Editorial introduction: The politics of psychological suffering

Medicalization as knowledge practice

In many parts of the world, the psy disciplines have gained the status of knowing the truth about the mind. Whereas in the past, problematic behaviors and emotions were understood in religious or moralistic terms (and still are in some cultural contexts), today psychiatry asserts that many of these are symptoms of neurobiological illnesses and matters of biomedicine. This regime of truth (Foucault, 1977), replete with its medical metaphors, is replicated and reasserted in popular culture (e.g. through the education system, print and electronic media, etc.). As a result, a wide range of human experiences has come to be understood in medicalized terms.

The term medicalization encompasses a set of interrelated meanings. In the broadest sense, it refers to the use of a medical metaphor to “make sense” of psychological suffering. That is, psychological suffering is re-presented as if it were akin to a biomedical disease. This re-presentation has a number of consequences. It presents psychological suffering as if it resided inside the individual and could be understood solely in terms of the interiority of the person. If the putative causes of suffering are inside a person (whether in the body or in the mind), then the societal, material, and interpersonal factors that are “outside” the person—such as social inequality, economic hardship, gendered violence, and horrific living circumstances—are seen as immaterial to psychological suffering (Marecek, 2017).

Further, medicalizing discourses make sense of psychological suffering by defining such suffering as clusters of signs and symptoms—lists of discrete difficulties and dysfunctions. Such symptom criteria reduce human experience to a collection of sub-personal parts. The person who receives such a diagnosis is easily reduced to a generic patient (e.g. a “schizophrenic” or an “anorexic”) for whom a one-size-fits-all treatment is prescribed. In this way, medicalized diagnoses set aside the whole person and their intentions, self-understandings, motives, emotions, and moral visions, as well as the social and material context.

Two of the articles in this special issue provide sobering illustrations of ways in which diagnostic framings of people’s distress can compromise the possibilities for good care. Harper, O’Donnell, and Platts (2021, this issue) present a pair of studies carried out in London that examine how mental health personnel talk about psychosis. The authors show how this talk is premised on the assumption that adverse experiences—no matter how severe—have little clinical import. In the explanations of psychosis that psychiatrists articulated, adverse experiences were spoken of as merely the “trigger” that activated an inborn predisposition for a psychotic disorder. As Harper and his colleagues point out, “agency is thus placed elsewhere – in an ambiguous and vague entity …” (2021, p. 28). Other ways of linking past events and present suffering disappear.

In the second instance, Holmes, Malson, and Semlyen (2021, this issue) analyze troubling stories told by women who had been treated for anorexia nervosa in inpatient facilities in the UK. In effect, the women reported that clinical staff members viewed (and treated) them as deceitful, manipulative, and devious, characteristics viewed as intrinsic to anorexia nervosa. “The anorexia” was regarded as the locus of causality of patients’ behavior. As Holmes and her colleagues show, this construction of anorexia led to a number of counter-therapeutic, if not dehumanizing, practices by the staff. Rather than fostering an alliance with the patients, this view positioned staff members as adversaries of “the anorexia” and, therefore, of the women as well. Such practices are not confined to a single treatment facility or to the UK. Rebecca Lester’s (2019) book, Famished: Eating disorders and failed care in America, reviewed by Maree Burns (2021, this issue), also depicted routine practices that discounted the personhood of patients diagnosed with anorexia nervosa. Lester carried out a long-term ethnography at a treatment clinic in the US that specialized in treating eating disorders. She observed that several of the key treatment strategies appeared to mirror the social relations and embodied practices that had led to the eating disorder. Nearly 20 years ago, Gremillion (2003), who conducted an ethnographic study in a different treatment facility elsewhere in the US, observed similar practices. It has been longstanding clinical wisdom that treatments for eating disorders often fail. Rather than viewing eating problems as “treatment resistant,” it seems wise to ask whether the treatments are ill conceived.

These two articles direct readers to ask how psychiatric diagnoses set the clinicians’ gaze. They also direct readers to examine the gendered aspects of clinical theories and the gendered dynamics of treatment protocols. What stories about patients are prefigured? What comes into view and what is eclipsed? How does the framing imposed by diagnostic categories shape mental health care? How is it helpful or harmful to patients? When we relinquish the idea that diagnostic categories are objective facts and instead view them as knowledge practices that confine clinicians and patients within certain frameworks of meaning, questions such as these emerge.

The biologization of psychiatry and the DSM

The imposition of a medicalized model onto psychological suffering occurred in tandem with the thoroughgoing project of biologizing psychiatry. As documented by medical historians, this overhaul was not occasioned by new scientific information. Rather, it was a pragmatic accommodation to the looming corporatization of medicine and the establishment of managed care organizations in the US (Wilson, 1993). By the late 1970s, the drive to corporatize biomedicine and to institute mechanisms for containing costs had gathered considerable momentum. If psychiatry were to survive, it was imperative that psychiatrists re-position themselves as “real” doctors who treated “real” illnesses (Wilson, 1993). Otherwise, psychiatrists would be cut out of healthcare reimbursements. For that reason, the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the compendium of conditions that psychiatrists might treat—was reengineered so that its entries were in a format resembling biomedical diagnoses. This overhaul, which led up to the publication of the DSM-III in 1980, was the centerpiece of psychiatry’s campaign to legitimize itself as a branch of medicine. In repositioning the DSM to align with biomedicine, the DSM was “transformed from an obscure desk reference – a peripheral clinical tool – into an omnipresent, huge compendium” (Kirk & Kutchins, 1992, p. 6).

The DSM-III embodied two aspects of medicalization. It inserted psychological suffering into a categorization scheme based on lists of signs and symptoms. In addition, the descriptive texts that accompanied most diagnostic categories selectively cited evidence for possible genetic or biophysical origins of disorders, while downplaying the contributions of the social, material, and relational context. The four successive revisions of the DSM subsequent to 1980 have replicated this framework.

Along with the move to medicalize psychiatry, the pharmaceutical industry initiated an aggressive campaign to market drugs alleged to cure psychiatric illnesses, effectively colonizing the field of psychiatry as part of that process (Whitaker & Cosgrove, 2015). Direct-to-consumer advertisements (permitted in some countries) asserted that a so-called chemical imbalance in the brain was the cause of depression and anxiety, despite the lack of evidence in support of this claim (Angell, 2011; Gardner, 2003; Moncrieff & Kirsch, 2005). This notion is now accepted as fact by the public at large and also by primary care physicians, who write most of the prescriptions for antidepressants and anti-anxiety drugs. As Harper, O’Donnell, and Platts (2021, this issue) and Thompson (2021, this issue) point out, biologized versions of psychological suffering now define psychiatric care in much of the world.

The medicalization of psychiatry also prompted dramatic shifts in psychiatric training and research. Psychiatry departments shunted aside staff members with psychological or psychosocial expertise (especially those with psychoanalytic or psychodynamic orientations) and replaced them with psychopharmacological and neuropsychiatric researchers. Faced with a similar (or perhaps greater) threat to the pocketbooks of clinical psychologists, the American Psychological Association endeavored to re-brand clinical psychologists with pseudo-medical titles such as “behavioral health care provider” and “health service psychologist.” Most textbooks in abnormal psychology were organized to accord with the DSM’s categorization scheme. From 1980 onward, these texts have indoctrinated millions of undergraduate university students in the DSM’s nomenclature and symptom criteria, skipping past consideration of the well-established negative effects of adverse experiences, poverty, and structural racial, ethnic, and gendered health disparities.

Medicalized views of psychological suffering also neglect the myriad of culture-specific forms of psychological suffering. Instead, they promote the notion that psychological suffering—like biophysical disease—is the same worldwide. This notion is easily refuted by the rich literature assembled by medical anthropologists, historians of science, cultural historians, cultural psychologists, and decolonial psychologists. This literature illustrates the manifold ways in which forms of psychological suffering, idioms of distress, the nature of stigma, and effective forms of care are embedded in specific places and times. Unfortunately, this body of knowledge is seldom referenced in the training of mental health professionals. The article by Hamley and Le Grice (2021, this issue)—psychologists who identify as Māori—speaks to this gap. Writing in Aotearoa/New Zealand, they charge the mental health professions with being complicit in perpetuating the colonization of Māori. Focusing in particular on young Māori men, they argue that framing their difficulties in terms of psychiatric diagnoses conceals the ill effects of colonization, racist social structures, and interpersonal racism.

The DSM as knowledge practice

In the 40 years since the DSM-III was published, there has been persistent dis-ease about the contested nature of psychiatric knowledge. This dis-ease boiled over into the public arena during the process of compiling the DSM-5. The number and range of critiques was unprecedented. Several of the most renowned and respected psychiatric researchers in the US leveled scathing critiques in public forums. Steven Hyman, a former Director of the US National Institute of Mental Health, called the effort to revise the DSM “a fool’s errand,” noting that the DSM had “locked psychiatrists into an epistemic prison” (Hyman, 2010, p. 157). Thomas Insel, also a former Director of the US National Institute of Mental Health, posted a damning appraisal of the DSM on the Institute’s official website (Insel, 2013). The DSM, he said, was “at best, a dictionary, creating a set of labels and defining each. […] Patients with mental disorders deserve better.” Because the labels had no scientific validity, Insel said, researchers’ quest for better diagnostic tools, better understanding of causal mechanisms, and more effective treatments had largely failed. At the same time, the National Institute of Mental Health announced that it would no longer award grants for research projects that were based in DSM diagnoses (Lane, 2013). Yet another prominent psychiatrist, Allen Francis, campaigned strenuously to, in his words, “save normal.” Francis, who had chaired the Task Force responsible for the DSM-IV, publicly blasted the DSM-5 for pathologizing more and more everyday stresses and strains by willy-nilly adding new diagnostic categories (such as Binge-Eating Disorder, Attenuated Psychosis Syndrome, and Prolonged Grief Disorder) and inflating others (such as ADHD) (Francis, 2013). As he and other critics saw it, those in charge of producing the DSM-5 had been seduced by lavish financial inducements of the pharmaceutical industry. They were, in effect, selling sickness in order to sell pills (Whitaker & Cosgrove, 2015). For several months, such acrimonious criticisms and accusations were aired not only among psychiatrists, but also in leading medical journals, in professional organizations, on social media, and in the popular press.

Psychologists and other psychosocial practitioners also leveled strident critiques, but they assailed the DSM-5 for a different set of failures. Critical clinical psychologists condemned the DSM’s continuing failure to attend to societal context, interpersonal relations, and adverse events, and its neglect of cultural differences. In 2011, the British Psychological Society (BPS) and the Society for Humanistic Psychology (a division of the American Psychological Association) jointly issued an Open Letter to the DSM-5. Among other criticisms, the Open Letter asserted that:

… clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.

As most readers know, this onslaught of objections, critiques, calls to action, and bad press was to no avail. The American Psychiatric Association launched the DSM-5 at its annual conference in mid-year 2013. It was instantly adopted as the lexicon of health insurers, managed care organizations, mental health service providers, patients, and the general public.

Diagnostic categories: Making up persons

Feminist and critical psychologists have long argued that psychiatric categorizations cannot stand apart from the material circumstances, societal structures, moral visions, and power relations of their time and place. The historical record is replete with examples. In the late 19th century, “nymphomania” was identified as a mental disorder in the US and Europe (Groneman, 1994). Nymphomania involved “excessive” sexual desire on the part of a woman, as evidenced by sexual fantasies, masturbation, or even simply a greater sexual appetite than that of her husband. Treatments included leeches and borax applied to the woman’s genitals and, in stubborn cases, clitorectomy. Today, most of us would condemn such treatments as forms of genital mutilation. Another example is homosexuality, which remained in the DSM as a mental disorder until 1987, when the DSM-III-R was published. It took about 20 years longer for mental health organizations in the US to speak out officially against the use of so-called conversion therapies to “cure” homosexuality. These examples (and many more) cannot be dismissed as quaint relics of a bygone era. Instead, they point to the power of psy disciplines to define, pathologize and control gendered human experience (including gendered sexual experiences). They also point to the persisting need to hold the psy disciplines to account for the power they wield.

Feminist scholars have paid close attention to the ways in which psychiatric diagnoses echoed and amplified prejudicial and derogatory views of women that circulated in Western Europe and North America. Elaine Showalter (1985) examined medical understandings and literary images of “mad” women in English culture from the mid-1800s onward, tracing the emergence and disappearance of such female disorders as hysteria and neurasthenia. Rachel Hare-Mustin (1983) discussed Sigmund Freud’s analysis of Dora, a teenager whom Freud (2013 [1905]) diagnosed with hysteria. Dora’s father had handed her over to Freud for psychological treatment because Dora had repeatedly rebuffed the sexual advances of one of her father’s friends. Freud gratuitously diagnosed Dora’s mother (whom he had never met) with “housewife’s psychosis.” Feminist scholars also pointed to the alacrity with which psychoanalytic psychotherapists heaped blame on mothers. The American psychoanalyst Frieda Fromm-Reichmann (1948) put forward the construct of the schizophrenogenic mother. Such mothers, Fromm-Reichmann claimed, embodied a mix of overprotection and rejection so toxic that it caused their children to become schizophrenic. The notion that schizophrenogenic mothers were the cause of schizophrenia in their offspring remained in force for some 25 years. It was laid to rest only when studies of adopted twins reared apart provided strong evidence for the heritability of the disorder. Another psychoanalyst, Bruno Bettelheim (1967), promulgated the notion that “refrigerator mothers”—mothers who unconsciously harbored a cold hatred of their child—caused autism.

Since at least the 1920s, when Karen Horney took aim at the ideas about femininity put forward by Sigmund Freud and Karl Abraham, feminists have cast a critical eye on the claims put forward by mental health professionals about women’s nature and character, about proper femininity, about healthy female sexuality, about the malicious influence of mothers, and so on. Since the resurgence of feminism in the 1970s, feminist scholars and researchers in psychology have disputed many such assertions and instead brought forward analyses of societal inequities, systems of domination and subordination, and ideologies that shaped the experiences of women and that valorized male domination. Feminists pointed to the ways family therapists failed to address (and in some instances promoted) the unequal distribution of power in heterosexual marriages (Hare-Mustin, 1979). Feminists also called the field of family therapy to task for its blindness regarding the extent of men’s physical violence toward their intimate female partners (Bograd, 1992).

Some articles in this special issue carry forward the tradition of feminist scrutiny of diagnostic categories and diagnostic practices. Thomas and Gurevich (2021, this issue) interrogate the ways that recent editions of the DSM have attempted to define and delimit women’s embodied sexual desire. Rather than pathologizing certain forms of female desire, Thomas and Gurevich insist that differences in desire be understood in relation to relational, contextual, and sociopolitical factors that shape women’s sexual experiences. Holmes, Malson and Semlyen (2021, this issue), whose work we discussed earlier, point out that mental health professionals’ understanding of anorexia nervosa justified practices of distrust, intrusive surveillance, and lack of privacy as routine aspects of clinical care. These articles carry forward the long line of work that has demonstrated the ways in which the psy professions have positioned women as mad or bad (e.g. Gremillion, 2003; Lester, 2019; Malson, 1998; Ussher, 2011).

Trauma and its discontents

It has long been understood that catastrophic and world-shattering events can evoke profound psychic consequences for those who experience them. During the First World War, military doctors and psychiatrists grappled with how best to understand soldiers’ responses to war trauma and how to alleviate the suffering they experienced. Trench warfare evoked prolonged bouts of terror for many soldiers. They responded with psychic responses such as involuntary shivering, crying, profound fear, somatosensory loss, and repeated intrusive memories. In the psychiatric understanding of the time, such symptoms would have been diagnosed as hysteria. But the feminized (and disparaged) diagnosis of hysteria was incompatible with ideals of manliness and military valor. Instead of hysteria, the men were deemed to be suffering from “shell shock,” a term coined to suggest a physiological basis for the symptoms. Resituating soldiers’ suffering as medical illness served to legitimize it as “real,” and to garner more services and greater public sympathy (Quosh & Gergen, 2008). Some 60 years later, healthcare providers in the US Veterans Administration were confronted with scores of soldiers returning from service in the Vietnam War with disabling psychic wounds. After concerted political pressure, including Congressional hearings, a new diagnostic category pertaining to combat injuries, Post-Traumatic Stress Disorder (PTSD), was devised. It appeared for the first time in the DSM-III (1980).

As most readers are aware, the cultural meanings of “trauma” and the social groups thought to be at risk for PTSD have since undergone dramatic changes. Many of these changes were set in motion by the publication of Judith Herman’s Trauma and Recovery (1992). Herman, an American psychiatrist, offered a masterful and persuasive treatise that expanded the scope of trauma beyond the horrors of the battlefield to the everyday lives of women and girls. Herman drew resonant connections between men’s combat experiences and women’s experiences of childhood sexual abuse, rape, and domestic violence. Of special interest to feminist researchers and practitioners was that Herman located the sources of psychological suffering in the adverse conditions in the environment—reinforcing a foundational concept of feminist clinical theory. In the US, many feminist practitioners held that PTSD was a (or even “the”) “feminist diagnosis” because, as they put it, PTSD signified that the client “is normal.” That is, a therapist could assure her client that her difficulties were a normal reaction to the adverse events she had experienced. As Marecek (1999) pointed out, “trauma talk” stitched together a number of contradictory ideas. Nonetheless, it came to be a key discourse that feminist practitioners and their clients drew on to make sense of the client’s difficulties.

In the years since Trauma and Recovery was first published, the trope of trauma has been taken up widely, both in the mental health professions and in self-help culture (Becker, 2013; Haaken, 2020). Perhaps as a result of its broad usage, “trauma” came to be a prime entry in what Kagan (1998) has called psychology’s lexicon of unconstrained words, and a prime exemplar of the field’s semantic permissiveness. (Both are qualities that Kagan bewailed.) To begin with, over time, the range of occurrences said to lead to PTSD has expanded far beyond the original formulation of “catastrophic” occurrences. Quite prosaic occurrences are now declared to be trauma-inducing. The unconstrained meanings can be tracked in the successive editions of the DSM, and they are even more evident in self-help culture. By now, virtually any negative event can be spoken of as a “trauma.”

Another crucial change is that “trauma” has come to refer not only to an external occurrence (like rape or combat), but also to an inner subjective state. That is, a trauma was said to “traumatize” those who experienced it, who were then said to harbor a psychic affliction that was also referred to as a trauma (Becker, 2013). The construct of trauma was thus reframed to fit within the medical model. With this reframing, attention shifted from the external conditions that produced the trauma to the internal affliction and to healing trauma’s symptoms. In this way, “trauma” was effectively de-politicized. Working within this medicalized frame of reference, prominent trauma specialists soon claimed that trauma was an affliction of the brain. They put forward pop-neurological notions about “traumatized brains,” and promoted treatments to “scrub the brain.” For example, an advertisement for a professional training seminar (received by one of us in September 2020) described three popular trauma therapies-—EMDR, tapping, and Somatic Experiencing— as based in “brain science.” Treatment techniques were described as “re-wiring your clients’ brains,” “dialing down the fear centers of the brain,” “ramp[ing] up the problem-solving and self-regulation centers of the brain,” and “activating your clients’ mirror neurons.” Notably absent was any mention of the client’s lived experience of the traumatic event. Rather, it seemed as if any traumatic experience —a soldier’s remorse about causing others’ deaths; the terror of living through a catastrophic earthquake; a girl child’s experience of repeated sexual violations by her father—was reduced to a trigger of a brain disorder. Perhaps a medicalized understanding of trauma may serve to legitimize people’s distress; however, such an understanding presents a host of troubling consequences as well (Lafrance & McKenzie-Mohr, 2013, 2014). The focus on healing the brains of trauma victims appears to relinquish feminists’ insistence that the social causes of trauma be addressed.

Thompson (2021, this issue) offers a trenchant feminist perspective on the theoretical and political troubles with trauma discourses. She turns her attention beyond the therapy professions to consider trauma discourses in the culture at large. Thompson takes issue with the “contemporary captivation with neurobiological accounts of trauma” (p. 103), arguing that such accounts neglect the systemic production of people’s distress. “If violence is institutional,” she insists, “then so is trauma” (p. 113). Informed by the work of Dorothy Smith (1987), Thompson argues for what she terms “institutional trauma,” a construct that underscores how trauma is an everyday “organizing and sustaining feature of institutions and institutional power” (p. 113).

The psy professions and “outsiders”

Three articles and a book review in this special issue call attention to social groups that have been marginalized by the “psy” professions—the indigenous Māori of Aotearoa/New Zealand, lesbians in the UK, and racialized peoples in the UK and the US. The authors explore ways that members of these groups are positioned in psy discourses, as well as their encounters with mental health treatment. Historically, the psy professions have characterized members of these groups in ways that justified discriminatory treatment and bolstered the status quo. Psychiatrists and psychologists have sometimes portrayed members of such groups as less worthy—for example, less emotionally developed, less capable of abstract thinking, less psychologically mature, and so on, For example, since the late 1800s, a number of prominent psychologists (including Francis Galton, G. Stanley Hall, Hans Eysenck, Philippe Rushton, Arthur Jensen, and Richard Herrnstein) have claimed that the genetic make-up of Black people rendered them intellectually inferior to white people (Richards, 2010). Also, the first three editions of the DSM (spanning the period from 1952–87) categorized homosexuality as a form of psychopathology. It was only in the DSM-III-R (1987) that it was removed. Characterizations like these, of course, serve to maintain institutional structures that have perpetuated inequalities. The pieces in this special issue bring to light a variety of issues: persisting racist biases in the psy professions; the failure to develop culturally-appropriate treatment modalities for indigenous peoples; and strategies of resisting psy discourses.

In Institutional racism in psychiatry and clinical psychology (reviewed by Marecek, 2021, this issue), Suman Fernando (2017) explores institutional racism in psychiatry and mental health services in the UK and the US, focusing on Black Africans and brown-skinned South Asians. Fernando sets the stage by examining the parameters of “race thinking” in the longue durée. Colonial psychiatrists, for example, put forward claims about the diminished moral and intellectual capacities of the colonized subjects of the British Empire. Such claims helped to justify 19th- and 20th-century British imperialism as a civilizing mission. Also, race-based diagnoses were invented to rationalize the enslavement of Black Africans in the British colonies in the Caribbean and in the US. Fernando—a Sri Lankan who has had a lifelong career as a UK psychiatrist—examines persisting biases in mental health care in the UK. A longtime anti-racist activist, he describes the efforts of the Transcultural Psychiatry Society and other groups to counter racism and race-thinking in UK mental health services.

Spandler and Carr (2021, this issue) report on an archival study of lesbian periodicals published in the UK during the ’60s, ’70s, and ’80s. Their reading of these periodicals focuses on activists’ efforts to counter the prejudicial views of lesbians held by UK psychiatrists. They trace three successive strategies by which lesbian activists challenged the “psycho-pathologisation of homosexuality” (p. 120): collaborationist overtures in the 1960s; oppositional tactics in the 1970s; and radical separatist activism in the 1980s. Outlining the overlaps and discontinuities in the strategies deployed over these decades, Spandler and Carr detail how these efforts countered the pathologization of lesbians and gay men.

The article by Hamley and Le Grice (2021, this issue) turns to Māori, the indigenous people of Aotearoa/New Zealand, who are heirs to a legacy of colonial oppression and racialization. Hamley and Le Grice depict the depredation of Maori land and lifeways by the Pakeha (white people of European descent) colonizers who established dominion over the land. Pejorative characterizations of Māori, they say, have not disappeared. Māori men are characterized as either prone to violence or passive and childlike. Psy professionals deem young Māori men to be at risk for behavioral problems like conduct disorders and substance abuse. Hamley and Le Grice point out that such individualizing diagnoses serve to conceal the systemic injustices and social disparities that many Maori face. They note further that the cognitive-behavioral treatment modalities that are typically favored by psychologists are not compatible with the Maori ethos.

The final paper is concerned with racialized “others” whose ways of enduring psychological suffering lead them to avoid engaging with the psy professions. Graham and Clarke (2021, this issue) describe the experiences of African Caribbean women in the UK. They discuss the idealized Strong Black Woman (SBW) as a valued identity and a mode of lived experience for African Caribbean women in the UK (as it also is for African American women in the US). Living up to the SBW ideal obliges a woman to be incessantly resilient, to reliably be available to care for others, and to silently endure her own suffering. Such an ideal can, of course, incur considerable psychic costs. At the same time, the Strong Black Woman ideal inhibits African Caribbean women from seeking help from the mental health system.

Conclusion

Some 50 years of critical feminist interventions have challenged the knowledge base of psychology. There are now vibrant international networks of feminist and critical scholars in psychology. With the backing of feminist organizations, women have made a place for themselves in academic psychology and in the clinical and counseling psychology. In addition, therapists and counselors who are feminists have experimented with treatment strategies aimed at assisting clients to challenge and change the relational contexts that contribute to their difficulties. Nonetheless, as several pieces in this special issue make clear, there remains a need for critical attention to the knowledge practices of the psy disciplines. Indeed, even for practitioners who embrace a feminist identity, the sway of medicalized thinking and biologism may be nearly irresistible. Boyle (2006, p. 191) put it succinctly: “Many challenges to medical models of emotional distress are all too easily assimilated into a medical model and thus lose part of their power.”

Even some ostensibly progressive reforms can be challenged as insufficient. Hamley and Le Grice (2021, this issue), for example, point out the over-arching ethnocentrism that is embedded in so-called multicultural training in clinical psychology in Aotearoa/New Zealand. Such training, they point out, is grounded in Eurocentric theories of human development and wellbeing, which are falsely imagined to be culture-free. Imagining that the norms and practices of one’s own social group are culture-free handily serves to reinforce white racial superiority (Perry, 2001). Hamley and Le Grice further point out that student clinicians in Aotearoa/New Zealand learn to assess patients using the DSM, with no consideration of its grounding in the ethos of liberal individualism that prevails in Western high-income countries. Students are further trained in highly individualized modes of therapy (such as Cognitive Behavior Therapy and Dialectical Behavior Therapy). These too are presented as if they were basic clinical tools that are culture-free. At worst, such training leads students to assume that “culture” is the problem that must be remedied, not “inflexible, ethnocentric service models” (Douglas, 1992, p. 36). Indeed, all the papers in this special issue make clear that radically different ways of understanding are needed to respond more fully and more fairly to people’s psychological suffering. Several of the authors argue further that the psy professions operate to reproduce the very conditions that cause distress. This special issue, we hope, will stimulate dialogue and self-scrutiny that furthers critical scholarship about psychological suffering.