Feminist Issues and the DSM-V

ABFH linked this article from the Los Angeles Times, which calls wider attention to the heated argument in the letters pages of the second July issue of Psychiatric News over the extent to which the process of drafting the DSM-V should be made accessible to the public.

In response to this June 6 editorial, describing the process as "complex but open," Robert Spitzer (the psychiatrist who chaired the DSM-III and DSM-III-R task forces) wrote a letter denouncing DSM-V task force vice-chair Darrel Regier's refusal to give him a copy of the task force's meeting minutes. (That same issue also printed a response, co-written by Regier, DSM-V task force chair David Kupfer, APA President Nada Stotland, and APA Medical Director and CEO James Scully, Jr.).

The LA Times writer, Christopher Lane (who has written a book, Shyness: How Normal Behavior Became a Sickness, which accuses DSM-III-era psychiatry of essentially making up disorders to sell drugs to healthy people), argues that the task force's failure to make the minutes public betrays an insularity and protectiveness that undermine its efforts to improve the DSM's validity:

Spitzer counters that "the real purpose ... is to avoid possible criticism of the ... process." He has called the attempt to revise the DSM in secret "a big mistake" and a likely "public relations disaster."

I fear that I may have unintentionally contributed to Regier's excessively secretive behavior. Back in the 1970s, during the creation of the third edition of the manual, I published much of the correspondence that had circulated between committee members. Some of the exchanges were frankly hair-raising. They included proposals for the approval of such dubious conditions as "Chronic Complaint Disorder" and "Chronic Undifferentiated Unhappiness Disorder." When asked to define how he was using the term "masochism," one leading psychiatrist replied: "Oh, you know what I mean, a whiny individual ... the Jewish-mother type." And so it went for dozens of other terms that later became bona-fide illnesses. (emphasis mine)

Regier obviously wants to prevent any such embarrassment for his task force; he apparently fears the public will not find his committee's work entirely convincing.

The ideas Lane ridicules in this passage (Chronic Complaint Disorder, Chronic Undifferentiated Unhappiness Disorder) were more than just silly attempts to turn everyday grumpiness into a medical problem; they functioned to lend authority to long-standing stereotypes about women, and to deflect attention away from social conditions that might distribute life stresses unequally between the sexes. That's what Carol Tavris argues in The Mismeasure of Woman, in the chapter on women and psychiatry:

Self-defeating Personality Disorder and codependency are the latest incarnations of an old American game that we might call "Name What's Wrong With Women." Every few years a wave of best-selling books sweeps over the land, purporting to explain to women the origins of their unhappiness. In many of the self-help versions of these books, the author begins by describing how she herself suffered from the disorder in question, and, through persistence, effort, or revelation, found the cure.

Thus, in the 1950s, women's problem was said to be their inherent masochism, an idea that derived from Freud's theory that female psychology includes an unconscious need for, and pleasure in, suffering. Wrong, said Martina Horner in the late 1960s. The problem is women's fear of success; the cure is to understand and then overcome their internal barriers to achievement. Wrong, said Marabel Morgan, Phyllis Schlafly, and other religious conservatives in the 1970s. The problem is that women want success, when they should be spending their energies being obedient to God and husband; the cure is to strive to become "The Total Woman," "The Fulfilled Woman," or "The Positive Woman." Wrong, said Colette Dowling in 1981. The problem is that women have a "Cinderella Complex --- a hidden fear of independence"; they must struggle against their desires to be rescued by Prince Charming. Wrong, said a spate of writers in the early 1980s. The problem is that women "say yes when they mean no," and "when they say no, they feel guilty"; the cure is assertiveness training. Wrong, said Robin Norwood in 1985. The problem is that women love too much. Wrong, said a flurry of books in rebuttal. It's not that women love too much but that they love the wrong men --- men who are immature, angry, abusive, chauvinistic, and cold. Wrong, said Melody Beattie in 1987; the poor guys aren't to blame, because they are sick. Women love too much because they are codependent --- addicted to addicts, addicted to bad relationships.

Long ago in The Feminine Mystique, Betty Friedan wrote of "the problem that has no name" --- the vague emptiness and desolation that plagued many women in the postwar era. But in fact the problem has gone by far too many names. The symptoms that all these books attempt to treat are invariably the same: low self-esteem, passivity, depression, dependency on others, an exaggerated sense of responsibility to other people, a belief that it is important to be good and to please others, and an apparent inability to break out of bad relationships. I do not doubt that many women are unhappy, and I do not doubt that these descriptions apply to many women --- and to a goodly number of men. But it is time to ask why these psychological diagnoses of women's alleged inner flaws, which keep returning like swallows to Capistrano, year after year, fail to deliver on their promises. And it is time to ask why the explanations we make of female problems differ in kind and function from those we make of male problems.

Thus, the problems that are more characteristic of men than women --- such as drug abuse, narcissism, rape, and other forms of violence --- are rarely related to an inherent male psychology in the way women's behavior is [related to an inherent female psychology]. When men have problems, it's because of their upbringing, personality, or environment; when women have problems, it's because of something in their very psyche. When men have problems, society tends to look outward for explanations; when women have problems, society looks inward.

For example, psychologist Silvia Canetto has compared attitudes toward people who attempt suicide (typically women) with those toward people who abuse drugs (typically men). Both of these actions, says, Canetto, are "gambles with death"; both actions can be lethal although the individual may not intend them to be. Suicide attempters and drug abusers share feelings of depression and hopelessness. Yet mental-health experts tend to regard suicide attempts as a sign of a woman's psychological inadequacy, reports Canetto, whereas they regard drug abuse as "caused by circumstances beyond the person's control, such as a biological predisposition."

Likewise, people speculate endlessly about the inner motives that keep battered wives from leaving their husbands. Are these women masochistic? Do they believe they deserve abuse? Are they codependent, unwittingly collaborating in the abuse against them? Whatever the answer, the problem is construed as the battered wives, not the battering husbands. But when experts ponder the reasons that some husbands abuse their wives, they rarely ask comparable questions: Are these men sadistic? Do they believe they deserve to abuse others? Rather, their explanations focus on the pressures the men are under, their own abuse as children, or the wife's provocations. Male violence is not considered a problem that is inherent in male psychology; but the female recipients of male violence are responsible because they "provoked" it or "tolerated" it or "enabled" it or are "masochistic" --- problems presumed to be inherent in female psychology. A man who gets into a fight with a stranger and hits him may spur an observer to ask, "Why is this guy so aggressive and hostile?" But if the same man goes home and hits his wife, the same observer is likely to wonder: "Why does she stay with him?"

The DSM-III/DSM-III-R disorders Tavris cites --- Self-defeating Personality Disorder (which appears in an appendix to the DSM-III-R), Dependent Personality Disorder, Histrionic Personality Disorder (which are not included in the passage I quoted, but are discussed in a later section of the same chapter) --- explicitly locate the reasons for women's problems in their own defective personalities. Because the symptoms of these disorders closely match common stereotypes of feminine behavior, and because personality disorders in general are understood to reflect long-standing self-destructive patterns in one's thought and behavior, women with the kind of diffuse, generalized malaise that Friedan's interviewees complained of, and that might in the consciousness-raising groups of the 1970s have prompted an examination of the conflicts between women's desires and society's expectations of them, are now once again directed to blame themselves for their unhappiness. The only difference is that now, instead of merely being labeled sick for failing to be feminine enough, a woman can also be pathologized for being too feminine.

I bring all this up because one of the proposed new categories of mental illness being considered for inclusion in the DSM-V threatens to do a similar thing: to muddy the waters around lingering issues of gender inequality by overpersonalizing those issues.

The diagnostic category in question would encompass the relational disorders --- those "persistent and painful patterns of feelings, behavior and perceptions involving two or more partners in an important personal relationship." No individual would get a diagnosis; whatever pathology exists is understood to be an emergent property of the relationship --- a diseased whole that might be composed of perfectly healthy parts who just interact pathologically. While this is an intriguing idea, and strikes me as potentially very useful in therapy, I worry about its implications for domestic abuse. The Research Agenda for DSM-V mentions domestic violence explicitly, classifying it as Marital Abuse Disorder or, alternatively, Marital Conflict Disorder With Violence. I am extremely uncomfortable with classifying all, or even most, domestic violence as a diseased interaction because that conception of it implies that both partners contribute to the hostility, when the simple truth is that all of the blame lies with the battering partner. An abuser could easily use the pretext of wanting to work through a "relational disorder" to maintain contact with his victim, or guilt her into staying with him. Abuse victims already have a strong tendency to blame themselves for their partners' violence, and a DSM diagnosis that seems to corroborate that belief would be a giant step in exactly the wrong direction.

To get back to the beginning paragraphs, this is exactly the sort of criticism that would be brought to the attention of the DSM-V task force if they made their discussions public. While there are feminist psychologists, they are a small minority within the profession, and I doubt more than one or two (if any at all) are represented on the task force. Without opening the discussion to the public, and inviting the feminist critique that is marginalized within psychiatry, these objections may never be heard, and psychiatry will continue to lend its support to societal misogyny.