Women and Madness

by Phyllis Chesler

  Psychologist Jane Ussher, author of Women’s Madness: Misogyny or Mental Illness, writes, “In Britain, women are still more likely than men to be diagnosed and treated as mad. Sexual abuse of women still abounds—both inside and outside psychiatric institutions. There may now be more women working as clinical psychologists but the professional discourse (still) reifies psychiatric taxonomies through diagnosis and categorization of female ‘symptoms.’”

  In 1993–94, a student at a well-known East Coast college led a campus campaign against the male head of Psychological Services, who eventually resigned rather than face a college-ordered review. The student writes that, specifically, he “either ignored eating disorders or encouraged dieting in normal weight or anorexic students. He blamed female students when their boyfriends hit them; he sometimes encouraged them to remain in violent partnerships. He involuntarily withdrew students in crisis from the school based on his reading of the college’s legal liability.” In one case, he vigorously attempted to involuntarily withdraw an incest victim who was experiencing flashbacks, which nearly forced her to return to the incestuous home.

  Although he was not an MD, he asserted strong, sometimes incorrect, positions on medication. Although he disapproved of psychiatric medication, he encouraged the use of birth control pills by depressed female students. In addition, he failed to properly diagnose major psychiatric disorders and failed to properly assist students who required emergency psychiatric hospitalizations.

  The early studies I cited in Women and Madness on therapist bias have, sadly, been confirmed many times over. For example, in 1993, Drs. Kenneth Pope and Barbara Tabachnik published their findings that therapists are far from “neutral.” Eighty-seven percent of 285 randomly selected clinical psychologists admitted they were “sexually attracted to a client,” and 58 percent admitted feeling “sexually aroused while in the presence of a client.” Between 64 and 78 percent admitted they were “angry” at their patients for a variety of reasons; nearly a third reported “hating” a client, and 46 percent said they had been so angry that they had done something to the patient they later regretted.

  Few therapists are taught to expect intense emotions toward their clients, or how to deal with such emotions.

  THE TWENTY-FIRST CENTURY

  In 2005, Drs. Paula J. Caplan and Lisa Cosgrove published an excellent anthology titled Bias in Psychiatric Diagnosis. It confirms that many of the bias areas I first raised in Women and Madness, including sexism, racism, classism, and homophobia still exist. However, the volume extends the biases to include those against the aged, the mentally retarded, the learning disabled, and against those who suffer from eating disorders; it also challenges several legally as well as clinically relevant diagnostic categories such as “posttraumatic stress disorder,” “false memory syndrome,” and “parental alienation syndrome.” It is masterful in its discussion of the Diagnostic and Statistical Manual of Mental Disorders.

  In an article in this same volume, Drs. Jeffrey Poland and Paula J. Caplan present how bias continues in psychiatric diagnosis. They discuss real-life biases such as having to pathologize or diagnose a patient in order to receive insurance reimbursement. In addition, when clinicians are overworked and have limited time in which to see and diagnose a patient, they may literally jump to [false] conclusions. Clinicians may “tend to seek out and record information that confirms previously held beliefs and expectations and ignore or minimize information that fails to fit in … [clinicians also] tend to assign a higher priority to initial information received rather than to subsequently collected information.”

  In 2005, in the same volume, Autumn Wiley reviewed ten widely used undergraduate textbooks in abnormal psychology. Shockingly, she found that none included the feminist critique of institutional psychiatry and diagnostic practices; seven of the ten texts included no mention of sex or gender bias; and none of fourteen major feminist critics is cited in any of the books. Such feminist critics include Laura Brown, Paula J. Caplan, myself, Beverly Greene, Rachel Hare-Mustin, Hannah Lerman, Lynn Rosewater, and Lenore Walker.

  Wiley concludes that “decades of feminist criticism have had little impact on the way that authors of abnormal psychology textbooks present the DSM. The absence of that criticism from the textbooks is not because it is not available or of the highest quality.”

  Thus, although there has been enormous progress—a sea change even—the clinical biases that I first wrote about in 1972 still exist today. Many clinical judgments remain clouded by classism, racism, anti-Semitism, homophobia, ageism, sexism, and by cultural and anti-immigrant biases as well. I have reviewed hundreds, possibly thousands, of psychiatric and psychological assessments in matrimonial, criminal, and civil lawsuits. The clinical distrust of mothers, simply because they are women, the eagerness to bend over backwards to like fathers, simply because they are men is mind-numbing. Mother-blaming and woman-hatred sizzle on each clinical page. Mothers are often psychiatrically accused of alienating a child from the child’s father if that child does not resent or hate the mother, or prefer the father.

  Unbelievable—yes?

  Even those clinicians who are less likely to gender-stereotype still exhibit an (often unconscious) preference for men over women. Their sexism may be sophisticated, subtle. Sometimes, female clinicians are much harder on women than are male clinicians. They may feel they have to be—as a way of distancing themselves from a despised group.

  For example, one 1990 study confirmed that there was less gender-stereotyping among psychiatrists in 1990 than in 1970. However, more of the female psychiatrists rated masculine traits as optimal for female patients while more male psychiatrists chose more undifferentiated, androgynous traits as optimal for both male and female patients.

  Thus, women mental health professionals are not necessarily more objective or neutral about other women than their male counterparts are. Like men, women hold sexist views. Perhaps this is psychologically similar to people of color who prefer light skins and who have internalized racist views. The refusal to acknowledge such views makes it impossible to resist them.

  In general, women psychologically and socially matter to each other so much that they tend to expect too much from each other. The smallest error, the most minor disappointment between women is often magnified and resented. A woman can go from being a Fairy Godmother to being an Evil Stepmother in a flash. Also, women are afraid to blame men but are not afraid to blame other women.

  For example, many women report that they are far angrier at their mothers than at the fathers who raped them, far angrier at the women who refused to believe that they were raped than at their rapists. Precisely because female-female intimacy and sympathy are so important to women, it is quite painful when female intimates are not “there” for a rape or incest survivor.

  According to psychoanalysts Judith Lewis Herman and her mother, the late Helen Block Lewis, daughters in (incestuous) families feel “deeply betrayed” by their mothers. Such daughters feel that they have been “offered as a sacrifice in order to propitiate a powerful male, and they despise their mothers.” They also learn to expect no help from other women. Some daughters fight back or exact revenge—but mainly against their mothers.

  Thus, continuing clinical bias affects patients in at least five important areas: (1) Women—and to a lesser extent, men—with medical illnesses are often, and wrongfully, psychiatrically diagnosed and medicated; (2) Women who allege rape, incest, battery, sex discrimination, or harassment are being ordered into therapy and/or diagnostically pathologized at trial; (3) Women (and men) who have no money and no insurance cannot afford therapy nor are they always respected or understood by therapists who are mainly middle-class in orientation; (4) Women—and to a lesser extent, men—of color, immigrants, Semites, including Jews, still face an extra level of clinical fear and hostility; (5) Psychotherapist-patient sexual abuse still exists.

  WRONGFUL PSYCHIATRIC DIAGNOSES OF MEDICAL ILLNESSES

  When I first e
xplored sexist bias among mental health professionals in 1972, I did not realize that when western medicine does not understand and/or cannot cure an illness, it often first denies that the illness is real by saying it is merely a psychiatric disorder. As if mental illness isn’t real.

  Increasingly, women with disabling medical illnesses are being psychiatrically diagnosed and sedated rather than tested or treated for a non-psychiatric illness. Just as asthma and arthritis were once viewed as psycho-somatic, today lupus, multiple sclerosis, Lyme’s disease, chemical and food allergies, Gulf War Syndrome, Chronic Fatigue Immune Dysfunction Syndrome, and certain neurological and endochronological diseases are still being dismissed as primarily psychiatric in nature. Patients—usually women—are told, both by psychologists and psychiatrists, that they are probably imagining their pain, that their illness is all in their heads. Often it is not.

  While I also believe that psyche and soma are one, I know that viruses, parasites, bacteria, fungi, sexually transmitted diseases, and toxic chemicals are real and can cause neurological and cognitive dysfunction. Depression is real too, and has a neurochemical basis; however, depression can also be a secondary symptom of chronic pain.

  Many psychiatric inpatients are still not believed when they complain of physical pain. Non-psychiatric medical care is often withheld until a patient collapses—or is discovered to have a terminal illness, long past treating.

  THE DIAGNOSTIC PATHOLOGIZING OF WOMEN WHO REPORT RAPE, HARASSMENT, DISCRIMINATION, BATTERY, AND OTHER ABUSES

  I must repeat: I had an excellent education. Only, I was not taught that women or people were oppressed and that oppression and discrimination traumatizes people.

  It took a women’s liberation movement to teach me that. It took listening to and talking to women—not as inferior patients but as sisters in a struggle for social justice—to understand that most women did not receive equal pay for equal work and that this had definite psychological and medical consequences; did suffer physically as well as psychologically when they menstruated or went through menopause; were sexually harassed on the job; and were victims of violence at home.

  It took years for the women’s liberation movement to understand that the most common forms of rape were among intimates, not strangers; that rape was rarely reported and even more rarely prosecuted; that rape is no longer a spoil of war but has increasingly been used as a weapon of war—for example, in Algeria, Bosnia, Rwanda, and the Sudan.

  However, despite all that we have learned, today, when women allege sexual harassment or sex discrimination they are sometimes disbelieved or blamed; have often been punitively diagnosed for having a normal human reaction to trauma. Sometimes, when women charge rape or sexual harassment, some truly strange things can happen.

  For example, in 2005, Jessica Brakey, an Air Force Academy cadet, was one of two women who charged an Air Force officer with sexual assault. Brakey’s mental health counselor, Jennifer Bier, was ordered to turn over her session notes. So far, Bier has refused to do so. In other words, if a rape victim appropriately seeks counseling, what she says can and will be used against her in a court of law. What this usually means is that the rape victim will be portrayed as “crazy” or as a “slut.”

  Here’s another example. In the early 1990s, Lieutenant Darlene Simmons, a Navy lawyer, was ordered to take a psychiatric exam after she accused her commander of sexual harassment. A psychiatric exam? How absurd. How familiar.

  And, in the late 1980s, Dr. Margaret Jensvold, herself a psychiatrist and the winner of a prestigious fellowship at the National Institute of Mental Health (NIH), complained that her supervisor, Dr. David Rubinow, repeatedly denied her opportunities that her male counterparts enjoyed to conduct scientific research and publish her findings. Jensvold also accused Rubinow of making sexist comments, thereby creating a hostile work environment. Jensvold was “advised” to see a psychotherapist if she wished to stay at NIH. The psychiatrist she was referred to was also an NIH employee and could not guarantee confidentiality. Ultimately, Jensvold was fired. She sued.

  Jensvold is at least the second woman researcher at NIH who filed discrimination and harassment charges. Psychiatrist Jean Hamilton, who settled an EEOC complaint in 1986 against the same supervisor, testified on Jensvold’s behalf that women researchers were routinely called names like witch, wicked bitch, booby lady, and, more benignly, sugar.

  CLASS BIASES

  According to psychotherapist Marcia Hill, “Class and classism is in the position that gender and sexism was thirty years ago: denied, surrounded with myth, silenced.” Women may constitute a caste but, if every woman is, indeed, one man away from welfare or homelessness, to what class do women themselves belong? If educated and accomplished women earn far less than their male counterparts, and remain as vulnerable to male violence as other women are, in what sense are they middle class? If a working-class woman is the (only) head of household, and is treated with the respect usually reserved for men only, in what sense is she working-class? According to psychotherapist Bonnie Chalifoux, “Working-class women live on a fault-line, as Lillian Rubin has described it. They are only one crisis away from falling into poverty, and they walk the line without a safety net.”

  We don’t have the answers to these questions, but myths about class still abound among both psychiatrists and psychotherapists, (e.g. a wealthy woman is spoiled and is probably only faking neurosis in order to get attention). A poor woman can’t afford neurosis—she has to keep going, no matter what. When the workload, stress, heartbreak, and tragedies mount up, and she cracks up—as most human beings would under similar circumstances—many psychiatrists may think: Nothing to do but diagnose, medicate, and ship her off to an institution. She can’t afford private therapy anyway.

  Actually, these days, very few people can.

  Most early feminist theories about women were really about white, heterosexual, middle-class, educated women. By definition, such theories rendered both poor and wealthy women “other.”

  In my time, psychotherapists were trained to “analyze” late fee payments as resistance to therapy. However, in 1996, Marcia Hill wrote, “Those with few economic resources sometimes avoid both paying and talking about the problem. The avoidance is, in my experience, more likely to symbolize feeling helpless about money (and perhaps resentful about the cost of therapy) than to signify feelings about therapy per se. On the other hand, many people from working class or poor backgrounds are particularly conscientious about paying me, because they know the importance of getting paid for one’s work and feel pride in their ability to pay their bills. People with less money can find it very hard to take what they perceive as ‘charity,’ and I have sometimes found myself in the odd position of talking someone into paying me less.”

  RACE BIASES

  I do not assume that the more a woman is oppressed that the “stronger” she is. This is neither fair nor true. In fact, in Women and Madness, I wrote, “The problems of being both black and female in a racist and sexist society are staggering, the permutations of violence, self-destructiveness and paranoia endless…. Racism in psychiatric diagnosis and treatment is usually further confused by class and sex biases.”

  Just because I—and many others—have continued to challenge the diagnostic pathologizing of poor people, people of color, immigrants, and gay people does not mean that such practices have disappeared. Double and triple diagnostic and treatment standards still exist. Native-, African-, Hispanic-, and Asian American women have good reason to—and do—mistrust the mental health care system. They know they are often seen as inferior when they are at their psychological and moral best, and as commendably self-sufficient when they are about to expire of grief.

  Accordingly, many women of color are deeply suspicious of psychiatric medication and psychotherapy. Although they are more likely to be raped than white women, they may be less likely to report it to the police or to their families and, with dire consequences, less likely to seek help. If a woman is p
oor, or speaks no English, her chances of getting the psychological help she may need are often minimal. If she is also a lesbian, and angry—or actually freaking out—she’ll probably be diagnosed as more seriously ill than her white heterosexual counterpart.

  Many Latina Catholics and Asian women may feel too ashamed to report rape; they may not even think of it as “rape” but as “sex” (which is culturally forbidden to them outside of marriage, but not to men). If and when such women break down, emotionally, they may not even connect it to their having been raped. If their attackers are also members of their own race, or family, they may not want to sacrifice their attackers to a racist criminal justice system.

  Most women are trained to put their own needs second, the needs of any man—including a violent man—first.

  It is also important to remember that women of color are more at risk than their white counterparts. For example, according to one study, 78 percent of the women who were killed in New York City were killed at home by their husbands and boyfriends, or by someone they knew. Contrary to myth, this phenomenon was even more true of African American women who live in poverty.

  SEX BETWEEN PATIENT AND THERAPIST

  When I first wrote about sex between patient and therapist I was virtually alone; few others ever had written on the subject. Now, there are hundreds of studies, and many books, documenting this abuse of power. It hasn’t gone away, but at least it is being documented, as well as challenged. Patients are suing for damages; I and many other professionals are testifying on their behalf.