Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 9, 319–331 (2002)

A Woman-Centred Psychological
Intervention for Premenstrual
Symptoms, Drawing on
Cognitive-Behavioural and
Narrative Therapy
Jane M Ussher,1 * Myra Hunter2 and Margaret Cariss3
1
Health Psychology Research Group, School of Psychology, University of
Western Sydney, Australia
2
Department of Psychology, St Thomas’ Hospital, London, UK
3
Avon and Wiltshire Hospital Trust, UK

A women-centred psychological intervention for premenstrual symp-

toms, drawing on cognitive-behavioural and narrative therapy, has
been developed. In a randomized control trial previously reported,
this treatment was found to be as effective as SSRIs in reducing mod-
erate or severe premenstrual symptoms. The purpose of this paper
is to outline the multifactorial model of premenstrual symptoms that
underpinned this intervention, describe the treatment in detail ses-
sion by session, and present two case examples drawing on narrative
interviews conducted pre and post treatment with the women who
took part in the randomized control trial, in order to illustrate the
process of change. It is argued that premenstrual symptoms arise from
a complex interaction of material, discursive and intrapsychic factors,
and that this needs to be taken into account when designing clinical
interventions. Copyright  2002 John Wiley & Sons, Ltd.

INTRODUCTION Disorder (PMDD) (Steiner & Born, 2000). A number

It is now widely recognized that premenstrual
symptoms affect substantial numbers of women,
with 40–75% estimated to experience moderate
symptoms, categorized as Premenstrual Syndrome
(PMS), and between 3 and 8% severe symptoms,
that warrant a diagnosis of Premenstrual Dysphoric
* Correspondence to: Professor Jane M Ussher, School of
Psychology, University of Western Sydney, Locked Bag 1797,
Penrith South DC, NSW 1797, Australia. Tel: 00 612 9772 6491.
Fax: 00 612 9772 6736. E-mail: j.ussher@uws.edu.au
Contract/grant sponsor: North Thames Regional Health
Authority, UK.
Contract/grant sponsor: University of Western Sydney.
Contract/grant sponsor: FPA Health.
of biomedical explanations and treatments for
PMS and PMDD have been proposed (Parry,
1994), with recent reviews concluding that Selec-
tive Serotonin Uptake Inhibitors (SSRIs) should
be the treatment of choice for women (e.g. Barn-
hart, Freeman, & Sondheimer, 1995; Kessel, 2000;
Steiner, 2000). However, there have also been a
number of recent developments in psychological
treatments for moderate to severe premenstrual
symptoms. Cognitive behaviour therapy (Blake,
1995; Blake, Salkovskis, Gath, Day, & Garrod, 1998;
Estes, 1993; Koons, 1999; Morse, Dennerstein, Far-
rell, & Varnavides, 1991; Slade, 1989), behavioural
psychotherapy (Kuczmierczyk, 1989), rational emo-
tive therapy (Morse, Bernard, & Dennerstein,

Copyright  2002 John Wiley & Sons, Ltd.

Published online 15 August 2002 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.340
320
1989), and relaxation training (Konandreas, 1990;
Kuczmierczyk, 1989; Morse et al., 1989) have all
been found to be effective in reducing symptoms,
and in increasing women’s ability to cope with
changes across the menstrual cycle.
Psychological treatments for premenstrual symp-
toms are based on the assumption that women’s
cognitive appraisal of symptoms, of ‘PMS’ as an
entity, and of their own ability to cope, are impli-
cated in the development and management of
distress (Blake, 1995; Slade, 1989; Ussher, 1996).
Treatment packages vary, but the majority focus
on critically examining attributions for symptoms,
increasing coping skills, developing social support,
and relaxation training. In a recent randomized
control trial, a women-centred psychological ther-
apy drawing on these principles, was found to be
as effective as SSRIs in reducing symptoms over
a 6-month period, and more effective at 1-year
follow-up (Hunter, Ussher, Cariss, Browne, & Jelly,
2002). The purpose of this paper is to outline the
multifactorial model of premenstrual symptoms
that underpinned this intervention, describe the
treatment in detail session by session, and present
two case examples drawing on narrative interviews
conducted pre and post treatment with the women
who took part in the psychological treatment arm
of the randomized control trial, in order to illustrate
the process of change.
A MATERIAL–DISCURSIVE–INTRA-
PSYCHIC MODEL OF PREMENSTRUAL
SYMPTOMS
This research was conducted from a critical realist
epistemological standpoint (Bhaskar, 1989), using
a Material–Discursive–Intrapsychic (MDI) model,
(Ussher, 1997a; 1999; 2000) to conceptualize ‘PMS’.
Critical realism affirms the existence of reality,
but recognizes that its representations are char-
acterized and mediated by culture and language,
leading to the use of a variety of methodologi-
cal approaches, both qualitative and quantitative,
without one being privileged over the other. There
is also acceptance of the legitimacy of subjec-
tive experience, hitherto marginalized in positivist
psychological research, as well as in research on
PMS (Ussher, 1996). The MDI model posits that
an ongoing interaction of material, discursive, and
intrapsychic factors combine to produce emotions,
bodily sensations and behaviours, which come to
be diagnosed as ‘PMS’ or ‘PMDD’ by the woman
herself, or by a clinician (Ussher, 1999).
Copyright  2002 John Wiley & Sons, Ltd.
J. M. Ussher, M. Hunter and M. Cariss
‘Material–discursive’ approaches have recently
been developed in a number of areas of psychol-
ogy, such as sexuality, reproduction, and mental or
physical health (see Ussher, 1997b,c; Yardley, 1996,
1997). This has resulted from both a frustration with
positivist-realist psychology, which has tended to
adopt a solely materialist standpoint, thus serv-
ing to negate discursive aspects of experience, and
a dissatisfaction with the negation of the material
aspects of life in many social constructionist or post-
modern accounts, where the focus is entirely on
discourse (Ussher, 1996). This integrationist mate-
rial–discursive approach is to be welcomed, yet
arguably does not go far enough, as the intrapsychic
is still left out. The MDI model incorporates all three
levels together—material, discursive and intrapsy-
chic—without privileging one above the other, in
order to provide a multidimensional analysis of the
development, course and meaning of both premen-
strual symptomatology and the diagnostic category
‘PMS’ (Ussher, 1999).
‘Material’ factors are those that exist at a cor-
poreal, a societal or an institutional level: factors
which are traditionally at the centre of biomedical
or sociological accounts. This would include bio-
logical factors associated with psychological symp-
tomatology, such as hormones, neurotransmitters
or physiological arousal (Parry, 1994); material
factors which institutionalize the diagnosis and
treatment of premenstrual experiences as ‘PMS’
(Ussher, 2002a); inequalities in heterosexual rela-
tionships (Ussher, 2002b); and previous history of
abuse or trauma (Golding, Taylor, Menard, & King,
2000). There are also many material consequences
of experiencing or being treated for ‘PMS’, in terms
of physical or psychological vulnerability, as well
as powerlessness at an economic or societal level
(Collins, 1991).
The ‘discursive’ centres on the social and lin-
guistic domains—language, visual representation,
ideology, culture, and power. What is arguably of
most relevance here is the discursive construction
of ‘PMS’ (Ussher, Hunter, & Browne, 2000), of men-
tal health and illness (Foucault, 1967; Ussher, 1991),
and of gender (Smith, 1988; Ussher, 1997c). A grow-
ing body of feminist, social constructionist, and
cross-cultural researchers have argued that PMS is
a gendered illness, a discursively constructed phe-
nomenon, that has become an inappropriate source
of attribution for a whole range of distress and
dysfunction experienced by women (Caplan, 1995;
Figert, 1995; Nicolson, 1995; Rittenhouse, 1991). In
societies where ‘PMS’ does not circulate widely as
a discursive category, women do not associate the
Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms
premenstrual phase of the cycle with psychological
symptoms, and ‘PMS’ is a diagnosis rarely applied
to women (Chandra, Chaturvedi, & Gururaj, 1994;
Chaturvedi, 1994). This has led some critics to dis-
miss PMS and PMDD as nosological categories,
arguing that they merely act to medicalize unhap-
piness or distress that is an understandable reaction
to the social role of women (Figert, 1996; Ussher,
1989). Conformity to hegemonic constructions of
femininity, within what has been described as a
heterosexual matrix (Butler, 1990), has been seen to
put women at risk of mental health problems (Stop-
pard, 2000), including PMS (Ussher, 2002b), as it is a
role which requires self sacrifice, self degeneration,
and a stiffling of independence and desire.
‘Intrapsychic’ factors are those that operate at
the level of the individual and the psychological:
factors which are traditionally the central focus of
psychological analyses of PMS (see Bancroft, 1993;
Walker, 1995). This would include perceptions and
attributions for symptoms; analyses of the way in
which women blame themselves for problems in
relationships, as well as psychological explanations
for why this is so, incorporating factors such as
low self-esteem, depression, the impact of previous
neglect or abuse, guilt, shame, fear of loss or
separation. It would also include an analysis of
psychological defences, such as repression, denial,
projection or splitting, as mechanisms for dealing
with difficulty or psychological pain.
The MDI is not the first multifactorial model
of PMS, as a number of bio-psychosocial models
have previously been put forward (e.g. Blake,
1995; Ussher, 1992; Walker, 1995), in parallel with
developments in other areas of health and clinical
psychology, such as chronic fatigue syndrome
(e.g. Johnson, 1998; Mostofsky & Barlow, 2000).
However, the MDI model differs from bio-psycho-
social models of PMS as it does not privilege
either psychological (e.g. Slade, 1989) or biological
aetiological factors (e.g. Bancroft, 1993; Blake, 1995),
and gives equal status to discursive representations
of ‘PMS’ and femininity. It also differs in being
positioned within a critical realist, rather than a
positivist, epistemology (Ussher, 1996). This model
is outlined graphically in Figure 1.
As is demonstrated in Figure 1 above, we are
representing this graphically within a circle, rather
than in the hierarchical manner common to bio-
psycho-social models (Blake, 1995; Ussher, 1992;
Walker, 1995). For whilst the different aspects of
the model outlined in Figure 1 are often discussed
separately, the MDI model assumes that it is
their relationship with each other that produces
Copyright  2002 John Wiley & Sons, Ltd.
321
Discursive
Material
Intrapsychic
Figure 1. A material–discursive–intrapsychic model
of premenstrual symptoms
experiences that women come to label PMS or
PMDD. That is, each is part of a whole, rather
than a ‘causal entity’ in itself. Thus, whilst biological
factors may be associated with increased sensitivity
and vulnerability premenstrually, these are only
problematic, and experienced as ‘PMS’, if they
interact with life stresses and other environmental
factors (such as levels of responsibility, family
and work relationships), with women’s perception,
evaluation and means of coping with symptoms,
and with the discursive construction of ‘PMS’
and femininity in a particular cultural context.
Equally, a premenstrual ‘symptom’ will always
have a material, a discursive and an intrapsychic
component; one cannot be separated from the other.
To illustrate this, a brief case example, is described
below.
Mary presented with symptoms of anger, irri-
tability, and feelings of being ‘out of control’
premenstrually. She felt that she could not cope
with her normal work and family responsibili-
ties, and oscillated between losing her temper at
the slightest thing, or weeping and wanting to be
alone. She also felt much more sensitive to factors
such as light or noise and experienced physical
symptoms of breast tenderness and headaches. Her
husband put all of her problems down to ‘PMS’, and
told her to ‘get her hormones sorted out’. She felt
guilty and ashamed after her premenstrual period
had passed, and vowed that next month it would
not happen again, and that she would make an
effort to be a perfect wife from now on. But by the
end of the month she found that she was feeling
overwhelmed, unable to cope, and was losing her
Clin. Psychol. Psychother. 9, 319–331 (2002)
322
temper all over again. She said that PMS was to
blame—it turned her into a different woman.
There were a number of ‘material’ factors that
were associated with Mary’s symptoms. In addition
to the biological changes occurring across the
menstrual cycle, she was a woman who worked full
time, and also took full responsibility for domestic
tasks. There were difficulties in her relationship
with her husband, which she managed to ignore
for most of the month, but which came to the
fore premenstrually. Her own early family life
had been difficult; her father had been violent,
and her mother depressed. Intrapsychic factors
centred around the high expectations Mary had
of herself and of her relationships, her means of
coping with any inconsistency or perceived failure
to live up to her own standards, and her ability
to ask for help or support from others. In the
premenstrual phase of the cycle, memories of her
childhood that she otherwise tried to repress, and
subsequent feelings of depression, often emerged.
These unresolved issues impacted upon her adult
relationships, adding to her feelings of anger or
grief when she was faced with difficulties in her
marriage. This was in the context of hegemonic
discursive constructions of women as always able
to cope and be in control; of the woman who
‘has it all’ being someone who works full time yet
also can be the perfect mother and wife at home;
of marriage as a ‘happy ever after’ relationship;
and of constant positive mood being the norm
for mental health. As a result of the premenstrual
phase of the cycle being discursively constructed
as a time when women are out of control, and
PMS as an uncontrollable hormonal disorder that
is to blame, ‘PMS’ was the diagnostic category that
was adopted by Mary and her husband to make
sense of her unhappiness and distress. Thus, the
material, discursive and intrapsychic elements that
led to Mary’s ‘symptoms’ and to her self diagnosis
as having PMS, are not separate but are irrevocably
intertwined.
A WOMEN-CENTRED
PSYCHOLOGICAL TREATMENT FOR
PREMENSTRUAL SYMPTOMS
The psychological treatment described below
addresses the material, discursive and intrapsy-
chic factors that contribute to women’s premen-
strual symptoms, emphasizing the interconnection
between these different aspects of experience. It is
an approach that draws on existing psychological
Copyright  2002 John Wiley & Sons, Ltd.
J. M. Ussher, M. Hunter and M. Cariss
treatments for PMS using a cognitive-behavioural
framework (Blake, 1995; Blake et al., 1998; Morse
et al., 1989; 1991; Slade, 1989), but also on narrative
and social constructionist therapy (Hoyt, 1998). In
the description of each session, below, reference
will be made to previous research where specific
strategies were developed or adopted.
The aims of the treatment were as follows: to
valorize women’s knowledge and expertise regard-
ing premenstrual experiences; to provide a non-
pathologizing space for women to tell their story
of PMS; to develop a collaborative therapeutic
relationship; to examine cognitions and narrative
constructions of PMS; to help women challenge
negative cognitions and reframe their narrative to
reduce distress; to examine perceptions of stress
and of premenstrual symptoms; to critically exam-
ine cultural constructions of femininity and PMS
and how they impact upon women’s premenstrual
symptoms; to develop coping strategies for dealing
with symptoms; to encourage assertiveness and
self-care throughout the cycle; to allow for reflexiv-
ity on the part of the therapist. Eight 1-h sessions
were scheduled on a fortnightly basis, as shown in
the following schedule.
Session 1
The aim of this session was to examine the
woman’s experience of premenstrual problems,
to develop a working model of PMS, based
on the material–discursive–intrapsychic model
underpinning the treatment, and to develop a
therapeutic alliance.
Listening to the Woman’s Story of PMS
(1) Assessment and listening to the woman’s story
of PMS: the history and development of her
symptoms as she sees it, in order to recognize
her expertise (Hoyt, 1998), and to provide a
basis for future re-authoring of her experience
(Epston, White, & Murray, 1992; Lee, 1997).
(2) Assessment of the effect on her life: the current
situation and what influences symptoms both
historically and currently (Slade, 1989). What
makes symptoms better or worse, what treat-
ments has she already tried, why has she sought
help now.
(3) Social context—her view of the impact of PMS
on those around her and their response.
(4) Development history.
Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms
(5) Emotional themes in a woman’s life—the
meaning of PMS to her (Miota, Yahle, & Bartz,
1991).
Developing a Working Model of PMS with the
Woman
I. The woman’s model
(1) The woman’s thoughts and feelings
regarding her PMS and an exploration
of perceptions of psychological treatment
(Slade, 1989).
(2) What aspect of her PMS does the woman
define as the most difficult and what aspects
would she most like to change.
(3) The function of her PMS: e.g. does it
allow expression of emotion otherwise
repressed? Does it allow time away from
responsibilities? (Ussher, 2002c).
II. Presentation of the psychological treatment
package
(1) Introduction and clarification of treatment.
(2) Education and information regarding the
menstrual cycle (Blake, 1995; Chau &
Chang, 1999; Levitt, Freeman, Sondheimer,
& Rickels, 1986; Pearlstein, Rivera Tovar,
Frank, & Thoft, 1992).
(3) Presentation of the material–discursive–
intrapsychic model of PMS (Ussher, 1996,
1999).
III. Development of a collaborative model
(1) Highlight how the women’s narrative fits
with, or challenges, our model of PMS, as
part of a collaborative process in therapy
(Freedman & Combs, 1996).
(2) Exploration of thoughts and feel-
ings regarding psychological intervention
(Blake; 1995; Slade, 1989); in particular dis-
cussion of any ambivalence or unrealistic
expectations regarding treatment.
(3) Examination of what the woman expects
from treatment.
(4) Clarify the individual and specific goals of
treatment.
Work between sessions: ask the woman to think
about her aims for treatment. Examining the leaflet
Introduction to Treatment, which outlines the model
underpinning treatment and the leaflet Looking After
Yourself By Coping With Stress. This aims to provide
the women with an outline of how stress influences
the body, thoughts, feelings and behaviour. The
premenstrual phase was presented as a source
Copyright  2002 John Wiley & Sons, Ltd.
323
of potential stress that adds to other everyday
stressors. It was clarified that the emphasis of the
treatment was on managing stress throughout the
cycle. The leaflet also aims to help the woman
identify the stressors in her life.
Session 2
The aim of sessions 2 and 3 was to develop a
formulation of PMS and to understand in more
detail the context of women’s symptoms. In session
2, the specific focus was the relationship between
stress and PMS; introduction of relaxation training,
and recording of cognitions.
(1) Discuss with the woman her thoughts and
feelings following the first session.
(2) A discussion of the woman’s lifestyle and fac-
tors that may increase or reduce psychological
and physical symptoms throughout the cycle,
focusing on the woman’s current life stresses
and ways of coping with them (Burrage &
Schomer, 1993; Mitchell & Mitchell, 1998a,b).
(3) Reinforce the importance of the relationship
between body and mind, in the context of stress
and PMS (Woods, Mitchell, & Lentz, 1995).
Introduce the discussion of self-care, time out,
and relaxation in order to be able to deal with
stresses throughout the cycle, but particularly
in the premenstrual phase.
(4) Introduce progressive muscular relaxation and
abdominal breathing, and discuss the rationale
and practicalities of relaxation (Goodale, 1990;
Levitt et al., 1986; Mohan & Chopra, 1992). Use
relaxation training to explore the relationship
between thoughts/feelings/bodily sensation,
showing how women can change physical
tension and have a greater sense of control.
Each woman was given a relaxation tape, and
practiced relaxation in the session. For some
women it was necessary to do some preparatory
work on allowing themselves time out for
relaxation.
(5) Begin the process of recording thoughts,
feelings and attributions for psychological
and physical symptoms throughout the cycle
(Morse, 1997; Slade, 1989; Ussher, 2002c).
(6) The goals were also discussed again.
Work between sessions: continue the formulation of
the problem; leaflet on relaxation, use the relaxation
tape, and leaflet on assertiveness.
Clin. Psychol. Psychother. 9, 319–331 (2002)
324
Session 3
Focus of the session: examining relationships and
PMS; looking after yourself by being assertive
(1) Outline the importance of assertiveness in
dealing with difficult issues in the family and
at work, using examples from the woman’s
life. Discuss the importance of assertiveness
in expressing needs, saying no (Kuczmierczyk,
1989).
(2) To consider with women the ways of being
assertive without being passive or aggressive.
(3) Examination of the association between
PMS, assertiveness and relationship difficulties
(Coughlin, 1990; Frank, 1995; Kuczmierczyk,
1989; Ryser & Feinauer, 1992; Winter, Ashton,
& Moore, 1991) and women’s expectations
concerning gender relationships (Freedman &
Combs, 1996).
(4) Encourage women to ask for support and
increase personal resources (Morse, 1997; 1999;
Warren & Baker, 1992).
(5) Continue discussion of specific symptoms
affecting individual women since the last
session.
Work between sessions: read the leaflet on diet and
exercise; doing things you enjoy.
Session 4
Focus of the session: continuing the re-authoring
of PMS; looking after yourself by doing things you
enjoy; the importance of diet and exercise.
(1) Discuss the social expectations placed upon
women, in particular that of caring for others
before caring for themselves, and the impli-
cations of multiple and often conflicting roles
(Freedman & Combs, 1996; Ussher et al., 2000).
(2) An examination of things women enjoy doing,
particularly if they experience depression or
tiredness premenstrually, to ensure that women
allow themselves time to do pleasurable activ-
ities as well as completing chores or tasks.
Examining narratives about why they currently
do not, or cannot, do things they enjoy.
(3) Activity scheduling and PMS: planning positive
things for each day (Blake, 1995; Corney,
Stanton, Newell, & Clare, 1990).
(4) The importance of eating healthily was stressed
for the whole cycle. In the premenstrual phase,
women were advised to eat small amounts
of food on a regular basis to avoid drops in
Copyright  2002 John Wiley & Sons, Ltd.
J. M. Ussher, M. Hunter and M. Cariss
blood sugar; eat complex carbohydrates; reduce
salt, sugar, caffeine and alcohol intake (Daiss &
Krietsch, 1997).
(5) The benefits of regular exercise for general
health and for reducing premenstrual symp-
toms, in particular anxiety, were discussed
(Choi, 1992; Kirkby & Lindner, 1998; Miota et al.,
1991). A programme of activity and exercise that
was compatible with a woman’s lifestyle was
developed.
(6) Any difficulties with relaxation were discussed
and the importance of data collection reinforced
(Slade, 1989).
Work between sessions: read the leaflet on positive
thinking.
Session 5
Focus of the session: looking after yourself by
positive thinking and re-authoring premenstrual
experiences
(1) Using the records of perceptions, attributions
and styles of coping collected over the preced-
ing weeks, discuss with the woman the vicious
cycle of thoughts, feelings and behaviour inher-
ent in their experience of premenstrual symp-
toms (Blake, 1995; Kirkby, 1994; Kuczmierczyk,
1989; Morse et al., 1989; Slade, 1989; Toner,
1994). Discuss the woman’s symptoms through-
out her menstrual cycle, highlighting attribu-
tions, and how these may vary across the cycle.
(2) Ask women to describe in detail a PMS incident.
Highlight vicious cycles of thoughts, feelings,
expectations and behaviours.
(3) Encourage women to challenge thoughts,
reframe their premenstrual experiences, and
explore alternative ways of thinking that might
lead to better outcomes (Morse, 1999).
(4) Explore the internalized effects of the external
environment and social expectations placed on
the woman (Ussher, 2002c). Where appropriate,
explore the role of early experience on current
cognitive style.
(5) Continue discussion of specific symptoms
affecting individual women since the last
session.
Work between sessions: challenging unhelpful
thoughts or schemas.
Session 6 and 7
Focus of the sessions: continue the work on cogni-
tive restructuring developed in session 5, to reframe
Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms 325

Figure 2. KATHY 0532 (numbers beside text refer to line numbers in the interview)

Copyright  2002 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 319–331 (2002)
326 J. M. Ussher, M. Hunter and M. Cariss

Figure 3. MARGO—0114

Copyright  2002 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms
women’s narrative of PMS. Where appropriate
introduce anger management and stress inocu-
lation (Corney, 1990; Slade, 1989; Kuczmierczyk,
1989; Kirkby, 1994).
(1) Review records of moods, thoughts and
behaviours.
(2) Discuss practice of strategies used over the
preceding weeks.
(3) Discuss and role-play positive strategies for
dealing with difficulties.
(4) Continue discussion of specific symptoms
affecting individual women since the last ses-
sion.
(5) Continue work on reframing women’s narra-
tive of PMS (Lee, 1997).
Session 8
Focus of the session: review and ending
(1) Review of intervention and goals of therapy.
(2) Discussion of woman’s current narrative of
PMS.
(3) Ending of therapy and integration of change.
(4) Discussion of ways of maintaining change.
Follow-up Sessions at 3 and 6 Months
(1) Complete a progress report.
(2) Problem solve any difficulties.
(3) Reinforce aims of treatment.
(4) Give information about where to go for further
help, if necessary.
Processes of Change: Pre–Post Intervention
Narrative Interviews
In a recent randomized control trial (RCT), reported
previously (Hunter et al., 2002), this treatment was
found to be as effective as SSRIs in reducing symp-
toms over a 6-month period, and more effective
at 1-year follow-up. In addition to the standard-
ized outcome measures used in the RCT, the COPE
(Mortola, Girton, Beck, & Yen, 1990), narrative inter-
views were conducted pre and post intervention
with 36 women, the aim being to examine women’s
subjective experience of ‘PMS’, what ‘PMS’ meant
to each individual woman, and how this might
change following treatment (Ussher, 2002a; Ussher
& Hunter, 2002; Ussher et al., 2000). To illustrate the
way in which symptoms changed over the course
of treatment, the themes from two of the coded
interviews pre and post treatment are presented
Copyright  2002 John Wiley & Sons, Ltd.
327
in summary from below (Figures 2 and 3) using a
conceptually clustered matrix (Miles & Huberman,
1994). These two case studies were selected for
illustration as they were representative of a ‘typical’
case, the nature of the narratives, and the change
pre–post treatment, common to the majority of
women interviewed.
In the interviews, in order to elicit narratives,
the following question was asked: ‘In this inter-
view 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 ques-
tion and answer situation. The interviews were
analysed within a framework of thematic narra-
tive analysis (Reissman, 1993). After transcription,
the interviews were coded, line-by-line, themati-
cally. 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 coher-
ent themes or narratives which reflect subject posi-
tions 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, rhetori-
cal, replete with assumptions and interpretive (Pot-
ter, 1986, p. 5; Reissman, 1993, p. 5). The interpreta-
tion of these themes was conducted by a process of
reading and re-reading, as well as reference to rel-
evant literature and consultation with colleagues.
The major themes that emerged from the inter-
views were: the PMDD sufferer as split; relational
issues; responsibility; control; methods of coping;
and attributions for symptoms (Ussher, 2002a,b,c;
Ussher et al., 2000), as is illustrated in Figures 2
and 3.
CONCLUSION
The women-centred psychological treatment pre-
sented in this paper draws on existing narrative
and cognitive-behavioural interventions, and on
critical analyses of the social construction of PMS,
in order to develop an intervention which is both
effective, and does not pathologize the woman or
medicalize her symptoms. As is illustrated in these
Clin. Psychol. Psychother. 9, 319–331 (2002)
328
two cases, it was found to be effective in reducing
the impact of symptomatology, increasing women’s
self-efficacy, developing positive coping strategies,
and in re-attributing the factors associated with
distress, through reframing women’s narratives
of PMS.
Further research is currently being conducted
to examine the efficacy of this intervention as a
self-help package (J. M. Ussher & E. Weisberg,
unpublished data), and as a group treatment.
As relationship issues were found to be one of
the major presenting factors in these women’s
accounts of PMS (Ussher, 2002b), as has been
found by previous researchers (Berglund, 1997;
Jones, Theodos, Canar, Sher, & Young, 2000), it
is also suggested that future work should examine
couples or family therapy as an intervention to
alleviate premenstrual symptoms and to develop
positive means of coping with difficulty throughout
the month for women and their partners. The
psychological intervention described in this paper
could be adapted for work with couples, with the
addition of a critical examination of the way in
which PMS is constructed within couple or family
units, and examination of the function of different
narratives adopted by women and their partners
(Freedman & Combs, 2000).
In conclusion, premenstrual symptoms arise from
a complex interaction of material, discursive and
intrapsychic factors. Both biomedical and psy-
chological interventions have been found to be
effective in reducing symptoms, in particular, SSRIs
and cognitive-behavioural or narrative-based treat-
ments (e.g. Blake et al., 1998; Estes, 1993; Koons,
1999; Morse et al., 1991; Slade, 1989). However,
as the majority of women are unhappy with the
notion of taking long-term psychotropic medica-
tion for the management of premenstrual symp-
toms (Hunter, Swann, & Ussher, 1995), psycho-
logical treatments should arguably be the first
option offered for the treatment of moderate
to severe premenstrual symptoms. This moves
away from a reductionist biomedical analysis of
women’s premenstrual distress, to a multifacto-
rial approach that empowers women, increases
coping skills, and alleviates many of the difficulties
that are implicated in the aetiology of PMS
or PMDD.
ACKNOWLEDGEMENTS
This research was funded by a grant from the North
Thames Regional Health Authority and conducted
Copyright  2002 John Wiley & Sons, Ltd.
J. M. Ussher, M. Hunter and M. Cariss
when the authors were based at University College
London. Funding for coding of the qualitative
interviews was provided by a University of Western
Sydney Research Partnership Scheme grant, in
conjunction with FPA Health. Susannah Browne
conducted the interviews, and Shirley Heilemann
conducted the coding.
REFERENCES
Bancroft, J. (1993). The premenstrual syndrome: A
reappraisal of the concept and the evidence.
Psychological Medicine, 241, 47.
Barnhart, K.T., Freeman, E.W., & Sondheimer, S.J.
(1995). A clinician’s guide to the premenstrual
syndrome. Medical Clinics of North America, 79,
1457–1472.
Berglund, D.M.F. (1997). Premenstrual syndrome
and relationship dynamics. Dissertation Abstracts
International Section A: Humanities and Social Sciences,
58(6-A), 2405.
Bhaskar, R. (1989). Reclaiming reality: A critical introduction
to contemporary philosophy. London: Verso.
Blake, F. (1995). Cognitive therapy for premenstrual
syndrome. Cognitive and Behavioral Practice, 2, 167–185.
Blake, F., Salkovskis, P., Gath, D., Day, A., & Garrod, A.
(1998). Cognitive therapy for premenstrual syndrome:
A controlled trial. Journal of Psychosomatic Research, 45,
307–318.
Burrage, J., & Schomer, H. (1993). The premenstrual
syndrome: Perceived stress and coping efficacy. South
African Journal of Psychology, 23, 111–115.
Butler, J.P. (1990). Gender trouble: Feminism and the
subversion of identity. New York: Routledge.
Caplan, P.J. (1995). They say you’re crazy: How the
world’s most powerful psychiatrists decide who’s normal.
Reading, MA, USA: Addison-Wesley/Addison Wesley
Longman Inc.
Chandra, P.S., Chaturvedi, S.K., & Gururaj, G. (1994).
Identification and assessment of premenstrual
symptoms and syndromes in women: An
epidemiological approach to investigation. NIMHANS
Journal, 12, 1–8.
Chaturvedi, S.K. (1994). Prevalence of premenstrual
symptoms and syndromes: Preliminary observations.
NIMHANS Journal, 12, 9–14.
Chau, J.P., & Chang, A.M. (1999). Effects of an educational
programme on adolescents with premenstrual
syndrome. Health Education Research, 14, 817–830.
Choi, P.Y. (1992). The psychological benefits of physical
exercise: Implications for women and the menstrual
cycle. Journal of Reproductive and Infant Psychology, 10,
111–115.
Collins, A. (1991). Premenstrual distress: Implications
for women’s working capacity and quality of life. In
M. Frankenhaeuser (Ed.), Women, work, and health: Stress
and opportunities (pp. 239–254). New York, NY, USA:
Plenum Press.
Corney, R.H., Stanton, R., Newell, R., & Clare, A.W.
(1990). Comparison of progesterone, placebo
Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms
and behavioural psychotherapy in the treat-
ment of premenstrual syndrome. Journal of
Psychosomatic Obstetrics and Gynaecology, 11,
211–220.
Coughlin, P.C. (1990). Premenstrual syndrome: How
marital satisfaction and role choice affect symptom
severity. Social Work, 35, 351–355.
Daiss, S., & Krietsch, K. (1997). Use of dietary intervention
in treating PMS. Journal of Psychological Practice, 3,
174–185.
Epston, D., White, M., & Murray, K. (1992). A proposal
for a re-authoring therapy: Rose’s revisioning of
her life and a commentary. In S. McNamee (Ed.),
Therapy as social construction. Inquiries in social
construction (pp. 96–115). Thousand Oaks, CA, USA:
Sage Publications Inc.
Estes, J.H. (1993). The premenstrual experience:
A cognitive experiential approach to treatment.
Dissertation Abstracts International, 54(2-A), 424.
Figert, A.E. (1995). The three faces of PMS: The
professional, gendered, and scientific structuring of
a psychiatric disorder. Social Problems, 42, 56–73.
Figert, A.E. (1996). Women and the ownership of PMS: The
structuring of a psychiatric disorder. Hawthorne, NY,
USA: Aldine de Gruyter.
Foucault, M. (1967). Madness and civilisation: A history of
insanity in the age of reason. London: Tavistock.
Frank, C.E. (1995). Conjoint treatment: Impact on married
couples with and without PMS. Dissertation Abstracts
International Section A: Humanities and Social Sciences,
55(8-A), 2588.
Freedman, J., & Combs, G. (1996). Gender stories. Journal
of Systemic Therapies, 15, 31–44.
Freedman, J.H., & Combs, G. (2000). Narrative therapy
with couples. In F.M. Dattilio (Ed.) Comparative
treatments for relationship dysfunction. (pp. 342–361).
New York, NY, USA: Springer Publishing Co Inc.
Golding, J.M., Taylor, D.L., Menard, L., & King, M.J.
(2000). Prevalence of sexual abuse history in a sample of
women seeking treatment for premenstrual syndrome.
Journal of Psychosomatic Obstetrics and Gynaecology, 21,
69–80.
Goodale, I.L. (1990). The effects of the relaxation response
on premenstrual syndrome. Dissertation Abstracts
International, 50(8-B), 3731.
Harre, R.D.B. (1990). Positioning: the discursive
production of selves. Journal for the Theory of Social
Behaviour, 20, 43–63.
Hoyt M.F. (Ed.). (1998). The handbook of constructive
therapies: Innovative approaches from leading practitioners.
San Francisco, CA, USA: Jossey-Bass Inc
Publishers.
Hunter, M., Ussher, J., Cariss, M., Browne, S., &
Jelly, R. (2002). A randomised comparison of
psychological (cognitive behaviour therapy, CBT),
medical (fluoxetine) and combined (CBT and
fluoxetine) treatment for women with Premenstrual
Dysphoric Disorder. Journal of Psychosomatic Obstetrics
and Gynaecology (in press).
Hunter, M.S., Swann, C., & Ussher, J.M. (1995). Seeking
help for premenstrual syndrome: Women’s self-reports
Copyright  2002 John Wiley & Sons, Ltd.
329
and treatment preferences. Sexual and Marital Therapy,
10, 253–262.
Johnson, S.K. (1998). The biopsychosocial model and
chronic fatigue syndrome. American Psychologist, 53,
1080–1081.
Jones, A., Theodos, V., Canar, W.J., Sher, T.G., &
Young, M. (2000). Couples and premenstrual
syndrome: Partners as moderators of symptoms?
In K.B. Schmaling (Ed.) Comparative treatments for
relationship dysfunction. (pp. 217–239). Washington, DC,
USA: American Psychological Association.
Kessel, B. (2000). Premenstrual syndrome. Advances in
diagnosis and treatment. Obstetrics and Gynecology
Clinics of North America, 27, 625–639.
Kirkby, R.J. (1994). Changes in premenstrual symptoms
and irrational thinking following cognitive-behavioural
skills training. Journal of Consulting and Clinical
Psychology, 62, 1026–1032.
Kirkby, R.J., & Lindner, H. (1998). Exercise is linked to
reductions in anxiety but not premenstrual syndrome
in women with prospectively-assessed symptoms.
Psychology, Health and Medicine, 3, 211–222.
Konandreas, G.K. (1990). The effect of biofeedback and
relaxation on premenstrual syndrome. Dissertation
Abstracts International, 51(1-B), 433.
Koons, S.R. (1999). Cognitive-behavioral symptom
management of premenstrual dysphoric disorder: A
multi-element design with replications. Dissertation
Abstracts International: Section B: The Sciences and
Engineering, 60(5-B), 2346.
Kuczmierczyk, A.R. (1989). Multi-component behavioral
treatment of premenstrual syndrome: A case report.
Journal of Behavior Therapy and Experimental Psychiatry,
20, 235–240.
Lee, J. (1997). Women re-authoring their lives through
feminist narrative therapy. Women and Therapy, 20,
1–22.
Levitt, D.B., Freeman, E.W., Sondheimer, S.J., & Rick-
els, K. (1986). Group support in the treatment of PMS.
Journal of Psychosocial Nursing and Mental Health Services,
24, 23–27.
Miles, M.B., & Huberman, A.M. (1994). Qualitative data
analysis: An expanded sourcebook (2nd ed.). Thousand
Oaks, CA, USA: Sage Publications Inc.
Miota, P., Yahle, M., & Bartz, C. (1991). Premenstrual
syndrome: A bio-psycho-social approach to treatment.
In D.L. Taylor (Ed.), Menstruation and health
(pp. 143–152). Washington, DC, US: Hemisphere
Publishing Corp.
Mitchell, L.L., & Mitchell, C.W. (1998a). Effects of
premenstrual syndrome on coping style. Psychology:
A Journal of Human Behavior, 35, 2–10.
Mitchell, L.L., & Mitchell, C.W. (1998b). Premenstrual
syndrome personality alterations and psychological
type: An hypothesized, nonpathological explanation.
Journal of Psychological Type, 47, 12–20.
Mohan, V., & Chopra, R. (1992). A follow-up study of
personality of high premenstrual tension syndrome
group. Journal of Personality and Clinical Studies, 8,
67–70.
Morse, C., Bernard, M.E., & Dennerstein, L. (1989). The
effects of rational-emotive therapy and relaxation
Clin. Psychol. Psychother. 9, 319–331 (2002)
330
training on premenstrual syndrome: A preliminary
study. Journal of Rational Emotive and Cognitive Behaviour
Therapy, 7, 98–110.
Morse, C.A., Dennerstein, L., Farrell, E., & Varnavides, K.
(1991). A comparison of hormone therapy, coping
skills training, and relaxation for the relief of
premenstrual syndrome. Journal of Behavioral Medicine,
14, 469–489.
Morse, G. (1997). Effect of positive reframing and social
support on perception of premenstrual changes among
women with premenstrual syndrome. Health Care for
Women International, 18, 175–193.
Morse, G. (1999). Positively reframing perceptions of
the menstrual cycle among women with premenstrual
syndrome. Journal of Obstetrics, Gynecologic, and Neonatal
Nursing, 28, 165–174.
Mortola, J.F., Girton, L., Beck, L., & Yen, S.S. (1990).
Diagnosis of premenstrual syndrome by a simple,
prospective, and reliable instrument: the calendar of
premenstrual experiences. Obstetrics and Gynecology,
76, 302–307.
Mostofsky, D.I., & Barlow, D.H. (Eds). (2000). The
Management of stress and anxiety in medical disorders.
Needham Heights, MA, USA: Allyn and Bacon Inc.
Nicolson, P. (1995). The menstrual cycle, science and
femininity: Assumptions underlying menstrual cycle
research. Social Science and Medicine, 41, 779–784.
Parry, B. (1994). Biological correlates of premenstrual
complaints. In J.H.S. Gold (Ed.), Premenstrual dysphoria:
Myths and realities (pp. 47–66). London: American
Psychiatric Press.
Pearlstein, T., Rivera Tovar, A., Frank, E., & Thoft, J.
(1992). Nonmedical management of late luteal phase
dysphoric disorder: A preliminary report. Journal of
Psychotherapy Practice and Research, 1, 49–55.
Potter, J.W.M. (1986). Discourse and social psychology.
London: Sage.
Reissman, C.K. (1993). Narrative analysis. London: Sage.
Rittenhouse, C.A. (1991). The emergence of premenstrual
syndrome as a social problem. Social Problems, 38,
412–425.
Ryser, R., & Feinauer, L.L. (1992). Premenstrual
syndrome and the marital relationship. American Journal
of Family Therapy, 20, 179–190.
Slade, P. (1989). Psychological therapy for premenstrual
emotional symptoms. Behavioural Psychotherapy, 17,
135–150.
Smith, D. (1988). Femininity as discourse. In L. Roman,
& L.K. Christian Smith (Eds), Becoming feminine: The
politics of popular culture. Brighton: Falmer Press.
Steiner, M. (2000). Premenstrual syndrome and
premenstrual dysphoric disorder: Guidelines for
management. Journal of Psychiatry and Neuroscience, 25,
459–468.
Steiner, M., & Born, L. (2000). Diagnosis and treatment
of premenstrual dysphoric disorder: an update.
International Clinical Psychopharmacology, 15(Suppl. 3),
5–17.
Stenner, P. (1993). Discoursing jealousy. In E. Burman,
& I. Parker (Eds), Discourse Analytic Research
(pp. 114–134). London: Routledge.
Copyright  2002 John Wiley & Sons, Ltd.
J. M. Ussher, M. Hunter and M. Cariss
Stoppard, J. (2000). Understanding depression: Feminist
social constructionist approaches. London: Routledge.
Toner, B.B. (1994). Cognitive behavioural treatment of
functional disorders. Cognitive and Behavioural Research,
1, 157–178.
Ussher, J.M. (1989). The psychology of the female
body. Florence, KY, USA: Taylor and Fran-
cis/Routledge.
Ussher, J.M. (1991). Women’s madness: Misogyny or
mental illness? Amherst, MA, USA: University of
Massachusetts Press.
Ussher, J.M. (1992). Research and theory related to female
reproduction: Implications for clinical psychology.
British Journal of Clinical Psychology, 31, 129–151.
Ussher, J.M. (1996). Premenstrual syndrome: Reconciling
disciplinary divides through the adoption of
a material–discursive epistemological standpoint.
Annual Review of Sex Research, 7, 218–251.
Ussher, J.M. (1997a). Towards a material–discursive–
intrapsychic analysis of madness, sexuality and
reproduction. In J. Ussher (Ed.), Body talk: The material
and discursive regulation of sexuality, madness and
reproduction. London: Routledge.
Ussher, J.M. (1997b). Body talk: The material and discursive
regulation of sexuality, madness and reproduction. London:
Routledge.
Ussher, J.M. (1997c). Fantasies of femininity: Reframing the
boundaries of sex. London: Penguin.
Ussher, J.M. (1999). Premenstrual Syndrome: Reconciling
disciplinary divides through the adoption of
a material–discursive–intrapsychic approach. In
A. Kolk, M. Bekker, & K. Van Vliet (Eds), Advances in
women and health research. (pp. 47–64). Tilberg: Tilberg
University Press.
Ussher, J.M. (2000). Women’s madness: a mate-
rial–discursive–intrapsychic approach. In D. Fee (Ed.),
Psychology and the postmodern: Mental illness as discourse
and experience (pp. 207–230). London: Sage.
Ussher, J.M. (2002a). The role of Premenstrual Dysphoric
Disorder in the subjectification of women. Journal of
Medical Humanities (in press).
Ussher, J.M. (2002b). PMS as a relational issue. Journal of
Family Therapy (in press).
Ussher, J.M. (2002c). Processes of appraisal and coping
in the development and maintenance of Premenstrual
Dysphoric Disorder. Journal of Community and Applied
Social Psychology (in press).
Ussher, J.M., Hunter, M., & Browne, S.J. (2000). Good,
bad or dangerous to know: Representations
of femininity in narrative accounts of PMS.
In C. Squire (Ed.), Culture and psychology
(pp. 87–99). New York, NY, USA: Routledge
Falmer.
Walker, A. (1995). Theory and methodology in
Premenstrual Syndrome research. Social Science and
Medicine, 41, 793–800.
Warren, C.J., & Baker, S. (1992). Coping resources of
women with premenstrual syndrome. Archives of
Psychiatric Nursing, 6, 48–53.
Winter, E.J., Ashton, D.J., & Moore, D.L. (1991).
Dispelling myths: a study of PMS and
Clin. Psychol. Psychother. 9, 319–331 (2002)
Psychological Intervention for PM symptoms
relationship satisfaction. Nurse Practitioner, 16,
34, 37–40, 45.
Woods, N.F., Mitchell, E.S., & Lentz, M.J. (1995). Social
pathways to premenstrual symptoms. Research in
Nursing and Health, 18, 225–237.
Yardley, L. (1996). Reconciling discursive and materialist
perspectives on health and illness: A reconstruction of
Copyright  2002 John Wiley & Sons, Ltd.
331
the biopsychosocial approach. Theory and Psychology, 6,
485–508.
Yardley, L. (Ed.). (1997). Material discourses of health
and illness. Florence, KY, USA: Taylor and
Francis/Routledge.
Clin. Psychol. Psychother. 9, 319–331 (2002)