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The ongoing silencing of women in families: an
analysis and rethinking of premenstrual syndrome
and therapy
Jane M. Ussher
a
Traditionally, explanations for premenstrual symptomatology have
focused on the individual woman as the site of difficulties, and as the
sole target of intervention. In contrast, from the perspective of a material-
discursive-intrapsychic model, this paper will focus on the ways in which
‘PMS’ is experienced, constructed and dealt with in family relationships.
Drawing on in-depth narrative interviews conducted with women with
moderate to severe premenstrual symptoms, it is argued that ‘PMS’ is
closely tied to relationship difficulties and responsibilities; familial
expectations and attributions for women’s behaviour provide a discursive
context for behaviour and emotions to be positioned as ‘PMS’; and that
the ongoing self-silencing and pathologization of women’s emotions in
families are key attributes of ‘PMS’. This suggests that a consideration of
relationship issues should be central to any assessment or intervention for
premenstrual symptoms, and conversely, that attention should be given
to premenstrual exacerbation of relationship difficulties in family or
couples therapy.
Introduction
Premenstrual symptomatology is now widely recognized as a major
psychological problem, with epidemiological surveys estimating that
up to 40 per cent of women experience moderate to severe
premenstrual symptoms, diagnosed as ‘PMS’ (Premenstrual Syn-
drome) or more recently ‘PMDD’ (Premenstrual Dysphoric Disorder)
(Mortola, 1992; Steiner and Born, 2000).
1
The costs of this problem,
in terms of women’s quality of life, economic functioning and family
discord, are estimated to be considerable (Collins, 1991). Yet despite
rThe Association for Family Therapy 2003. Published by Blackwell Publishing, 9600 Garsington
Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2003) 25: 388–405
0163-4445 (print); 1467 6427 (online)
a
Professor of Women’s Health Psychology, School of Psychology, University of
Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. E-mail:
j.ussher@uws.edu.au Fax: 00 612 9772 6736.
1
I will use the term ‘PMS’ to refer to the diagnostic category ‘premenstrual syndrome’,
the label most commonly used to describe women’s experience of moderate to severe
premenstrual symptoms.
r2003 The Association for Family Therapy and Systemic Practice
research across several disciplines, efforts to understand and
ameliorate premenstrual symptomatology have not succeeded.
Rather, this is a field riddled by contradictory discourses and
perspectives, with biomedical and psychological researchers offering
numerous competing etiological theories and treatments, and social
constructionist critics deconstructing and dismissing ‘PMS’ and
‘PMDD’ as legitimate syndromes (Ussher, 1996).
For example, the major focus of research in this field to date has
been the establishment of agreed diagnostic criteria for ‘PMS’,
epidemiological surveys, the development of standardized tools for
assessment, and the evaluation of biomedical or psychological
theories and treatments (for reviews see Bancroft, 1993; Gold,
1997; Walker, 1995). This has resulted in a range of competing
approaches, each associating premenstrual symptoms with a single
causal factor. These include: gonadal steroids and gonadotrophins,
neuroendocrine factors, serotonin and other neurotransmitters,
endorphins, or other potential substrates (including prostaglandins,
vitamins, electrolytes and CO
2
) (see Parry, 1994); or psychological
factors such as personality, cognitions associated with femininity and
menstruation, attribution of changes in physiological arousal, the
influence of stress and life events, or propensity for psychological
illness (see Ussher, 1992b; Walker, 1995). Positioned within a positivist
epistemological framework (Ussher, 1996), all of this research reifies
‘PMS’ as a disorder occurring within the woman, with the occurrence
(or non-occurrence) of symptoms as the end-point of analysis. The
cultural construction of ‘PMS’, women’s ongoing appraisal and
negotiation of changes in emotion, behaviour or bodily sensations,
and the role of relationships in the development of premenstrual
symptoms are issues that are all marginalized or negated (Ussher,
2002).
In contrast, from the standpoint of a material-discursive-intra-
psychic (MDI) model (Ussher, 1999, 2000), this paper will posit that
premenstrual symptoms are not static or fixed, but that they result
from an ongoing interaction of material (e.g. changes in hormones or
neurotransmitters, life stresses), discursive (e.g. cultural constructions
of reproduction and femininity) and intrapsychic (e.g. mode of
evaluating changes, expectations of self, defence mechanisms,
reflective functioning) factors, which produce changes in emotions,
bodily sensations and behaviours, that come to be positioned as ‘PMS’
by the woman herself, her family or by a clinician (Ussher, 2002,
2003; Ussher et al., 2000). More specifically, drawing on in-depth
The ongoing silencing of women in families 389
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narrative interviews conducted with women with moderate to severe
premenstrual symptoms, this paper will focus on the ways in which
‘PMS’ is experienced, constructed and dealt with in the context of
close family relationships.
A small number of previous studies have examined the influence of
relationship difficulties, or marital disharmony on premenstrual
symptoms (Hamilton, 1988), with questionnaire studies reporting
that women with ‘PMS’ have high levels of relationship dissatisfaction
(Coughlin, 1990; Frank et al., 1993; Ryser and Feinauer, 1992; Winter
et al., 1991; Wright, 1986). For example, Kuczmierczyk et al. (1992)
compared women with a prospectively confirmed diagnosis of ‘PMS’
to routine gynaecological care non-PMS controls, and found that the
‘PMS’ group scored significantly higher on amount of conflict in their
families, but lower on direct emotional expressiveness within the
family. The findings of this research have led to the suggestion that
‘PMS’ is not an individual problem, but a marital issue (Ryser and
Feinauer, 1992), and that family or couples therapy may be an
appropriate form of intervention (Jones et al., 2000; McDaniel, 1988).
However, to date, there has not been an in-depth qualitative analysis
of the way in which premenstrual symptomatology is experienced
and constructed within close family relationships. This paper will
redress this imbalance.
In contrast to the many competing biomedical and psychological
accounts of ‘PMS’, where the focus of attention is on the individual
woman, with aetiological theories exploring the way in which
biological or psychosocial factors produce the symptoms within (see
Bancroft, 1993; Gold and Gold, 1994), it will be argued that a systemic
analysis, which would position ‘PMS’ as a relational issue, is more
appropriate. For when women in this study were asked to describe
their ‘PMS’, they did not talk about the experience or impact
of symptoms at an individual level, but referred to ‘PMS’ as
an emotion or behaviour experienced and expressed in relation to
others.
The interview study: method and participants
Thirty-six women who reported a 30 per cent increase in premen-
strual ‘symptoms’, as measured by prospective diaries over a three-
month period, and who met diagnostic criteria for PMDD (DSM-IV)
(APA, 2000), took part in in-depth narrative interviews. The women
were randomly selected from a larger group, who were taking part in
390 Jane M. Ussher
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a controlled clinical trial comparing medical and psychological
treatments for moderate to severe premenstrual symptoms (Hunter
et al., 2002). Twelve women from each of the treatment conditions
(medical, psychological, and a combination of the two) were randomly
selected for interviews pre- and post-treatment. The average age of
the women was 38; middle- and working-class affiliation was evenly
balanced, as was parity. The majority of women were in paid work.
Narrative interviews were conducted by the same trained interviewer
before and after treatment, the aim being to examine women’s
subjective experience of ‘PMS’, and what ‘PMS’ meant to each
individual woman (Ussher, 2002, 2003).In order to elicit narratives,
an open-ended question was asked at the beginning of the interview:
‘In this interview I’d like to explore some of the meaning ‘‘PMS’’
has for you, and the part it plays in your life. I’d like to start by
asking ‘‘what does ‘PMS’ mean to you?’’ ’ The interviewer then
followed the woman’s lead, asking questions of clarification
as and when necessary. The interview was thus framed as a
dialogue between two people, rather than a question-and-answer
situation.
The analysis presented in this paper draws on the pre-treatment
interviews, which were analysed within a framework of thematic
narrative analysis (Reissman, 1993). After transcription, the inter-
views were coded, line by line, thematically. Themes were then
grouped together, and then checked for emerging patterns, for
variability and consistency, for commonality across women, and for
the function and effects of specific narratives. This process follows
what Stenner (1993, p. 114) has termed a ‘thematic decomposition’, a
close reading which attempts to separate a given text into coherent
themes or narratives which reflect subject positions allocated to or
taken up by a person (Harre
´, 1990). It is based on the assumption
that narratives do not simply mirror a world ‘out there’, but that
they are constructed, creatively authored, rhetorical, replete
with assumptions and interpretive (Potter and Wetherall, 1986,
p. 5; Reissman, 1993, p. 5).
The major themes that emerged from the interviews were: the
‘PMS’ sufferer as split; over-responsibility is linked to PMS;
‘PMS’ 5lack of control; methods of coping; attributions for symp-
toms; and ‘PMS’ as a relational issue. These narrative themes were
common across women, regardless of age, parity or occupation. This
paper will focus on the theme of ‘PMS’ as a relational issue, drawing
on the other themes where they intersected.
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Results: narrative analysis of interviews – ‘PMS’ as a relational
issue
In discussions of ‘PMS’ as a relational issue, the four major themes
that were identified were: ‘PMS’ 5emotional reactivity; ‘PMS’ 5sen-
sitized response to specific problems in relationships; coping with
‘PMS’ by avoiding relationships; self-pathologizing in relation to
others.
‘PMS’ 5emotional reactivity
One of the key attributes of ‘PMS’ in women’s accounts, and in the
research literature (Bancroft, 1993), is a premenstrual increase in
emotional sensitivity. While a number of women reported noticing
premenstrual changes in emotional sensitivity independent of the
presence of others (Ussher, 2002), it was only when they outwardly
expressed these emotions in relationships that they were described as
problematic, as ‘PMS’. This expression was described primarily as
emotional reactivity – irritation, anger and intolerance.
Interviewer: What’s the worst aspect of your premenstrual experience do
you think?
Pat: I think for me it’s the angry outbursts it’s the temper the aggressive it
all of those kind of things this the awful sort of way that I have of
arguing and ahmm you know turning something that’s quite normal
and trivial into something that is an absolute nightmare.
Nicola: It’s almost as if it’s sort of you’re unaware of what’s happening. Um,
until you know something will, will sort of happen at home or, you
know, the children will say something and I’ll react to it.
All of the women described this expression of emotion, this ‘PMS’,
as loss of control.
Anne: But you haven’t got any control over, you can’t control how you feel.
Or sometimes if it’s really bad I, I sort of get [inaudible]. I get stroppy,
you know? And it must be really (hurtful) for my husband. I mean he’s
great. I mean he won’t but that’s not fair on him. You can’t go on like that
forever.
As is illustrated in the above example, the major concern women
reported about this loss of control was the impact upon others, in
particular partners and children. The primary reason why women
sought treatment was positioned as the need to protect others from
‘PMS’, or to save the relationship. As one woman commented: ‘I
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should imagine it (PMS) could be the answer to a lot of marriage
breakups’ [Mary]. This stands in contrast to a decontextualized view
of ‘PMS’ as a problem that impacts primarily upon an individual
woman, to one where premenstrual symptoms are only deemed
problematic, indeed only categorized as ‘PMS’, when the woman
perceives that others are affected. Or alternatively, as was the case
with many of the women interviewed, when family members suggest
that the woman seeks help for ‘PMS’. This may explain the so-called
false positives and false negatives in ‘PMS’ research (Hamilton, 1990)
– the women who fail to show a cyclical pattern of symptoms when
assessed prospectively, despite a self-diagnosis of ‘PMS’, and those
who do experience premenstrual symptoms, but do not position
themselves as ‘PMS’ sufferers (e.g. Hardie, 1997). It is possible that in
the former case, family difficulties (or other psychosocial stresses) are
being inappropriately positioned as ‘PMS’; conversely, in the latter, as
other people are not affected, the woman may simply not make a self-
diagnosis of PMS.
PMS 5sensitized response to specific problems in relationships
In addition to positioning ‘PMS’ as a generalized emotional reactivity,
women also positioned it as the expression of otherwise repressed
emotion associated with specific problems in relationships, particu-
larly with partners or children. Without exception, when women
were asked to characterize their experience of ‘PMS’, they used a
‘short-fuse’ metaphor to describe incidents which were viewed as
annoying, or even as catastrophic premenstrually, being tolerated or
dismissed at other points in the cycle.
Shirley: The funny thing is the week before they could have been twice as
bad and really horrible and you’ve put up with it and you’ve let them get
away with it. You know. But then when they do something really little
and you’ll go bananas over it.
All the women described ‘losing it’ or snapping in relation to domestic
matters, where they were normally expected to have unending
patience, and to take the lion’s share of tasks – in addition to
undertaking paid work outside the home – as we see from the
following examples.
Nita: Earlier in the week my daughter hadn’t put her cereal bowl in the
dishwasher again. And I just I called, I screamed at her to come
The ongoing silencing of women in families 393
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downstairs, but once she got down I just went, ‘You haven’t done this!
You haven’t done that! Just look at this! Look at that!’
Erica:Every morning is particularly bad in our house when I’m
premenstrual. I’ve got three children. The youngest is 5, 7 and almost
10. Um and getting the children ready for school is just a nightmare
because I, I just I mean it’s, it’s always quite difficult but normally, you
know, I’ll be saying to them, ‘Come on’, you know, ‘Get dressed. Get
washed. Clean your teeth. Get your stuff together.’ You know, ‘It’s
nearly time to go’. When I’m premenstrual within minutes of the
children getting up for school, I’m screaming at them and if they don’t
do what I’m asking them to do I mean it, the whole thing just escalates.
I’ll just, it will get worse and worse and worse.
Conversely, a ‘pressure-cooker’ metaphor was used to describe
emotions building up during the month, and then overflowing
during the premenstrual phase of the cycle, as is illustrated in the
following example.
Margo: There’s a few days of the month where I feel I’m not myself,or
there’s you know, anger or tension that builds up and then I release it at
that point. And others around me suffer the consequences! Of that
buildup. Whatever it is.
At the same time, women talked of expressing more deeply held
grievances premenstrually, grievances they would contain during the
rest of the month.
Tracey: There’s things obviously in our relationship that I focus on which I
feel aren’t goodyI want to, want to face it now, whether it’s, you know,
him having breakfast in the morning or just about to go, I want to do it
now, and that’s not like me, I don’t believe.
The majority of women described this release of emotion as cathartic
in the short term: ‘getting things off my chest’ [Angela]. But this
catharsis was always followed by guilt, self-criticism, and a disassocia-
tion of the woman from the behaviour, through splitting the non-PMS
self from the ‘PMS’ self, who is ‘not like me’, as we see in Tracey’s
account, above.
Coping with ‘PMS’ by avoiding relationships
Reinforcing the view that ‘PMS’ exists primarily in relation to others,
women reported that temporary avoidance of social situations or
394 Jane M. Ussher
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relationships was the most effective way of dealing with premenstrual
symptoms.
Margo: I get really introverted during that time. I don’t want to see anyone, I
don’t want to socialize, I don’t want to be near anyone. Noise really annoys
me. Peo p l e annoy me. Men annoy me! [laughs] Everything annoys me!
Interviewer: And then how did you feel when you stayed up there on your
own?
Jane: Better. Because I just want to be on my own. I don’t want people
around me. I don’t want to have to talk to anybody. I just want to be
alone. Without any demands on me or anythingyso I can have some
peace to make myself feel better. To calm myself down. It’s almost as if, I
suppose like a therapeutic thing. You know because I suppose I get to the
stage where I just feel that everybody’s demanding from me. Um, and
I’m tired and I don’t feel like it and I just want to rest.
A related strategy in families was for others to avoid the woman, or to
reduce demands:
Nita: They stay out of my way. I mean they won’t totally ignore me. I mean
the kids still come up for a cuddle and all the rest of it but they will
they’ll sort of suss the lie of the land and see whether I’m really ranting
and raving or just sort of my son will disappear into his bedroom and
suddenly find some important homework that’s got to be done for
tomorrow. My daughter will disappear off someyyou know, up into
her room or go and help my husband with something. He’ll just be in
the garage. You know, everybody just sort of stays out of the way.
Self-pathologizing in relation to others
When women were able to be alone, they reported that their
premenstrual symptoms were reduced; the ‘PMS’ effectively dis-
appeared, and they felt ‘better’. However, many of the women we
interviewed never took time out for themselves in the whole month,
and spent little time engaged in leisure activities, focusing instead on
the needs of others, common to women who present with ‘PMS’
clinically (e.g. Taylor, 1999; Ussher, 1999).
Margaret: It’s taken many years for me to admit that, and for me then to say
to, to, to my husband, you know, ‘It’s the time of the month’. I need
space. And that’s been very difficult.
In these cases, women pathologized the desire to be alone,
positioning it as a ‘symptom’ of PMS, reflecting hegemonic discursive
The ongoing silencing of women in families 395
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constructions of femininity that position relationships as the central
feature of women’s lives (Smith, 1999), and women who wish to be
alone as aberrant, or selfish. It also reflects standardized ‘PMS’
symptom questionnaires such as the MDQ (Moos, 1968), which
categorize ‘stay in bed’, ‘stay home from work’ and ‘stay in’ as
‘symptoms’ of PMS. As such, these questionnaires provide a frame-
work for women to interpret their experiences as pathology, as ‘PMS’
(Ussher, 2003), feeding into the ‘regimes of knowledge’ that delineate
and define ‘PMS’ as a biomedical or psychological disorder.
Discussion
The subjugation of women through self-silencing
Without exception, the women interviewed in this study positioned
premenstrual expression of irritation or anger as an over-reaction, or
as a sign of pathology. Conversely, it could be reframed as a natural
response to being overloaded with responsibilities, within a family
environment where women are expected to subjugate their own
needs and desires, in order to attend to the needs of others – a self-
silencing that can lead to depression (Jack, 1991). At the same time,
the ‘control’ that women position as positive during the remainder of
the menstrual cycle could be reframed as a repression of under-
standable frustration and irritation, which ultimately has negative
consequences. As we see from narrative accounts of ‘PMS’ as a
pressure-cooker, women express grievances under the legitimating
rubric of ‘PMS’, in the attempt to deal with perceived inequities in
relationships, to make demands of children or partners that they
otherwise would not make, or simply to release tension and
annoyance. However, if these issues are raised only during the
premenstrual phase of the cycle, they are easily dismissed as ‘just
PMS’ by both the woman and her family, as is evident in the following
example.
Lisa: I’ve been upset or angry or snappy with her, she doesn’t just think ‘It’s
because she’s out of order’, she will just say something like, ‘Is your
period due?’ or something like that. And I think that’s the worst thing
anybody could say. You know, ‘Are you getting your period? Are you
getting the curse now? When’s it due?’ And I think that’s awful!
This means that the underlying issues are not addressed, the woman
is more likely to feel guilty and to position herself as to blame for
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‘losing it’, and then continue the cycle of repressing irritation during
the rest of the cycle, so as not to upset others. However, when
pressure builds up, when a woman is tired, vulnerable because
premenstrual, or unable to cope with multiple and competing
demands, something will act to trigger a further expression of
emotion, and the cycle repeats itself.
It is important to state that the attribution of emotional expression
to ‘PMS’ is not simply an excuse for ‘bad’ behaviour – a misconception
sometimes found in media reports of ‘PMS’ (Parlee, 1987). There is
evidence from previous research to suggest that many women do
experience increased vulnerability or sensitivity to external stress
during the premenstrual phase of the cycle (Sabin Farrell and Slade,
1999; Ussher and Wilding, 1992), possibly resulting from a
combination of hormonal or endocrine changes (Parry, 1994),
sensitivity to changes in autonomic arousal (Kuczmierczyk and
Adams, 1986), and differential perceptions of stress premenstrually
(Woods et al., 1998), linked to cultural constructions of ‘PMS’ as
negative and debilitating (Rittenhouse, 1991; Ussher, 2003): a
material-discursive-intrapsychic interaction. Experimental research
has also demonstrated that dual or multiple task performance is more
difficult premenstrually (Slade, 1980), and while women may
compensate with increased effort, this can result in increased levels
of anxiety (Ussher and Wilding, 1991). It is thus not surprising that
many women report reacting to the stresses and strains of daily life
with decreased tolerance premenstrually – particularly when they
carry multiple responsibilities. This is the one time in the month when
they cannot live up to internalized idealized expectations of
femininity, leading to self-pathologization.
Familial expectations and attributions construct women’s emotions
and behaviour as ‘PMS’
Nancy: I mean my husband says it’s like Jekyll and Hyde, you know. He can
tell when a period [has] started just by how I am.
Margo: Um [my mother] says I’m a Jekyll and Hyde!
The key feature that determines whether an emotion or behaviour is
positioned as ‘PMS’ is that it is at odds with idealized cultural and
familial expectations of how a woman should feel or behave – being
angry, rather than calm; snapping, rather than tolerating; confront-
ing issues, rather than letting things go; being irrational, rather than
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in control. All of the women interviewed reported that they managed
to live up to these idealized expectations for three weeks of the
month, but premenstrually were unable to, and as a result were
described by others in terms such as ‘Jeckyll and Hyde’, as is
illustrated above. This is a construction of premenstrual change that is
pejorative and pathologizing, reflecting hegemonic discursive con-
structions of the premenstrual phase of the cycle as a time of madness
and badness (Ussher, 1989, 1992a), a construction is internalized by
women, through a process of subjectification (Ussher, 2003), so that
they come to pathologize themselves. In the interviews, when women
made a distinction between the ‘PMS self ’ and ‘non-PMS self ’,
emotions and behaviour that were positioned as bad, difficult or
unacceptable were attributed to something called ‘PMS’, in
the majority of cases framed as a biological disorder outside of the
woman’s control. Within a family system, this functions to position the
woman, or her ‘PMS’, as the problem, absolving others of
responsibility for unhappiness or difficulties between individuals. At
the same time, the process of projecting emotions such as anger and
irritation on to ‘PMS’ functions to position them as ‘not me’, and thus
to distance women from feelings and behaviour they see as
antithetical to their conceptualization of a ‘good woman’, or in many
cases a ‘good mother’, as is illustrated in the following extract.
Helen:Iknow I’m a good mother. I’ve got three very well-behaved,
balanced children. I’ve got their welfare at heart. Um, I just want what’s
best for my children, my husband um my all my family. Um and I, I sort
of I, I look sometimes at myself when I’m premenstrual and I think and
(that I don’t) I don’t like myself. I don’t like what I’ve become. But
rationally I think, ‘Well, it’s not me. It’s not me.’ And once, once I’ve
overcome being premenstrual and have, have, have I mean sort of two or
three days into the period then, then I feel it’s, it’s almost like I’m
refreshed and I’m reborn again (with) this new me.
Helen’s notion of a ‘good mother’ is not unique to her; she is drawing
on hegemonic constructions of idealized motherhood (Kaplan, 1992).
Equally, when Pat and Anne, quoted in the first section of this paper,
comment that they expect themselves not to not react to ‘something
that’s quite normal and trivial’, and that ‘PMS’ is a reaction to
something ‘I would normally not react to’, they are drawing on
discursive constructions of idealized femininity, in which good or nice
women are not angry, irritable or intolerant; where women don’t lose
control – unless they’re mad or bad (Ussher, 1991, 1997). They are
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also drawing on hegemonic constructions of mental health that
circulate in Western culture – the view that mood and emotions
should always be stable and positive, and if not, pathology is implied.
Failing to be superwoman 5self-pathologization
Few women can maintain the fac¸ade of superwoman for long
(Nicolson, 2002). In this study, failing to do so premenstrually led
to self-pathologizing – reports of feelings of self-blame and inade-
quacy, with a subsequent resistance to the desire for solitude, and the
adoption of ‘control’ (or repression) as the primary coping strategy
for emotions (Ussher, 2002), or conversely to ‘giving in’, needing to be
alone, and feelings of failure (Ussher et al., 2000). However, if ‘PMS’
were conceptualized as a relational issue, the avoidance of others
premenstrually could be reframed as a positive coping mechanism,
resulting in a reduction in self-blame and guilt. Equally, if women
have a sense of entitlement about saying ‘no’ to the never-ceasing
demands of others, to prioritizing their own needs at times, and feel
able to voice discontent about issues in relationships – when those
issues occur – the experience of the premenstrual phase as a
pressure-cooker would be less likely to happen. The ‘prescription’
of planned time out, relaxation, and the encouragement of women
doing things they enjoy, and for themselves, was one of the most
important components of the psychological treatment for ‘PMS’ that
was developed out of the MDI model (Ussher et al., 2002), a treatment
which was found to be as effective as Fluoxetine in reducing
premenstrual symptoms (Hunter et al., 2002). It is also a central
feature of other psychological treatments for ‘PMS’ (e.g. Blake et al.,
1998; Estes, 1993; Koons, 1999; Morse et al., 1991; Slade, 1989).
Accepting variability and offering support: the role of family members
in reducing premenstrual distress
If women are able to accept normal human fallibility in themselves –
variability in internal state, in reactivity, or in ability to cope – they can
reject the cultural representations of idealized femininity and mental
health: the myth of the consistently super-responsible, calm and
happy woman/mother. This leads to acceptance of premenstrual
changes without recourse to models of illness, and acts to
de-pathologize premenstrual symptomatology. As a result, women
are more likely to adopt self-care strategies, or to ask for support from
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others, when they are feeling overwhelmed or out of control
premenstrually, thus ameliorating the impact of symptomatology
(see Ussher et al., 2002). However, this shift in perspective is not
simply a task for the woman herself, since familial expectations and
attributions associated with women’s emotions and behaviour are
crucial in their experience of PMS, as is outlined above. Many of our
interviewees talked of other people expecting them to always be
happy, consistent and unwavering in dealing with the demands of
others. They also talked of family members often not understanding
when this isn’t possible, as is illustrated below.
Kathy: I do say to him ‘I just Neil I’m you know due on’ um he just accepts
it but I don’t he’s I suppose he’s understanding but like you’re saying
he’s sympathetic but he doesn’t understand because he doesn’t know
what it feels like.
Nicola: [My husband] does care that I’ve got a problem and he does try to
understand. But I think where he, and I think probably men in general,
fails to understand the problem is that you can’t rise above it. It’s not
something that you are able to get out of. I feel as if I’m in this hole and
when he says things like um, you know, ‘Why don’t you just’, you know,
‘rise above it?’
The reactions of significant others to premenstrual changes in
emotion or behaviour are thus of key importance in the development
and course of symptoms. If family and children have little under-
standing of the complex roots of premenstrual symptomatology, if
they believe that women should always be able to control their
feelings, and thus see women’s behaviour or emotions premenstrually
as irrational, or a sign of pathology, the issues that are raised at this
time of the month will inevitably be positioned, and dismissed, as
‘PMS’. Many women reported that they experienced themselves as
being dismissed as part of this process. They felt unsupported, and
not understood. It is for this reason that attention to the attitudes and
behaviour of family members is a central part of intervention
programmes, moving away from a position of blaming the woman
to one of understanding premenstrual symptomatology as something
that may emerge as problematic only in the context of relationships,
or in the face of unacceptable pressure and expectations. Acknow-
ledging vulnerability, the legitimacy of reactions to pressure, and
working on ways of dealing with premenstrual emotions, such as
offering support, being clear about what is acceptable and what is not,
rather than getting involved in arguments, and giving women space
400 Jane M. Ussher
r2003 The Association for Family Therapy and Systemic Practice
to be alone, are all helpful strategies that can be adopted, as is
illustrated below.
Antje: He’s very supportive um and he sort of unless he’s very um annoyed
and aggressive himself, he doesn’t go into any arguments and um that
helps a lot, just accepting that yif I feel unhappy about myself, I don’t
have to blame myself as well.
Agreeing to deal with substantive issues at a different time in the
menstrual cycle, or when emotions are not so dominant, is also an
important step, as is basic assertiveness training to facilitate the
process of women asking for support, or being clear about what is
concerning them, rather than letting unhappiness build up – other
strategies that are central to current psychological interventions for
‘PMS’ (Blake, 1995;Ussher et al., 2002).
Conclusion
Traditionally, explanations for premenstrual symptomatology have
focused on the individual woman as the site of difficulties, and as the
sole target for intervention, resulting in individualized biomedical
(e.g. Barnhart et al., 1995; Kessel, 2000; Steiner, 2000) or psycho-
logical treatments (e.g. Blake et al., 1998; Estes, 1993; Koons, 1999;
Morse et al., 1991; Slade, 1989). In contrast, this paper has posited
that premenstrual symptoms arise out of an ongoing interaction of
material, discursive and intrapsychic phenomena, with family
relationships being one of the major arenas in which ‘PMS’ emerges.
Drawing on narrative interviews, it has been argued that ‘PMS’ is
experienced and expressed primarily in relationships with close
family members; ‘PMS’ is closely tied to relationship difficulties and
responsibilities; and that familial expectations and attributions for
women’s behaviour provide a discursive context in which particular
behaviour and emotions come to be positioned as ‘PMS’, due to the
self-silencing and pathologizing of women’s emotions. This suggests
that a consideration of relationship issues should be central to any
assessment or intervention for premenstrual symptoms.
Equally, family or couples therapy can be a forum where
premenstrual difficulties may be usefully addressed, allowing the
way in which ‘PMS’ is constructed within relationships to be explored,
and the role of family members in exacerbating or ameliorating
symptoms examined. Partners and other family members should be
encouraged to offer support, to avoid dismissing or pathologizing
The ongoing silencing of women in families 401
r2003 The Association for Family Therapy and Systemic Practice
premenstrual vulnerability, and to develop ways of communicating
within the family that allow the woman to express her needs and
concerns, thus avoiding self-silencing and the subsequent ‘pressure-
cooker’ expression of premenstrual emotion. At the same time, family
and couples therapists should be sensitive to the way in which ‘PMS’
may be blamed inappropriately for underlying relationship difficul-
ties, with the premenstrual phase of the cycle acting as a time when
women’s repressed emotions are expressed, and subsequently
dismissed. Knowledge about the role of relationship issues in the
development and course of ‘PMS’, and the role of ‘PMS’ in
relationship difficulties, is thus also relevant to family and couples
therapists working in a wide range of areas, where ‘PMS’ is not the
presenting problem, and may not, without reflection, appear to be a
matter of concern.
Acknowledgements
This research was funded by a grant from the North Thames
Regional Health Authority and conducted when the author was based
at University College London. Funding for coding of the qualitative
interviews was provided by a University of Western Sydney Research
Partnership Scheme grant. Thanks are extended to Sarah Hartley for
assistance in coding of the interviews.
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