Anna: Um, a long time ago, that I feel I’m not myself. I’m not
given the fact that we found that many participants seemed to be
sleeping, um, my, I feel like I’m getting upset for anything… So the
ashamed about their emotional distress (see below), it may also be
doctor told me that he’s going to send me to you, because why, um, I
that an inability for, or social suppression of verbal emotional reaction
don’t sleep so he’s feeling that I am depressed and getting worse, so I
has a direct effect on the production of physical symptoms [54,55].
must see someone.
The women spoke not only of a physical tiredness, but also of
Superordinate theme 2: Emotional experiences of depression
an emotional fatigue. Interestingly, most of the women were more Participants, having explained the physical manifestations of
inclined to say “I am tired” rather than or before saying “I am sad”. depression, would eventually speak about the emotional experience
Tracey: I’m tired of fighting, with my own life. I’m really tired… of depression. Here, anger was usually prioritized:
I’m tired of fighting, about him and this bloody man. [Whispers] I’m Christine: My down days is when I’m angry.
tired… I’m fighting that for four years now. But it don’t want to stop.
I’m now full. I’m tired. I’m tired. Twela: When I’m sad, I get angry.

Ironically and poignantly, Tracey describes her utter sense of Anger emerged as a prominent feature of depression amongst
depletion, as a subjective sense of being “full”. Like Tracey, Evergreen the women who participated in the current study, a finding that was
also does not use the word “sad” or “upset”, even when the interviewer also prominent in other studies conducted by our research group
uses those words. [26,56,57]. While the DSM-5 [44] discusses anger as a possible feature
(not criteria) of depression, it does so with reference to “personality
Interviewer: So he doesn’t really understand your sadness? disturbances” and “cognitive styles” that may account for anger
Evergreen: [Crying] No. In my, um, lounge wall I have all the outbursts and/or depression. No mention is made of justifiable
photos of the children, and I just sit there. anger at the various social contexts and interpersonal conditions
that may logically cause one to feel angry. Unsurprisingly, it is this
Interviewer: [Whispers] You look very upset. individualistic and person-blaming stance of the DSM that is widely
Evergreen: [Whispers, crying] I’m tired. Oh. criticized by feminist scholars [58-60].

The fact that sadness was not directly spoken about is interesting. Other emotions associated with depression in our study were
We wondered whether there was a silent cultural norm that loneliness and anxiety:
disallowed the articulation of sadness. This hypothesis has been Elizabeth: It was now, the thoughts, the thought of loneliness.
explored by Swartz et al. [49] (1998) and Ussher (2013) [50], who Very often because my, my, I feel lonely now, I feel lonely now. Feel
contend that in certain contexts women signal their emotional pain
lonely.
through culturally approved symptoms, which allow their distress
to be considered “real”. In our study, “feeling tired” appeared to Evergreen: ...Because if I get anxious, I talk a lot… I’m scared,
function in this way. most anxious, scared, you know? … You know, because I always
had to be on the lookout, and be on my guard and, something to,
Depression was also associated with a “body full of pain...
something’s going to happen…
everywhere”:
Once again these findings are not unique, as both loneliness and
Elizabeth: My, um, I was still working in the library that Friday.
anxiety as features of depression have been recognized in other South
And I went to my doctor, he was in X-town and I didn’t realize it
African studies [56,57,61-63].
was depression. I thought, I look at people and I had no idea what’s
depression like, and I’ve never, I’ve never could imagine that your Feelings of guilt and shame were also expressed by participants.
whole body is full of pain. You feel like it everywhere, like your - Guilt, listed as a symptom of major depression in DSM-5, can be
Interviewer: Physical pain? defined as a feeling of responsibility or remorse for something, real or
imagined, that one has felt or done Although Twela does not use the
Elizabeth: Ja2, ja, you’ve got pain everywhere… word guilt, in the quote below, she expresses that she feels bad about
2 “Ja” (“yah”) is the Afrikaans word for “yes” and is widely used in everyday South something she is doing and feeling.
African English.

Dukas and Lou-Marié. Int J Womens Health Wellness 2016, 2:014 • Page 3 of 8 •
 Twela: I want to be that patient person, and then they treat me Evergreen: It means that I laugh just to, that people don’t see the
right… Want ek is baie ongeduldig (Because I am very impatient)… hurt. It just covers it up.
Ja, but sometimes I’m very impatient, and that’s my problem.
All the participants appeared to be aware of the social stigma
Shame can be defined in many ways [64], but generally refers to attached to being emotionally distressed and therefore tended to keep
unbearable psychological pain [65] related to perceptions of the self “quiet about my, my darkness” or developed what Evergreen calls “a
as being flawed, inadequate and bad [9]. Nina’s sense that she is “that smiling depression” so “that people don’t see the hurt”. It was clear
nothing” and “a problem for everyone” is an example of how shame that they were ashamed of the emotions associated with depression,
emerged as an important emotion associated with the experience of thus the paradoxical notion of a smiling depression. However, in
depression, even if the word was not used by participants themselves: hiding their feelings, they began to feel even more distressed, alone
and overwhelmed, and thus perpetuated the depressive experience.
Nina: …I’m that “nothing” again. And it’s not like I wants to
be something, but, it’s just… You see, all my life I’m depressed. The women’s emotional experiences of anger (reported above)
Because, I was the one that since the day I was born, I’m a problem were manifested in displays of aggression, swearing and shouting:
for everyone…
Nina: Even, even, I should yell out. I just feel like, if I had the
The shame articulated often was associated with a changed sense power, to hurt him so much that he will never bother me - I just want
of self, a gap between the ideal self and the actual self : to hurt him so much that he never wakes up again... It’s like I want to,
I just want to kill him3…
Tracey: …I want more people to understand what is depression
all about, because at that stage you aren’t yourself. Twela: … And I just… just... aggressive we (aggressive)… Yes. If I
told you to do the thing and you don’t do that, or you make too long,
Anna: I’m not myself anymore.
and I’m just angry and I shout at you, and, and, and… I just get angry
Shame and a “loss” or at least a “changed sense” of self was for every little thing…
commonly reported in this study, as in other similar studies
Anger and aggressive behavior as a prominent manifestation of
conducted by our research team . While these forms of emotional
depression in South African women has been recognized and discussed
distress have been considered by a number of feminist and critical
by other authors [26]. The women, however, did not consider their
writers [66,67], the phenomena of shame and a loss of sense of self
anger to be an ego-syntonic emotion, and the experience thereof
seem to be disregarded in mainstream diagnostic manuals (with the
consequently caused them to feel even more distressed:
exception of “dissociation” proper). We have argued elsewhere that
this experience of shame may be linked in pivotal ways not only to Twela: So I don’t want to be that person. I want to be, ah, calm…
feelings of anger and/or anomie, but also to acting out behaviours Yes, and I don’t want that angry. It’s, it’s frightening. I don’t want
ranging from verbal and physical aggression to passive withdrawal. that angry.
As such, these feelings should be listened for and attended to,
When questioned about suicide, which can be regarded as an
particularly in contexts where women are unable to live up to their
act of aggression that is directed towards the self [68], most of the
and others’ expectations of motherhood and womanhood.
participants immediately denied entertaining any such thoughts or
In some cases, these complex feelings of despondency can impulses, explaining that this would be wrong on two counts. Firstly,
be experienced as feelings of hopelessness, as articulated here by they regarded suicide as a religious sin:
Elizabeth:
Evergreen: if you believe in the Lord, you’re going to go to hell if
Elizabeth: What’s the, um, what’s the use of going on? you take your own life.
However, also apparent were the complex coping mechanisms Secondly, they believed that it would be wrong to abandon their
employed by the women, ranging from acting out behaviours to child and family caretaking responsibilities in that way. However,
covering up behaviours. These will be reported on in the next section. upon further careful questioning, many of the women eventually
admitted to experiencing suicidal ideation and even attempts.
Superordinate theme 3: The complexity of coping with
depression Evergreen: …And I was walking on the road, the 364. And you
know, a big, big truck came out from the beach side, with that ah,
Participants reported that they coped with their feelings of silver thing in front, shiny, glimmering in the sunlight. All of a sudden
distress in various ways. From the above it is apparent that they do this thought came to me, “you can just run in front! It will be over just
not feel comfortable with reporting emotions such as sadness, anger like that!” [snaps her fingers]. [Sighs] …I, I couldn’t believe it, this
and anxiety. Seemingly ashamed of such emotions they tend to be urge. Some time ago I had this thoughts and stuff, but the minute I
more likely to report physical problems. Also, coping mechanisms thought about Evan, “who’s going to take care of him now?” And then
that were prominent, often served to obscure the negative emotions. this truck just went past…
Some of the participants said that their feelings of depression For each participant, it appeared to be the idea of “escaping” -
became manifest though their substance-using behaviours (usually whether from past memories or current circumstances - that caused
cigarettes and alcohol). These women said that they used substances them to consider the idea of suicide. However, probably due to their
to alleviate boredom, to relax, to escape traumatic memories, or in subscription to cultural norms regarding religion and mothering,
response to feeling angry, frustrated or mistreated. they felt deeply shameful about such thoughts, and therefore tended
Their emotional experiences of self-recrimination, low self- not to speak about them.
esteem, as well as their belief that they should not show or burden Superordinate theme 4: Subjective beliefs about the factors
others with their sadness or admit that they needed support, were
that cause or exacerbate depression
manifested in the women’s tendencies to socially withdraw and hide
their feelings of sadness from others: This and other South African studies that have assessed women’s
constructions of the causes of their depression all report remarkably
Twela: I just kept quiet about my, my darkness and whatever I
similar findings: women tend to attribute their depression to social
feel inside me.
causes (such as abuse and deprivation) and interpersonal factors,
Evergreen: I just, no, I say I’ve got a smiling depression and then 3 The researcher in this study (a clinical psychologist) thoroughly risk-assessed
laugh… all mentions of suicidal or homicidal tendencies during the participant interviews.
As the interviews took place at a primary health care clinic, participants who
Interviewer: What does that mean to you? required prolonged assessment or hospital admission could be appropriately
attended to. None of the study participants required hospital admission.

Dukas and Lou-Marié. Int J Womens Health Wellness 2016, 2:014 • Page 4 of 8 •
specifically, how others could hurt or humiliate them [33,34,56,57,69]. to many of the participants. Engaging in prayer or religious ritual
When asked what might have caused their feelings of depression, the seemed to provide them with ways of remaining calm and hopeful in
women in this study typically gave reasons that focused on: the loss the context of daily trials and hardships. Similar findings have been
of an important relationship (whether by death or abandonment); a reported in other studies on depressive symptoms [71-73].
history of childhood trauma (physical or sexual abuse and/or negative
Elizabeth: The Lord will protect me… Trust in the Lord and he
relationships with parents); intimate partner relationship problems/
provides.
abuse; having multiple responsibilities; feeling either emotionally or
practically unsupported; and feeling constantly afraid by virtue of Evergeen: I had just this, this, feeling that I’m dirty, dirty, dirty…
living in dangerous and violent communities. I just live for, ah, church services, um, to have the Holy Communion,
to get Holy Communion to give myself faith, you know. Just to hear
While issues related to poverty or economic disadvantage were
the words “Your sins are forgiven.”
occasionally mentioned or implied, having limited financial resources
was never explicitly cited as a reason or explanation for feeling Two participants expressed their belief that medical treatments
depressed. Rather, what the women felt distressed them most in this for the symptoms of depression were both necessary and useful
regard, were the factors that were indirectly related to their economic (especially with regard to alleviating insomnia, which most of the
position. For instance, many of the women described not being able women identified as a particularly troubling symptom):
to provide for their children as particularly depressing [70]:
Elizabeth: They put me on Trepeline, and there’s a bit better,
Interviewer: When are you the most sad? and finally I was put on Fluoxetine, which did a lot for me, and I am
coping very well on Fluoxetine.
Melissa: When the babies is hungry. That time.
Anna: I was feeling well, because the sleeping pills did help, most
However, it was the loss of a relationship or the absence of a
of the time.
satisfying relationship that was the most frequently cited reason for
feeling depressed. In other words, it was in the context of relationships But the meds is up, it’s like going back… because I don’t sleep.
that the women’s depression came to the fore.
However, the majority believed that interventions that focused
Interviewer: What does it mean to you, to be depressed? exclusively on medication had only limited usefulness. They affirmed
that the protective and healing effect of feeling cared for in an
Christine: Just thinking and stress about stuff, just thinking about
empathic relationship should not be underestimated. Specifically,
my problems, and I seeing now “Oh, my relationship is not on a level
they felt that having a respectful, considerate relational encounter
now that it should be”…
with another provided them with tremendous relief from many of
Twela: [Crying] My relationship with, with, with John isn’t lekker their depression-linked experiences, including loneliness, despair,
(good/nice). There’s something wrong… and, when I talk about it, né, sadness and anxiety.
he just shuts me out. He just say I’m paranoid… But I don’t feel that.
Interviewer: Have you ever been given pills to help make you feel
My thing, when something is bothering me, né, I want to, I talk about
better?
it… and then when he gets angry, I feel that he just get lost me or that
he just want to end the relationship. Then, then I keep, then I keep Christine: No.
quiet… And I don’t want to leave, he’s not that bad, but I think “let’s
Interviewer: Do you think you need anything like that?
talk about those things that’s bothering you”, but he don’t want to...
He isn’t the right person for me. I just feel it. I just know it. Christine: No, just talking.
Superordinate theme 5: Subjective beliefs about the factors Interviewer: What do you think you need to help you to feel
that alleviate depression. better?
Participants identified a number of conditions that helped them Twela: Someone who listen, man, I, um, medicines or what didn’t
to feel better or more resilient in the face of depression. Most of these help for something inside you.
were simply the opposite counterparts of the factors that they had
identified as causing their depression. In particular, feeling cared Conclusion
for and able to share one’s feelings in the context of a supportive In order to plan better mental health interventions and contribute
relationship, involving oneself in religious activities, and having to policy development for low-income women in South Africa,
access to healthcare services, were all identified as being particularly psychological research on women’s lived experiences is urgently
valuable. needed. In this feminist phenomenological study our aim was to
Christine: Just making jokes and playing with me, he says “No, bring traditionally overlooked perspectives to the fore, by providing
don’t be like rich descriptions of the subjectively lived experience of depression,
as recounted by low-income women who had been diagnosed
that, there’s a lot of people who are like that, talk to me about it. as depressed. The findings revealed that the current dominant
Don’t worry conceptualization of depression may be culturally inappropriate
and insufficient, as it does not account for the multifaceted nuances
about stuff!” and he’s talking to me and I say “OK” …It helps me
of women’s psychological distress or attend to the social/political
a lot… because he always sees what I cannot see… Later he will come
contexts within which women become depressed.
back “Are you
In this phenomenological study concerned with a group of
feeling alright now?” “Yes, I am alright”…He really understands
low income women’s subjective experiences of depression a more
me.
complex picture (than that which is typically offered by mainstream
Elizabeth: Ja, we [the psychosocial rehabilitation group at the models and diagnostic systems alike) of “depressed” women’s
clinic] come together. We all had the same, had plus-minus the same psychological distress emerged While there were of course differences
experience… We understood each one’s problems… between participants, our most striking finding was the complexities
of the clinical picture that emerged for all the women, a clinical
Interviewer: It helps to be with people who have had the same
picture that seemed to be obscured by existing descriptions of major
experiences.
depression. Prominent for the participants in their experience of
Elizabeth: Ja, ja, ja. Very much! depression were sleeping difficulties, exhaustion and bodily pain.
More difficult for participants to talk about was their feelings of
Maintaining their religious beliefs was especially important

Dukas and Lou-Marié. Int J Womens Health Wellness 2016, 2:014 • Page 5 of 8 •
sadness, anxiety, loneliness and anger. They seemed to ashamed of of low-income women. The participants’ narratives highlighted how
their emotional distress and experienced it as a changed sense of self pervasive and chronic poverty, abuse and neglect affect generations
resulting in changed relationships. They coped with these complex of women and children: “Such situations are destructive to women’s
feelings by not directly recognizing the emotional distress: they used mental health, and must be challenged at a societal level, since social
substances, denied their depression by pretending to be happy and by change can only be achieved when women are able to question
acting out in aggressive ways. The depressed woman in this study felt the societal structures that sustain oppression” [27]. Researchers,
rejected, disconnected, alone, angry, vulnerable, afraid, tired, fragile, healthcare professionals and policy-informers must therefore become
frustrated, abandoned and uncared for. Participants clearly felt committed to highlighting the “links between the social conditions
overburdened by multiple and opposing responsibilities, understood of people’s lives and their suffering: When there is oppression, there
that their emotional distress was caused by feelings of isolation and is pain” [58]. However, highlighting the circumstances of people’s
loneliness, but despite desperately wanting and needing support, they lives is only the first step. Rather than simply helping people to adjust
seemed to be too ashamed to directly ask for it. to the conditions that cause their distress, the necessary second step
should be towards transforming those conditions [77].
It was evident that the emotional experiences of depression
and their corresponding physical and behavioural manifestations The women in this study clearly communicated their conviction
had a deleterious effect on the women’s daily lives. While all of the that being provided with both therapy and medication (primarily to
participants had at some stage experienced an overwhelming desire alleviate their symptoms of insomnia and bodily pain) were ultimately
to simply “give up” or disengage from their lives and responsibilities, beneficial treatments for depression. Given the strong emphasis on
none of them truly considered this to be a tenable option. So sleep disturbance and bodily pain as features of depression found in
committed were they to their roles and responsibilities, that they this study, it is also recommended that healthcare workers carefully
simply persisted in trying to meet them, even when doing so was to assess patients who present with somatic complaints for other
their own detriment. This picture of depression - of continuing to symptoms of depression [53].
function and engage with daily life, often in a way that is energized
Given the high incidence of depression in women and the
by anger - contrasts with the traditional portrayal of depression as
pervasive loneliness that depressed women feel, it may also be
being simply an inert state of disengagement and apathy [26]. It
worthwhile to consider the benefits of support group therapy,
quickly became apparent that depression in some low-income South
particularly in low-income South African communities where
African women might not always resemble traditional, mainstream
there are not enough mental health-care practitioners to support
depictions of the condition.
the number of people needing assistance. Overall, it is our belief
Indeed, despite certain commonalities between the participants that if treatment is to be effective, it should be concerned also with
in this study, it should be recognised that depression can manifest prevention; with the context of the illness as well as intervention; and
differently in different women, and that personal pain can be acted with care as well as cure.
out or hidden in a variety of ways, some of which might not typically
resemble “depression” as we currently know it. For instance, during Limitations of the current study
their times of greatest depression, the women in this study explained The study is limited in several ways. Firstly, the first author of
that they became anxious and angry with those who they felt did the present study was involved in every phase of the research. Such
not understand or support them adequately. In a medical model close involvement assisted us in gaining insight and a thorough
framework, the complexity of these women’s emotional experiences understanding of the data. While it is recognized that her subjectivity
and reactions might have resulted in the diagnosis of a personality as researcher undoubtedly affected every stage of the research process,
disorder. Yet such a diagnosis would undoubtedly obscure the fact the scope of the current paper did not allow for a more detailed
that symptoms are always an articulation of distress, and further, that investigation of exactly how her subjectivity influenced the research.
distress is intricately linked to historic, social and relational contexts. Secondly, the current study consisted of a very small number of
low-income women. This was deemed acceptable, based on the
The women interviewed attempted to explain why they had argument that the study was sacrificing breadth for depth of data. It is
become depressed in terms of their complex relationships and life possible that other groups of South African women might offer vastly
events. When asked about the causes of depression, participants different and valuable perspectives. We are not claiming that this is a
clearly constructed depression as a psychosocial, or more specifically, representative sample and that results can be generalized to all South
a relational phenomenon. Research on women and depression African women. Also, while in our analysis the emphasis was on how
supports the notion of the cause and experience of depression being ten individual women experienced depression, in this paper we focus
situated within the relational domain. For instance “(i)mpaired more on how the experiences of participant were convergent. Where
bonding and loneliness” were found as strong predictors or causes for appropriate, we have commented on divergences of experiences, but
postpartum depression in women [74]. Further important risk factors it is clear that case studies of the individual participants may yield
related to depression in women were found to be “inadequate social even richer results. . Thirdly, as English was not the primary language
support, high relational conflict, sense of belonging, and loneliness” of the women who participated in this study, it is likely that the
[75]. Relational well-being was also found to be a buffer against richness of the data has been compromised.
depressive symptoms in women [76].
In conclusion, depression, as experienced by the women in this
Throughout the course of their lives, the women in this study had and other South African studies [17,26,34], emerged as something
to cope with: childhoods marked by violence, disruption and abuse; far more complex than a discrete diagnosis as purported by the
partial schooling; absent parents; multiple pregnancies and deaths; biomedical model of depression. Rather, it was shown to be a
overcrowded housing; sexual violence; substance abuse; having to convoluted and pervasive state that infiltrated and changed every
make a living to support themselves and their families; and trying aspect of a woman’s body, personality, relationships and indeed,
to care (often single-handedly) for their children and other family life-world. Thus we suggest that it may be more useful to understand
members. However, to describe them simply as “depressed” would be depression as a dynamic and variable experience, rather than as
to capture only one fragment of their very complicated experiences. a static state, and as an ongoing element of the more complex
In fact, such a diagnosis might actually serve to obscure the intricacy experiences of a capricious self in a particular sociopolitical context.
of their emotional experiences as well as their ability to cope [58,77]. It seems that no single perspective (feminist, medical, social or other)
can provide both the breadth and depth of insight that is necessary for
Clinical implications a thorough understanding of a phenomenon as complex as women’s
The findings discussed in this study indicate that a wide range psychological distress. We suggest that it is important to think about
of interpersonal, social, political, emotional, physical and practical women’s emotional distress in new, broader and more inclusive ways
issues affect the quality of life and determine the health and wellbeing - not necessarily captured by a diagnosis of depression.

Dukas and Lou-Marié. Int J Womens Health Wellness 2016, 2:014 • Page 6 of 8 •
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