CHAPTER FOUR
THE FEMALE CAREER AS A PSYCHIATRIC PATIENT
The insistence that femininity evolves from necessarily frustrated masculinity makes femininity a sort of “normal pathology.”
Judith Bardwick1
SINCE CLINICIANS AND RESEARCHERS, as well as their patients and subjects, adhere to a masculine standard of mental health, women, by definition, are viewed as psychiatrically impaired—whether they accept or reject the female role—simply because they are women. Given this fact, it is not surprising that many studies report greater female than male “neurosis” or “psychosis,” often regardless of nationality, marital status, age, race, or social class. Psychologists and sociologists have always considered women as part of the social class their husbands and fathers belong to. This is not a valid classification, from either a psychological or an economic point of view.
In the past, women saw themselves as “troubled” or “disturbed.” They were also viewed as such by relatives and by mental health professionals. Thirty to forty years ago, women in America, England, Canada, and Sweden were seen and considered themselves as more “disturbed” than their male counterparts. A study published by the U. S. Department of Health, Education, and Welfare indicated that, in both the black and white populations in America, more women than men reported having suffered nervous breakdowns, having felt impending nervous breakdowns, psychological inertia, and dizziness.2 Both black and white women also reported higher rates than men for the following symptoms: nervousness, insomnia, trembling hands, nightmares, fainting, and headaches.
White women who were never married reported fewer symptoms than white married or separated women. These findings are essentially in agreement with an earlier study published by the Joint Commission on Mental Health and Illness.3 The Commission reported the following information for non-hospitalized American adults:
(1)Greater distress and “symptoms” were reported by women than by men in all adjustment areas. Women reported more disturbances in general adjustment, in their self-perception, and in their marital and parental functioning. This sex difference was most marked at the younger age intervals.
(2)A feeling of impending breakdown was reported more frequently by divorced and separated females than by any other group of either sex.
(3)The unmarried (whether single, separated, divorced, or widowed) had a greater potential for psychological distress than did the married. This was a very controversial issue. For instance, in a study of the psychiatric “health” of the Manhattan community, higher psychiatric “impairment” was found among single men when compared with married men than among single women when compared with married women. Among married people the sexes did not differ in the proportions rated psychiatrically “impaired.”4 The HEW report also documented the fact that single white women in the general population reported less “psychological distress” than married or separated white women. Hagnell, in his study of a Swedish population, found a higher probability of mental disorder in married than single women. Perhaps women who were single and employed behaved, in some ways, more like men than married women do: as such they were seen as “healthy”—but only up to a point.
(4)While the sexes did not differ in the frequency with which they reported “unhappiness,” the women reported more worry, fear of breakdown, and need for help.
Dr. Dorothy Leighton et al.,5 in a study of English- and French-speaking Canadians, found that women had a higher risk of “psychiatric disorder” than did men, at all ages (twenty to seventy), and that “symptomatology” increased with age. Dr. Olle Hagnell found a greater incidence of “mental disorder” among Swedish women than men.6
In the years between 1960 and 2005, it became clear to me that men, not women, were jailed for dysfunctional, unbalanced, and anti-social behavior, but were not necessarily diagnostically pathologized for it; male criminals, including drug addicts and alcoholics, did not necessarily see themselves as “mentally ill,” nor were they viewed by others this way.
In this same period of time, more women than ever before were also jailed for drug- and aggression-related crimes, but they were often viewed as “mentally ill,” not as master career criminals. Many imprisoned women have been beaten and raped in childhood and battered or prostituted as adults; they often find that jail is the first time in their lives where they can lead relatively violence-free lives. They are often very eager to join therapy groups in prison.
In 2000, Elizabeth A. Klonoff, Hope Landrine, and Robin Campbell found that women, more than men, had more “depressive, anxious, and somatic symptoms” because women “experienced a deleterious stressor that men do not: sexist treatment.” In fact, those women who experienced “frequent [or violent] sexism” (rape, battery) had “significantly more symptoms” than either men did or than other women did whose experience of sexism was less. Therefore, in their opinion, “gender specific stressors” play a role in “psychiatric symptoms among women” and may also account for “well-known gender differences in those symptoms as well.”
In other words, gender-violence leads to suffering and to diagnosable psychiatric symptoms. So, even though there is much to criticize about what the various versions of the DSM are actually diagnosing, it is also clear that oppression and violence in general and gender-violence in particular lead to a variety of “mental disorders,” and that women are therefore truly suffering—and are also being diagnosed in various ways.
In 2000–2001, the World Health Organization (WHO) found that more women than men, worldwide, suffer from gender-violence and therefore from specific kinds of “mental illness.” The WHO also relates the various female symptoms to “gender specific risk factors such as gender based roles, stressors, negative life experience … gender-based violence, socioeconomic disadvantage, low income and income inequality … and unremitting responsibility for the care of others.” It also indicates that sexual violence is very high for women, worldwide, and that women suffer from a “correspondingly high rate of Traumatic Stress Disorder (PTSD).” WHO estimates that a “lifetime prevalence rate of violence against women ranges from 16%-50%” and that one in five women suffer rape or attempted rape.”
In 2001, the National Institute of Mental Health (NIMH) reported that 22 percent of Americans (or 50 million people) suffer from a diagnosable mental disorder; that four of the ten leading causes of disability in the United States and other developed countries is a “mental disorder” such as depression, bi-polar disorder, obsessive-compulsive disorder, anxiety disorder, eating disorder, post-traumatic stress disorder. According to the NIMH’s statistics, approximately 18.8 million Americans are depressed in a given year. Interestingly, while NIMH does note that eating disorders are primarily a female problem, it does not provide a gender breakdown of the most frequently diagnosed illnesses.
And, in 2003, a study by Dr. Badri Rickhi et al. found that more Canadian women sought “complementary therapy” for a variety of reasons than did their male counterparts.
A double standard of mental health—combined of course, with misogyny and the female help-seeking and distress-reporting role—affects women far more seriously than by presenting relatively unflattering academic studies of them. Only some of the studies mentioned above are concerned with how many of these “psychologically distressed” women are also in various kinds of psychiatric and psychological treatment.
Many factors have already been discussed that would suggest or predict a large female involvement with psychiatric facilities. For example, the real oppression of women—which leads to real distress and unhappiness; the conditioned female role of help-seeking and distress-reporting—which naturally leads to patient “careers” as well as overt or subtle punishment for such devalued behavior; the double or masculine standard of mental health used by most clinicians—which leads to perceiving the distressed (or any) female as “sick,” whether she accepts or rejects crucial aspects of the female role. Men are not usually seen as “sick” if they act out the m
ale role fully—unless, of course, they are relatively powerless contenders for “masculinity.” Women are seen as “sick” when they act out the female role (are depressed, incompetent, frigid, and anxious) and when they reject the female role (are hostile, successful, and sexually active—especially with other women). Large female involvement with psychiatric facilities is also predicted by the comparatively limited social tolerance for “unacceptable” behavior among women—which leads to comparatively great social and psychiatric pressure to adjust—or be judged as neurotic or psychotic; the female need for some sort of vacation from the female role, yet one that would satisfy her needs for dependence and nurturance; and finally, the female nature of the psychotherapeutic and hospital institutions—which leads to their being accepted more easily by women than by men. Additional facts would also predict a large and increasing female psychiatric population. For example, female longevity, coupled with the relative shortening of the child-rearing years (and the emphasis on female youth), leaves many women “unemployed” at an early age; just as public employment discrimination against women and lack of job training and opportunities leave most women “unemployed” at every age—and with few alternatives to home life.
The data documents a consistently large female involvement with psychiatry and psychotherapy in America, an involvement that has been increasing rather dramatically since 1964. During the 1960s, adult women, far more than adult men, constituted the majority of private psychotherapy patients, as well as the majority of patients in general psychiatric wards, private hospitals, public outpatient clinics, and community mental health centers.7
A pattern of frequent and recurring hospital commitments, as well as lengthy stays, seems to characterize the female “career” as a psychiatric patient.8 There is some evidence that women are detained longer and die sooner than men with the same psychiatric diagnosis, and that the personality characteristics of long-term hospital “stayers” are “feminine” in nature.9 Although more men than women are admitted to state and county hospitals, women are detained for longer periods—especially women over thirty-five.
The female “career” as a psychiatric patient in America seems to follow a certain pattern as a function of age, marital status, social class, race, and most certainly, “attractiveness” (of course, this last is hard to document). It is important to remember that many more people are hospitalized for “mental illness” than for “mental retardation”—a basically genetic and biological phenomenon which, as a biological event shows a relatively stable prevalence rate over time. “Mental illness,” a primarily cultural event, increases and decreases over time. Also, more people may be incarcerated or diagnosed and treated in America for “mental illness” than for criminal offenses.
Thirty to forty years ago, women were most concentrated in outpatient facilities between the ages of twenty and thirty-four. Kadushin noted that among all the private therapy patients he surveyed, “young housewives [had] the most complaints.”10 In terms of age, twenty to thirty-four are women’s “prettiest” and childbearing years. Even if they are “unhappy” or functioning at low levels, their child-rearing responsibilities and/or sexually youthful appearance keep them within the “outside” patriarchal institutions such as marriage and private psychotherapy. The largest number of women in both general and private hospitals (institutions where women have predominated as psychiatric patients) were between the ages of thirty-five and forty-four. This was also true for men, but there were still significantly fewer men than women in this age bracket who were psychiatrically hospitalized. White and/or wealthy women in private hospitals, women of color and/or poor women in general psychiatric wards are reacting to being both overworked and, paradoxically, to the beginning signals of their sexual and maternal “expendability.” Hospitals provide them with warning therapy (via pills, shock treatments, and humiliation) to make as little protest about this state of affairs as possible. If they persist in being “depressed” about this state of affairs, or reacting with “hostility,” repeated or longer confinements in private and public hospitals await them. State and county asylums function as a final dumping-ground for “old” women.
The female “career” as a psychiatric patient requires a closer and more thoughtful analysis than statistics or small-sample studies can yield. Therefore, I wanted to talk to women about their patient experiences. I was curious to see to what extent the kind of psychiatric patient “career” suggested by national statistics also exists at a grassroots level. I also wanted to see how much my theoretical approach to “madness” would describe the circumstances surrounding female psychiatric hospitalization or treatment. I wanted to see how many of the clinical biases I outlined in Chapter Three would be spontaneously reported by “naive” women.
THE INTERVIEWS
As women, most of our lives with men are dramatic and theatrical affairs. We “play” at being women; we dress up like Mommy—for Daddy’s sake; we’re always on stage, working at being some other woman—a “beautiful” woman, a “happy” woman, a well-paid-for woman.
Our lives with women are generally less dramatic. The “play,” for better or worse, ended long ago. We talk more to women. Men don’t have the time, the interest, or the capacity to engage in “woman’s talk”—which never seems to “go” anywhere and often makes no “sense.” Thus, dialogue, words, interviews between women, reveal more about the female condition than do test scores or statistics.
I spoke with sixty women, whose ages ranged from seventeen to seventy, about their experiences in private therapy and mental asylums. Collectively, their experiences spanned a quarter century and a continent (from Rhode Island to California). Two women were in private therapy and mental asylums in England. The majority of these experiences took place in large cities in New York, New Jersey, Illinois, and California.
The interviews were very informal and were held in either of our homes, over long cups of coffee, and often more than once. They were tape-recorded—as long as and whenever it didn’t interfere with spontaneity or rapport. I encouraged and answered any questions about myself and about why I was, in effect, “interviewing” them. I did have a standard questionnaire form, which usually wasn’t properly filled out (by either the women or myself). We tended to “talk out” the details. I participated very actively in the conversations and, after no more than an hour’s grace, expressed my own views.
I met some kindred spirits—and some not; I made and received many midnight phone calls, some of which were exhausting and depressing. Hope often united with humor: for example, when someone would exclaim, with great surprise, that she was “telling me things she would never even tell her therapist!” I was as exhilarated as an amateur detective when different women told me about the same therapist or hospital. Unknowingly, they duplicated and corroborated one another’s experiences, and helped me re-create several years in the life of a particular therapist or hospital. I was more exhilarated when several of the women, who at first were even reluctant to talk to me privately, attended professional conferences of psychiatry and psychology some four months later in New York City where they were very vocal, angry, and thoughtful about their experiences.
More often, sorrow, anger, helplessness, and guilt marked my interviewing days. I remember arguing with someone about whether or not she was “crazy”: after six years of therapy and two hospital commitments, she thought she was, I thought she wasn’t. Slowly, some remembered fear silenced her. Slowly, and quite emphatically, she began agreeing with me—with Dr. Chesler, of course. (There is a possibility that that type of “experimenter effect” happened throughout the interviews—without my awareness. My report of the interviews, like any scientific or artistic report, will be as “truthful” as my sensitivity, integrity, and basic premises allow). I helped a lonely and unmarried woman avoid an unwanted psychiatric commitment. Afterward, quite understandably, she wanted to live with me “for a while.” I offered her money and other temporary shelters, both of which she refus
ed. I never saw her again. I was constantly asked to find lawyers, physicians, employers, landlords, therapists, and baby sitters. I failed these requests more often than not. I am not by temperament a “social worker.” My failings and strengths are those of an intellectual and an artist rather than those of a “crisis-intervener” or an organizer. However, these requests for help were from women who were less in need of “social work” than of a station on a feminist underground railroad.
At no time did I wish to classify these already “overclassified” women. I did, however, originally seek them out in terms of one of five categories of experience. These women comprise a non-random sample, in that they were sought because they had certain kinds of experiences: women who (1) had sexual relations with their therapists (SWT women); (2) had been hospitalized in mental asylums (MA women); (3) were lesbians (The word “lesbian” is problematic: it identifies a woman as strictly in terms of her sexual activities as the word “woman” does. It also, unfortunately, has a historically negative valuation. However, many lesbians think it a very “respectable” word—and those who don’t, think it should be used more often and positively in order to make it so); (4) were Third World women (TW women); and (5) were feminists in therapy. This categorization wasn’t simple. For example, in talking to a particular lesbian about her experiences in private therapy, it sometimes became apparent that she had also been psychiatrically hospitalized and had since become a feminist. Some Third World women, feminists, and SWT women had also been psychiatrically hospitalized. Naturally, since they were all women, their “psychiatric careers” often turned out to be rather extensive.
Table 1 presents a comparison of these five groups in relation to some aspects of their psychiatric patient careers. Fifty-four women are presented. Of the original sixty interviewed, five women were sexually propositioned by their therapists and refused him. They are not here included. One black woman who was also a lesbian but who had no private therapy experience, is not included either. As is indicated, the averages for a particular variable within each experience-category are based on a different number of women. Not all the SWT women were psychiatrically hospitalized (only four were, as compared to eleven MA women); not all the women in any of the five categories ever saw a female therapist, etc. Thus, there are usually unequal and often small numbers of women being compared on a particular category average. I decided not to run any statistical tests for this reason—and for a more important reason. Those trends that are important are as visible to my eye as to your own. Trends which echo those found in the national statistics (and there are many) will be better understood by an intelligent discussion of the individual interviews than by a clean bill of statistical “health.” Also, each of these fifty-four women has a universe of experience to relate—a universe that cannot be inhabited by any other woman. And what happened to this group as a whole happened absolutely. However, their experiences seem to parallel and make human sense out of the studies and statistics cited earlier.
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