Feminism and psychiatric diagnosis: Reflections of a feminist practitioner

Lessons from history

To illustrate my position, let me offer two contexts. The first is historical. Mercier (1904: 675) complained about the ‘higgledy-piggled conglomeration’ of categories that made up the psychiatric diagnostic system then in use in British lunatic asylums. He pointed out that disorders were being identified variously by their underlying disease process, cause, associated disorder, course or predominant symptoms. This had serious consequences. The history of psychiatry in the time before sophisticated diagnostic systems were devised is replete with devastating stories of men and women dying of misdiagnosed medical conditions that appeared to be some form of ‘madness’ for example, or being misidentified as psychotic when they were in fact traumatized or slipping in and out of dissociative states (Swartz, 1999a). This is illustrated by two examples, drawn from a rich archive on mental illness in the Cape Colony:

A young woman sailed on the Union-Castle line in November 1911, travelling third-class, to the Cape to join three brothers and a sister, already in the colony. She spoke only Yiddish, and like many Eastern European Jewish immigrants entering South Africa during this period, was escaping economic and social hardship, and hoping for a new world of opportunity and prosperity. It is known that conditions on board ship were far from comfortable; third-class passengers were herded together in barrack-like accommodation, and women were on occasion subjected to sexual harassment and even assault. She arrived, and was soon brought by her brother to a lunatic asylum in Grahamstown, in an acutely suicidal state. Her inability to speak English would have hampered attempts to communicate with her, but the case-notes state that she was ‘betrayed on board ship in coming to South Africa’. She spent just over 4 years in the asylum, before being discharged recovered, which in itself suggests that her illness was not of a chronic deteriorating kind. There is no record that she was re-admitted. It seems likely that the combined effects of immigration to a harsh new landscape, loss of family rituals and routines in the shtetl from which she came, and a traumatic event while alone on board ship contributed to her suicidal state. Without a good classification system yet in place, she was simply placed in a group of chronic psychotic patients, waiting out their time in custody. A case such as this one speaks eloquently to the usefulness of categories that describe and predict the course of stress-related disorders (Cape Archives, Grahamstown Asylum Casebooks, 1912).

A second case concerns a woman in her third marriage who attempted suicide in 1898, and was described by the certifying doctors as ‘vacant and expressionless’, ‘talking nonsense’, ‘always unloosening her clothes, and then dressing to go out’. She was disoriented, and had lost track of the whereabouts of her children. She had moved between Johannesburg and the Cape since the time of her immigration to South Africa 6 or 7 weeks before, and in her confusion spoke ‘constantly of going by the ship’. She was treated medically by her husband, who was at the time registered as a doctor in the colony, although his credentials were later questioned, and he left the Cape under a cloud, apparently to live in London. His own diagnosis for his wife was of anemia and general paresis and this diagnosis was recorded against her name on her admission to an asylum. Despite the diagnosis, which was at the time poorly understood, untreatable and carried a poor prognosis, she was discharged after some months in the asylum into the care of her husband (Cape Supreme Court Records, 1898). She died 24 years later, leaving a respectable estate to her children and grandchildren. Whatever ailed her, it was very unlikely to have been general paresis. The routinized description of her as showing psychotic symptoms was for the purposes of getting her admitted, certified, to an asylum; and there is no evidence that her context was taken into account as an influence on her symptoms, and neither was her general health. It is entirely possible that her confusion arose from physical illness (the reference to anemia here being significant), and that a thorough diagnostic screening would have brought this to light. It is also possible that multiple journeys in a strange land carried her into the internal landscape of an adjustment disorder, which corrects itself over time.

History complexities

The second context is one in which I work currently. In my clinical setting I am part of a training team, working with clinical psychology students, and our referrals come from populations with poor access to health care services. I see daily the ways in which delayed assessments, failure to provide a diagnosis and to institute some form of intervention have led to increased suffering, lack of access to grants, psychotherapies, appropriate school placements, and so on. Some Axis 1 diagnoses, loosely used, might medicalize, stigmatize and obscure real social problems, but the DSM also helps clinicians to think about a range of disorders, from intellectual disability, through addictions to dementias, and to consider social/relational problems and evidence-based interventions which take account of differences between anxiety and personality ‘troubles’; between depression and dissociation – and so on (Swartz, 1999b).

Clients admitted to the Child Guidance Clinic at the University of Cape Town go through a thorough period of assessment before they are admitted for treatment. A provisional diagnosis is assigned after information is collected from the family, schools and other health professionals, and is coupled with both an etiological formulation of the problem, and a therapeutic one, the former offering a narrative about the origins of the current problems, and the later a set of theoretically informed suggestions about the appropriate means of intervention. Our referrals come from communities marked by poverty, under-resourced schooling, unemployment, sexual violence, and drug and alcohol abuse. It is common for us to discover layer upon layer of trauma in the histories of our clients, with ongoing depression and anxiety a way of life, barely discernible as a problem through the obscuring traffic of multiple stressors, sudden changes, and challenges to material safety. The social and political terrain is not only significant in the role that it plays with individual’s mental health; it is often all that is visible. Problems of intellectual disability, poor eyesight, attention deficit disorder, high blood pressure, diabetes and hunger are part of what we need to train ourselves to discern. A systematic descriptive diagnostic manual that brings order to observation assists greatly in the careful teasing out of physical from psychological symptoms, and the potentially transitory Axis 1 states from the more intractable Axis 2 and 3 conditions. An example:

We see a woman who has been bringing up her sister’s child, following the mother’s death in a shack fire. It seems that the mother was drinking at the time of the fire, and because of this, the father refused to take her to hospital, although he had a car at the time. She died a month later of her injuries. Until she was ten, the child thought her aunt was her mother, and they had enjoyed a relatively harmonious life together. The facts of her past emerged suddenly and traumatically, when her father, who had disappeared when the mother died, accosted her at the school gates, and for reasons not entirely clear to either aunt or child, told her about her biological mother. He later suggested she come and live with him, his new wife, and young children.

The child has become a troubled adolescent, who is stealing and drinking and spending time with a local gang. She has failed every school year for the past 3 years, and the aunt is frightened for her future and for her safety. But the picture becomes more complex as we explore: the aunt seems loving, but is occasionally violently rejecting. She has sacrificed a great deal for this child, but also rejects her suddenly in the course of the intervention, deciding to send her to live with her father, despite previously voiced doubts about his motives. So we are faced with a family system that is in difficulties, but within it, two individuals each of whom have their own struggles. Several meetings later, we know more. The child has intellectual difficulties, and is comprehending schoolwork well below her current grade’s average performance. She has symptoms of depression, such as tearfulness, sleep disturbance and loss of energy and enjoyment of life, well concealed by bravado and defiant behavior. Her aunt is also depressed, and becomes irritable with the child nearly every day.

In cases such as this one, there is little we can do about the social context, except to hold it in our awareness, and accept the limitations it imposes on our treatment plans. We satisfy ourselves that a kaleidoscope of difficulties have formed a pattern that point not to infinite, but to several, causes in the past and courses into the future. Traumatic event after event are ordered into a narrative that we use to talk to aunt and daughter together, and separately. ‘Bad’ cheeky defiant behavior is unpacked as perhaps sad and scared. We are clear about the ways in which this adolescent will struggle at school. The causes of her scholastic difficulties are likely to be complicated – her mother drank while she was pregnant; the school system has failed repeatedly; there are no books in the home, or family history of scholastic success; and there is also a significant depression affecting her concentration. But she must not carry the burden of her school failure as a moral failing in herself, a result of insufficient diligence. So diagnosis seems in this case to have been a means through which to impose structure on despair, and to craft a way forward.

Feminist perspectives have much to contribute to a case of this kind. As so often in our clinic, a woman is the one identifying the problem and asking for professional assistance. The men – fathers particularly – tend to be reluctant to take on the burden of caring for children in a consistent way. There is also the spectre of a history of trauma repeating itself: an unemployed and unskilled mother living in poverty-stricken circumstances, at the mercy of a man who fails to take care of her in the most basic ways; a girl child courting a similar fate. The context is socially and economically oppressive, and girls and women have fewer choices and face more personal danger than men. However, the question to be answered here concerns the specific effects of diagnosis.

The child is diagnosed (after a set of assessments) as having a mild intellectual disability, and this information is used to begin the process of getting her into a school of skills that will provide some scaffolding for future employment opportunities. (There is no access to such a school without a preceding diagnostic assessment.) Her depression is addressed in weekly psychotherapy, which focuses on working through her difficulties in coming to terms with her family history, and on her relationship tangles. It is discovered that her cognitive limitations affect her grasp of appropriate social behavior, and that this is compounded by irritability and moody behavior. Over time, and with slow exploration, she becomes less sad, and her relationships less volatile, but the prognosis remains guarded.

Where to from here?

The kinds of cases I have described above offer no more than a glimpse of the kinds of knotty questions that might be untangled by careful feminist analysis. Like all clinical material, these three case vignettes are complex, but illustrate several points clearly. Accurate diagnosis may be a useful instrument; absence of diagnosis may have serious consequences for treatment; and finally the biological, the social and the psychological are woven together – and indeed speak to one another – in a comprehensive diagnostic survey.

In this reflection, I began with the material closest to the weave of women’s lives: their stories. I would like to end by moving from detail to the bigger picture, the one in which the stories begin to form a narrative. There are a number of challenges that feminist psychologists need to take on, specifically in relation to psychiatric diagnosis, and I list them by way of a conclusion.

Why classify?

At times, the feminist arguments against psychiatric diagnosis have suggested that classification in and of itself is anti-feminist, if for no other reason than that it places the root of disorder within the individual and backgrounds social and political contexts affecting mental health. I would counter this argument with a more nuanced one: that diagnosis may at times be helpful; or conversely that the absence of such a diagnosis may at times be harmful to a woman with some kind of psychological difficulty. Within this, there is a further argument to be made: that diagnoses might be useful in individual cases, may be generally, or generically, harmful. So for example, one woman may be saved from committing suicide by being diagnosed as suffering from a major depressive episode; but “women” suffer from being over-diagnosed as ‘prone to depression’. Either argument places the consequences of diagnostic activity squarely at the centre of research enquiry, and calls for a substantial survey of clinical material. Such an enquiry might take a number of forms, as different as qualitative explorations of a set of individual case histories in which a psychiatric diagnosis (or its absence) played a central role, through to broad-brush epidemiological surveys which attempt to describe the effects of psychiatric diagnosis on quality of life.

Are our categories gender-biased?

A second line of enquiry focuses attention on particular diagnostic categories that seem to shadow patriarchal interests, or to represent ‘normal’ womanhood in ways that serve patriarchal agendas. An obvious current example can be found in the gender imbalance in the borderline personality disorder and mood disorder diagnoses. So for example, volatile, angry, demanding, and sexually expressive women may attract a diagnosis of borderline personality disorder, be prescribed a range of medications, and have their relational difficulties represented to their family and friends as arising from internal instability. There is no doubt that women described as ‘borderline’ are reacting to an intersubjective field that is disturbed and disturbing (and may include exploitative or violent men, a history of sexual abuse, and a range of difficult life events).There are two challenges here for feminist researchers. The first challenge is to ascertain the effect of the diagnosis on that intersubjective field. The second is to consider whether a patriarchal social order is implicated in causing the disorder, or in using it to perpetuate power imbalances along gendered lines, and then in obscuring its effects by covering its tracks, through the deletion of its origins in a variety of oppressive social structures.

Who sets the research and treatment agendas?

A third feminist line of enquiry concerns an exploration of research agendas, their funding, and their outcomes. Such a study would foreground the ways in which particular diagnostic entities become the focus of intense research activity, attract funding, and lead to the development of programmes of intervention, including medication and ‘evidence-based’ therapies. Traditionally, clinicians complain that clinical research does not speak to the complexity of their environments; and clinical researchers feel that clinicians are sluggishly responsive to research findings. A feminist research agenda might tease out the complexity of this relationship, particularly its gender ramifications.

Practice versus theory

Finally, there is much work to be done in describing the ways in which diagnostic instruments are used in practice. Diagnoses are not always used in the ways that were intended by their originators: categories get over-used or under-used, and get linked to treatments by convention or convenience. These practices of course carry gender implications, and would provide much fruitful material for feminist research.