“Women who come from rural areas don’t know how to explain their health problems to psychiatrists like me. When I tell them that their problems have a psychological basis, they say, ‘Why? I have good living conditions’.” As he was adjusting his tie, the psychiatrist reasoned that since the lives of Kosovar village women mainly revolved around fulfilling their basic needs, they lacked a refined understanding of their emotions and psychological pains. With some disdain in his voice, he went on, “They think that having enough to eat and good living conditions is all they need (…)” and illuminated this point by saying, “It’s not just that they can’t talk about their mental health, they find it shameful. They are unaware that even Bill Clinton’s wife goes to the psychologist.”

His view, that women were unable to engage with their mental health or to properly talk about it, was not exceptional among mental health specialists and doctors. “Women here in Kosovo stigmatize mental illness,” a psychologist told me as he explained why village women refused referrals to mental health professionals. He considered the stigma as being related to the fact that women were convinced mental health practitioners only dealt with people who were “crazy”, “had lost their minds”, or behaved like “lunatics” – that is, people who exhibited characteristics that the women did not associate with. Consequently, I was told, women, especially those from rural areas, gossiped about people who frequented mental health and psychiatric services, talking about them in hushed tones. Health providers linked such behaviors to village women’s “primitive personalities”, “ignorance” and “low education.”

Women’s lack of education and attempts to avoid the clinics of psychiatrists and psychologists was also believed to explain their tendency to express their psychological problems through bodily pains rather than through their emotions. A psychiatrist stated, “They can’t help but to somatize their psychological problems.” Similarly, a doctor exclaimed in one of our many conversations: “If village women were better educated they would know how to come to terms with their psychological problems.” With a deep sigh she stated, “they aren’t literate and don’t know how to express their problems other than through their bodies.” Doctors like her were particularly frustrated with the women’s misconceptions of mental health problems as these complicated referrals to mental health specialists. Another doctor invited me to contemplate using myself as an example: “If you didn’t believe that you suffered from a mental illness, would you accept a referral to a psychiatrist? Probably not.  So, you can see, they try to convince me that their problems are physical. And, what do you think they want me to do?” Before I could answer his question, he continued by saying, “They demand to be seen by specialists like cardiologists and oncologists. They want blood tests and x-rays done in laboratories. They just don’t believe that anything is wrong with their mental health.”

While doctors considered such referrals futile, they nevertheless went along with the requests, not knowing how else to prove to the women the non-existence of their physical illness. Throughout my research, I came to realize that convincing patients of the non-existence of something was, in fact, a tactical action of what I call the “game of truth”. For the players to win the game, they need to convince the other party of the true underlying source of pain through reason and a process of elimination. If the health practitioner is winning, then each specialist-visit and negative test result creates health facts which show, to even the most stubborn that “there is nothing wrong with the body. At the same time, as each physical condition is eliminated, it becomes increasingly evident that the underlying cause of the pain is more likely to be a mental health one.

What it means to play this “game of truth” is illustrated in the following example, in which a doctor, working in a rural outpatient clinic, relayed to me, “I had a specific case where a woman said that she had headaches, chest pain, and stomach pain. She couldn’t sleep at night. She was scared that she might be suffering from cancer.” The doctor continued the example by saying, “She was convinced that there was nothing wrong with her body. But, no matter what I said, she didn’t believe me. So, I had to convince her with tests and x-rays that it’s not an organic disease and that there is nothing wrong with her body. But, she was fixed on the idea that she suffered from a tumor. For example, when she came to complain about headaches she would claim that she had a tumor in her brain. When I told her that it is impossible for her to have a tumor in her brain as her symptoms didn’t match, she would feel relieved for a little while. But, the following week she would come again complaining about the same things. Then she went to receive a head scan. After that she came back to me to tell me that my words were true. The same happened when she was complaining about chest pain believing that she suffered from breast cancer. I sent her to receive a mammography and ultrasound. Only then she was convinced that she was healthy.” Looking out of the window over the grapevine covered hills, she sighed and concluded, “So, you see, depending on the patient, you have to find different ways of convincing them.”

On the surface, the “game of truth” was usually settled in favor of the health professionals. Yet, as I took a closer look at the “game”, I became to realize that it was rigged and that the concept of “winners” and “losers” did not actually make sense. The game was rigged in such a way that it concealed key aspects of the “truth”, particularly those pertaining to the political dimension of health and healthcare delivery. To explain this, a quick detour into health system development is required. At the time of my research, the Kosovar mental health system was so underfunded, understaffed, and in many ways dysfunctional that a referral held little promise for adequate care or recovery. Only two percent of an already underfunded health budget was dedicated to mental health and there were only eight Community Mental Health Centers covering a population of about 250,000 respectively. Staff was lacking in all of them, with only about 1.9 psychiatrists, 0.3 psychologists, 8.8 psychiatric nurses and 0.6 social workers per 100,0000 inhabitants.[1] Moreover, medication was often lacking and, if there was medication, it often consisted of donations from various European countries and tended to be outdated with unpleasant side-effects. If no medication was available in the community mental health centers, it had to be paid privately out of patents’ pockets. Consequently, long-term treatment and follow-up care were close to impossible to achieve in a context characterized by enormous scarcity and lack of political will.

With this in mind, women’s attempts to avoid the mental health sector appear in a different light. It goes without saying that a “primitive mentality” had nothing to do with it and that the paternalistic reasonings related to misconceptions, lack of education, and stigmatizing attitudes covered up some of the underlying reasons for why women refused to visit mental health professionals. Instead, I would say that their demands were largely (understandable) reactions to systemic weaknesses. It becomes apparent that, in order to play this “game of truth” fairly, an open deck of cards is required whereby resource scarcity, lack of professional personnel, the withdrawal of humanitarian and development aid, and lack of political aid are understood as the main obstacles to adequate mental health care. In order for both the women and mental health professionals not to appear as losers of the game, I consider it crucial for the government to take mental health seriously by properly investing in it so that adequate and meaningful services, that are both needed and, in fact, wanted, are provided.

(Author: Hanna Kienzler)

Acknowledgements: I would like to sincerely thank members of the Culture, Medicine and Power Research Group for their valuable feedback and Sally Eales for editing the story.

[1] At the same time, Germany had 11.8 psychiatrists, 51.5 psychologists, 52 psychiatric nurses and 477 social workers per 100,0000 inhabitants (source www.who.int)