Psychiatry and feminism

Given the history of the treatment of women by psychiatry, it ought not to have come as a surprise when someone asked me recently if it was possible to be both a psychiatrist and a feminist. Many writers, particularly Elaine Showalter ^{Reference Showalter1} in The Female Malady: Women, Madness, and English Culture, 1830–1980 and Lisa Appignanesi ^{Reference Appignanesi2} in Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present, have catalogued this long and complex relationship.

For decades it must have seemed that psychiatry was in denial about its behaviour towards women. Sylvia Plath described the condescending way in which Esther Greenwood’s ‘conceited’ male psychiatrist Dr Gordon addresses her in The Bell Jar, ^{Reference Plath3} an attitude many of us, both patients and professionals will recognise – ‘Suppose you try and tell me what is wrong’ (p. 137). It may have been a novel, but it was her own experience. Phyllis Chesler’s interviews with women undergoing analysis in 1960s America, included in Women and Madness, ^{Reference Chesler4} exposed the problematic incidence and consequences of therapist (male) patient (female) sexual relationships. She was criticised by the psychiatric establishment for writing about it. Add to that Jon Stock’s very recent exploration of the appalling treatment of women by William Sargant in The Sleep Room, ^{Reference Stock5} in the 1950s and 60s in London, and there is plenty for us to reflect on. The specific experience of Black women in psychiatric institutions is a still neglected topic. ^{Reference Louis6} Misogyny and sexism are still with us, not only within society, where attitudes to women have deteriorated once again, ⁷ but also in psychiatry; not to the extent, perhaps, of Jessica Taylor’s view that ‘Psychiatry is patriarchy with a prescription pad’, ^{Reference Taylor8} but enough women have identified with that kind of statement to damage trust between women, feminists or not, and the profession.

At this point I should pause to say what I mean by feminism, of which there are almost as many different schools as there are of psychiatric thinking, including liberal, radical, Marxist and socialist feminism. ^{Reference Finlayson9} In Feminism is for Everybody, bell hooks ^{Reference Hooks10} provided a concise definition that has worked well for me: ‘Feminism is a movement to end sexism, sexual exploitation and oppression’. Although I am an older second-wave feminist, who ‘signed up’ as a teenager, my feminism is not about favouring women over men, or ‘man-hating’ as I was once accused of (by a senior colleague, no less, in the 1980s). It is about social justice. For those unfamiliar with the ‘waves’ of feminism, the first was about women getting the right to vote; the second about women’s place in the world: their right to choose, economic and legal rights and independence. The third wave looked for an intersectional approach to women’s struggles, focusing on issues of race and sexual orientation, and in the fourth wave women found their voice and power via the internet and social media – notably via #MeToo. (Some find the concept of waves unhelpful – and it has been observed that there are, anyway, enough of them in the sea.)

There have been moves in past decades to develop a ‘feminist psychiatry’; for example, by Hogie Wykoff and Joy Marcus at the Radical Psychiatry Center in California in the 1970s, ^{Reference Steiner, Wyckoff, Goldstine, Lariviere and Schwebel11} who eschewed individual therapy as ‘elitist’ and ran women-only groups where members could begin to deal with their oppression through a group problem-solving approach. Family therapy was also critiqued by feminists in the same period for not examining the ‘consequences of traditional socialisation practices that primarily disadvantage women’. ^{Reference Hare-Mustin12} Influential feminist psychotherapists, including Susie Orbach and Luise Eichenbaum at the Women’s Therapy Centre in London, emerged in the early 1970s; but mainstream feminist thinking has remained largely antagonistic to psychiatry, seeing psychiatric diagnosis and treatment as ways to blame, shame and control difficult women.

What, if anything, can we usefully learn from the principles of feminism that might improve care today for our patients – of any gender? How can psychiatry begin to address its historically difficult relationship with women, and what might we, as psychiatrists and other mental health professionals, consider doing differently in our everyday work?

How feminist thinking might inform psychiatry

Feminism theorists have explored many different themes. Here, because of space limitations, I will consider only four: feminist philosophy of science, feminist standpoint theory, feminist relational theory and feminist leadership.

Feminist philosophers of science have been critical of the way sexist values, assumptions and gender bias have influenced the structures, practice, research and content of established sciences. ^{Reference Wylie, Fricker and Hornsby13} When women are excluded from research, findings may be generalised without scientific basis. Differences may also be conceptualised unhelpfully in terms of gendered stereotypes that lack nuance – for example, depressed women as ‘passive and tearful’, and depressed men as ‘irritable and aggressive’. Feminist philosophy of science has helped to identify the role that particular social and cultural factors relating to sex and gender play in psychiatric diagnoses that are epidemiologically gendered, such as borderline personality disorder, eating disorders and depression. We still have a good deal to learn about how these factors interact with biology to explain, for example, the excess of women who are diagnosed with anorexia nervosa.

Feminist standpoint theory, ^{Reference Harding14} developed in the 1970s and 80s, prioritises thinking from the ‘standpoint’ of women’s or other marginalised lives, which it considers to be privileged sites of knowledge production. Because of their experiences of oppression, their standpoint, it suggests, provides insights into social power structures and realities that the dominant group in society (men) miss. This theory, which is rooted in Marxist ideas, allows us to challenge potentially biased knowledge. From her bedroom covered in yellow wallpaper, ^{Reference Gilman15} Charlotte Perkins Gilman’s protagonist provided a very different viewpoint of the world of a woman suffering from postnatal psychosis from that of her husband the doctor. Through the development of intersectional approaches, Kimberlé Crenshaw ^{Reference Crenshaw16} and bell hooks expanded this to include the key ‘other’ perspectives of race, class and sexuality. The importance placed within psychiatry in recent years of both listening to patients and genuine co-production with them is clearly relevant here, whether you accept that women have a privileged standpoint or not. It should also lead us to question the ‘gender neutral’ approach to the provision of mental healthcare, and what this means in practice (see below).

Feminist relational theory ^{Reference Koggel, Harbin and Llewellyn17} ‘uses the lens of relationships as a way of providing descriptions and analyses of the structures, institutions, norms and practices that shape individuals, social groups, and their specific and intersecting experiences of oppression’ (p. 4). Our desires, beliefs, values, experiences, everything that makes up who we see ourselves to be, indeed our narratives or ‘stories’ about our ‘self’ are shaped by the interactions between ourselves and those around us, including institutions such as our own, psychiatry, and develop over time. According to feminist psychologist Carol Gilligan, ^{Reference Gilligan18} women are more invested in social relationships and therefore more sensitive to their loss. As we move to a more relational approach to clinical practice in British psychiatry, with a welcome increased focus on the importance of developing collaborative therapeutic relationships, we might reflect on what could learn now from application of feminist relational theory.

The principles of feminist leadership ^{Reference Dean and Kawahara19} recognise that women and girls have developed different ways of leading because of our positions in the social and political hierarchy. Key tenets include accountability, collaboration, listening to diverse voices, empathic engagement, inclusive decision-making, transparency, taking the balance of power into account, self-reflection and not only self-care, but also care and regard for the team around you. It is about engaging with and empowering others. You do not have to be a woman to be a feminist leader, and these principles relate to our positions not only as team and opinion leaders within our profession, but clinicians working in collaboration with patients.

These feminist themes are relevant to both the profession as a whole and us as individual clinicians.

What the profession could do

A good place to begin to address the feminist standpoint on psychiatry might be to acknowledge, and own, psychiatry’s well-documented historical legacy of maltreatment of women, by not only teaching about, but being prepared to comment on, significant events in the recent past that might challenge our perceptions of previous leaders of the field. We need to listen, be honest and transparent.

We should be promoting understanding of how gender plays a significant role in how we experience mental health problems, its causes and consequences. My medical education, more than 40 years ago, was centred around the male body as the normative human being. That was at a time when there was no imperative even to include women in randomised controlled trials of treatment, because their pesky hormonal fluctuations got in the way of standardising groups and making comparison between subjects. My psychiatric education was similarly centred around the normative male patient, and even though so many of the patients I cared for were female, I was taught nothing of the impact of female hormones on mental health and the different effects of psychotropics on the male and female bodies. Much of that research has only recently been carried out. As the American feminist and legal activist Catherine Mackinnon wrote in Difference and Dominance: On Sex Discrimination:

Given the three-fold difference between suicide rates in men and women, It is tempting to view being a woman as somehow ‘protective’ in comparison to being a man. Unsurprising, because, as McKinnon has said, men are the reference point. Yet we still do not know enough about why women self-harm more than men or take their lives most commonly between the ages of 50 and 54. We cannot assume the reasons are the same for men and women. Our research questions should not only be gender sensitive, but we must provide sex/gender disaggregation of data in our research findings. ^{Reference Witt, Politis, Norton and Womersley21}

We should also be pressing for gender-sensitive mental healthcare. ^{Reference Judd, Armstrong and Kulkarni22} Consider the lack of attention until recently of the failure to provide adequate period products in wards. Rather than the profession, it has been patients at the forefront pressing for change, which is still wanting. ^{Reference Porter23} As Agenda Alliance’s research with young women, Pushed Out Left Out, their final Girls Speak report, demonstrated in 2022:

Gender neutrality is a concept that attempts to remove the notion of being male or female from a person or entity. It also encourages people, regardless of their sexual orientation or identity. to feel accepted, hence the adoption of gender-neutral language in recent years. But it is problematic when applied across the board to something like the provision of mental health care. Care must be informed by knowledge and understanding of gender differences and how they relate to childhood and adult life experiences, social, cultural and realities of family life, the experience and course of illness and treatment needs and responses. If it is not, our society’s entrenched bias towards the masculine reference point will prevail, even if we call it ‘neutral’.

To address issues observed from the standpoint of women, we should be raising awareness of the significant barriers that women face in society that impact on their mental health, ^{Reference Gask25} and helping women to address them by improving training in women’s mental health across the life cycle from teenage years to old age. From the impact of domestic violence and its association with suicide, sexual assault (including in our hospitals – which is not merely an issue of ‘sexual safety’ ^{Reference Torjesen and Waters26} ) and its consequences and the problems that continue to arise on mixed sex wards, to the intersectional factors experienced by Black and queer women. Women’s mental health is so much broader than perinatal mental healthcare (and it is welcome that this is now extending to include early-life mental healthcare). The serious lack of attention in the past to the sexual health needs of women with severe mental illness is now being addressed, but needs to be both more widely taught and implemented. ^{Reference Abel and Rees27} We should also be supporting campaigns for better access to alternatives to medication for common women’s mental health problems, anxiety and depression. That means promoting a truly biopsychosocial approach to care of women in the community, including attention to hormonal factors, better access to appropriate therapy for women who have experienced trauma and to women centres, which provide access to much needed social and psychological support. We should not simply accept the status quo with ever increasing antidepressant prescription rates. This is not to deny that they have a role to play, but for too many, this is the only help on offer.

What we, as professionals, could do

When women are asked what they would most like from mental healthcare professionals, they are in no doubt that what they want is to be treated with respect, dignity and compassion. ²⁸ Sadly, we know these are too often lacking. Training in trauma-informed care is only effective if it changes practice, and we seem to be re-traumatising too many people in our in-patient units. As mental health professionals we not only need to reflect on our own practice, but be willing to challenge others when we see any patient being treated in an undignified way, with a lack of respect or compassion. Too often, our patients are treated as merely ‘badly behaved’, especially women who self-harm. Relationships matter. As clinical psychologist Dr Jay Watts told me in Out of Her Mind:

Our ability to engage and develop relationships with our patients is crucial to our practice and requires we continue to strive for continuity of care, but it also requires that we receive high-quality, reflective, clinical supervision too.

Are feminists right about the misuse of diagnosis by psychiatrists? Unlike some feminist writers, I believe ‘depression’ is real, not merely distress – and is not only the product of a patriarchal society. To deny that reality is problematic. But that does not mean that the ‘depressed’ cannot also be ‘oppressed’. Many will disagree with my personal view that the use of the diagnosis ‘borderline personality disorder’ should be discontinued. I do not doubt that the insights of the great analysts are of help in understanding the relational problems that people given this diagnosis (three times more likely in women) experience, and in the process of therapy itself. I also know some find receiving this diagnosis helpful. However, it is too often applied without any credible assessment being carried out, many recipients never receive any specialist therapy, and the term carries considerable stigma. ²⁹

Listening to stories of the impact on women to whom this diagnosis has been given ^{Reference Watts30} was the main factor in my desire to challenge its use. How might we ensure that women with complex presentations receive adequate assessment and a psychological formulation and plan that considers other potential differential diagnoses such as complex post-traumatic stress disorder, autism, attention-deficit hyperactivity disorder, bipolar disorder and premenstrual dysphoric disorder? This means developing the skills to hear the complicated and painful stories of many women’s lives and to engage them, not simply dismiss them as ‘personality disorder’ or ‘unwilling to engage’ because they are ‘difficult’. Many women who come into mental health services have experienced serious trauma in their lives and are subsequently labelled as having a personality disorder. We cannot expect them to trust us immediately; we must gain that trust.

Finally, feminist leadership principles provide us with a framework within which to seek to be authoritative rather than authoritarian, both as consultants within a team, and in the clinic and the ward alongside our patients.

Listening is the key.

Feminism isn’t only for women

It is possible to be a feminist psychiatrist. A feminist psychiatry acknowledges the reality of mental illness but also that sexism, sexual exploitation and oppression play a major role in predisposing, precipitating and prolonging mental illness for all of us, and that this impact is greatest on those with the least power, on the margins, which includes women. Women’s mental health needs are misunderstood, misdiagnosed and underserved. But feminism isn’t only for women: it is about challenging harmful stereotypes, improving relationships, sharing responsibility and dismantling the oppressive power structures that affect all of us, patients and professionals.