Psychiatrist: Know Thy Own Bias

Feminist therapy, around for 30 years, is often misunderstood. Recently, a leading psychiatrist took a bold step by explaining its fundamentals to her colleagues and offering ideas on improving their treatment of women.

Dr. Nada Stotland

The recent selection of a noted feminist psychiatrist to assume the prestigious position of speaker-elect of the American Psychiatric Assembly demonstrates that ideas about women's mental health, once thought to be revolutionary, are now part of the mainstream.

At the same time, Dr. Nada Stotland, a professor of psychiatry and obstetrics and gynecology at Rush Medical College, is assuming her leadership role when basic tenets of feminist therapy are being undermined by the increasing reliance on drug therapy and the growing popularity of genetic explanations for mental illness.

In addition to her speaker post, Stotland also received this year's Alexandra Symonds Award, an honor bestowed by the psychiatric association and the Association of Women Psychiatrists on a woman psychiatrist for promoting women's health and the advancement of women.

Given the dais at the award ceremony at the association's annual convention in Chicago this spring, she seized the opportunity to explain her views about feminist therapy in a male-dominated profession. She exhorted psychiatrists to examine their own relationships with women and encouraged them to consider whether sexual discrimination and abuse contribute to their patients' illnesses.

In a wide-ranging speech, she touched on a host of issues from the reality of sex discrimination to psychiatrists' treatment of women, alighting briefly on whether feminist therapy is hostile toward men.

Feminist therapy calls for the therapist to consider the influences of factors such as employment discrimination and other forms of bias, menopause, domestic abuse and postpartum depression in the treatment process, she explained.

"Political and social reality shape individual symptoms and individual dysfunction," Stotland told the standing room only crowd. "It's a reality that there is discrimination against women and that women are disproportionately abused. The classic disease model-whatever that is-tends to blame the patient, rather than society." Such thinking can re-victimize the patient.

Stotland added that the idea that mental health professionals should take societal forces into account may not sound revelatory, but traditional medical and biological treatment models have often neglected to acknowledge such factors.

Stotland also tried to dispel the mistaken notion that feminist therapy is hostile to men and holds that men cannot be effective therapists for women, on the contrary, she said; male psychiatrists can do feminist therapy if they embrace its philosophy.

The main thrust of feminist therapy is to empower the patient, and it is not meant to be anti-male, she said, but noted that some women with histories of abuse and exploitation may feel uncomfortable with male psychiatrists.

She urged therapists to consider whether to ask women if they have been subjected to verbal or physical abuse, since women rarely volunteer that information. Lateness for therapy sessions, she said, might result from something as basic and widespread as child care issues.

And she pointed out that women still encounter discrimination for characteristics or behaviors associated with female hormones, such as moodiness, excitability that are associated with female hormones, although men do not experience discrimination linked to their male hormones.

"Where is the category of psychiatric illnesses linking problem behavior to male hormones?" Stotland asked rhetorically "If a woman is complaining about something and has a perfectly logical complaint but the person who hears it doesn't like it, the complaint may be attributed to menopause, premenstrual symptom or being pregnant," she said.

To better serve women, mental health professionals need to make sure they know a woman's reproductive health history and any hormone-related issues, Stotland said. Oral contraceptives and hormones for pre-menopausal women, as well as anniversaries of reproductive losses, can bring on or exacerbate symptoms.

And she urged her colleagues to examine how their political views shape their treatment recommendations for women.

For example, Stotland said in a recent interview, "If you're an anti-abortion person and you have a patient who's facing a decision, that's a very touchy question. Do you have an obligation to refer that patient to someone else?" she asked.

At the same time, she acknowledged, "We all have experiences. It's not that you're going to expunge those. I think your duty is to know where you're coming from as a psychiatrist. But there are no exact answers."

Ellyn Kaschak, editor of the journal "Women and Therapy" and author of "Engendered Lives," a key textbook on feminist therapy is impressed that Stotland spoke so frankly at the convention. Talking to psychiatrists about feminist therapy was a gutsy move, said Kaschak, a professor of psychology at San Jose State University.

Psychiatrists are traditionally conservative and attuned to the biological model of medicine, Kaschak said. Also, about two-thirds of the nation's psychiatrists are male, though half of the psychiatrists in training are women.

During the 30 years feminist therapy has evolved, Kaschak added, its legitimacy has waxed and waned. But many mental health professionals have adopted the practices associated with feminist therapy, such as establishing an egalitarian relationship with patients and prohibiting sex between therapist and patient.

However, like most time-consuming treatments, feminist therapy is threatened by managed care limits on the number of psychotherapy sessions, an overuse of medication and an infatuation with genetics as causing physical and mental illness, Kaschak said.

Denise Webster, who chairs the steering committee for The Feminist Therapy Institute, a collaborative of about 120 feminist therapists, agreed.

"The media is on this kick as though genetics is the answer to everything. And, everybody is into using a pill for everything. It is reductionist and the most narrow focus of what human behavior is all about. It ignores what it is to be a human being and what it is to be in society," Webster said.

Webster, a professor of nursing at the University of Colorado, also said that what psychiatry commonly identifies as illnesses are really injuries. For example, she said, women used to be put on tranquilizers when they complained about being in danger from domestic violence.

"Now, if they've got a problem, the thinking is: just put them on Prozac" Webster said, "Nobody asks why everybody is so depressed. They just think more people need to be on medication. Our view is that a lot of problems that people have are the result of inequities."

Melinda Voss has a master's degree in public health. A former reporter for The Des Moines Register, she freelances and teaches journalism at the University of Minnesota.