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"Hold Hope Always"

March 07, 2023
by Lucile Bruce

A Conversation on Women's Mental Health with Dr. Erika Carr

In celebration of International Women’s Day, we caught up with Erika Carr, PhD, a psychologist who specializes in working with women with serious mental illness. Dr. Carr, Associate Professor in the Yale Department of Psychiatry, directs the Inpatient Psychology Service and the Behavioral Intervention Service at Connecticut Mental Health Center. She is the co-author, with Lauren Mizock, PhD, of Women with Serious Mental Illness: Gender-Sensitive and Recovery-Oriented Care (Oxford University Press, 2021) and chairs the Committee for Women Who Experience Serious Mental Illness, a working group of the Society for the Psychology of Women (Division 35) of the American Psychological Association.

Q: Dr. Carr, what experiences are common for women with serious mental illness?

Dr. Carr: Most common are their extreme experiences with trauma. We know that women with serious mental illness experience more traumatization than men with similar mental health problems. Women also experience much higher rates of sexual trauma. They experience more financial crises, making about half of what men with serious mental illness make annually – so an even deeper level of poverty. It’s widely known that people with serious mental illness have a shorter life span than the general population, but specifically, within that statistic, women die younger than men. This is very different from the general population, in which women typically live longer than men. All of these things contribute to unique disparities.

Q: How does the objectification of women play a role?

Dr. Carr: Sexual objectification—this idea that women are valued in culture predominantly as sexual objects, and not as highly intelligent beings who are helping lead the world in so many different ways—has been shown to impact women’s mental health. It contributes to things like depression, eating disorders, substance use, monitoring your body for how it measures up. It affects your flow, which is the idea of peak performance. It's also more correlated with psychosis. The barrage of sexual objectification can impact all these things, and I think it’s exacerbated for women with serious mental illness, especially those who are homeless and experience high levels of trauma.

Q: In your book, you apply the idea of “intersectionality” to your work with women with serious mental illness. Can you explain what this means?

Dr. Carr: When women come to us for mental health services, they aren't just facing symptoms of a mental health diagnosis. They're living at the intersection of all these multiple oppressive experiences. It's being a woman, it's also racism, classism, often homelessness, and stigma. And sexism. We can't forget sexism, and how dangerous it is to be a woman on the streets. For women with serious mental illness, there's a high statistical likelihood that they have experienced sexual assault in the prior month, if they are homeless. It's a constant and integrated experience for them, especially for women who are living in deep poverty and experiencing homelessness at the same time. So much of their trauma goes untreated. We're much more likely as a profession to address the diagnosis that seems most prominent, and not recognize that women have years and years of trauma that is layered and interwoven with their experiences. In our profession, there's less than a 5% likelihood that a woman's trauma will be assessed, recognized, recorded in their chart, and treated appropriately.

Q: For women with serious mental illness, what is their experience of motherhood?

Dr. Carr: These women often experience the loss of their children. Men with similar mental health conditions have children too, but women are typically in the parenting role, and most of them experience the loss of custody. If they're connected to a mental health agency, sadly, the literature shows that they are even more likely to lose their children. They're often scared to participate in mental health care because they’re worried about losing their children. Eyes are on them, and they intuitively know this. Dealing with the sadness and trauma of losing custody is very difficult. Sometimes people think women with serious mental illness don't have children, but actually, they do have children—often at even higher rates than the general population. We as a profession have to have more holistic ways of helping mothers with serious mental illness in their parenting roles, rather than exacerbating their traumas.

Q: What does a holistic approach to women's mental health look like?

Dr. Carr: I think a holistic approach means we're using a gender-responsive lens as we look at what's going on for women. When we work with them, we understand that they probably experience some of these multifaceted issues, so we assess for that. When women come in, we take a more multifaceted treatment planning approach that centers the woman herself—because so much of the time, women's voices are not heard. We try to put them in the driver's seat. We ask, what do they want out of being here? Many times they've experienced trauma within systems of care. They may have been hospitalized against their will or experienced seclusion or restraint. We can aim for no coercion or punitive measures within any of our settings, inpatient or outpatient.

And then, how do you put women in the driver's seat of their treatment? What are the goals they have for their life? Why are they connecting with us? Most times they're not going to say, "I want to take my medications and attend my therapy appointments." But they will say, "I want to get reconnected with my kids," or "I want to go back to school and then work." From what they want in life, we engage in a shared decision-making approach toward what will best serve them and their goals. For the provider who is using a gender-responsive lens, the challenge is how do you integrate your knowledge, while centering them in the treatment process.

Q: What does success look like with women on the inpatient unit?

Dr. Carr: We often think people’s dreams seem impossible inside the box of an inpatient unit—a literal box, right? I think success means offering hope always. Holding hope for people. Too many times, the message people get when they experience these chronic conditions is that their life is about their condition. It's not. Even from the inpatient setting, we can help move a person toward a vision of what they want for their life.

Years ago, we helped a woman develop better skills at being a mother. Her child had been in foster care, and she wanted more of a role in the child's life. There were certain things she needed to learn. We worked on this with her. It was beautiful. A woman's thoughts about herself as a mother shift over time. A lot of women who lose their children think they're not good mothers. There's so much pressure on women, period, as mothers, and there's this myth that you can't be a good mother if you ever lose custody of your child. Actually, one of the bravest things I've ever seen some women do is give up their children because they know they can't take care of them.

Q: Why is equality so important in a woman’s therapeutic relationship?

Dr. Carr: I think it's extremely important. I come to therapy with a multicultural feminist framework, because I think equality is so important, and because we still haven't reached equality for women in the world anywhere that I know of. And if not in therapy, where? There is some inherent power differential and as a provider, you have to acknowledge that. But as much as I can, I try to provide a collaborative, egalitarian space that centers them and empowers them.

Many women have been so disempowered by their experiences in the world, told their perceptions are inaccurate, told their beliefs are inaccurate and their trauma isn't even real. They need to be validated. They need to be heard. They need to feel like they can trust the space. When we do that in therapeutic work, I feel there's a leveling of some power. It is very important work. For example, it's important for people who identify as non-binary, because much of their experience may be about invalidation and not being seen for who they are, to be as validated and supported as they need to be. Trans women have even higher rates of sexual assault and rape, and many times their experience in the world is fraught with discrimination and oppression. It's just so important that we see people for who they are, provide validation and empowerment, and offer safety and culturally responsive treatment.

Q: What is feminism to you?

Dr. Carr: There are so many things I could say, but at its base, I think feminism means equality and equity for every human being. And also, understanding what women have faced. This is such a typical feminist phrase, but "the personal is political." I mean, it's so true. It can't be said better. And as a feminist, for me, a huge piece is believing in social justice and advocacy. On the inpatient unit, I work with an amazingly beautiful team of people who are great about advocacy. They let their voices be heard about rights for people, and rights for women, and I love that. I have an elected seat on the Council of Representatives for the American Psychological Association and we're working on how to advocate for the rights of women around the globe. We are active on Capitol Hill, by getting involved in advocacy and passing policy that impacts the daily lives of women. All these things are crucial, I think, for the benefit of women, so they can continue to advance in this nation and everywhere.

Submitted by Lucile Bruce on March 06, 2023