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Critiquing the "psychiatric paradigm" revisited: reflections on feminist interventions in mental health.

I still remember my first meeting with Jeri Wine. It was the fall of 1986 and I was visiting Toronto from the west coast. The notion of going to graduate school had just begun to take form in my mind and I was in Toronto to investigate what was reputed to be a fabulous feminist program in Community Psychology at the Ontario Institute for Studies in Education. In Vancouver I had recently completed a degree in Psychology and simultaneously had become involved in feminist anti-violence activism working for the WAVAW Rape Crisis Centre. The gap between what I was learning in my classes at the university and the stories I heard from women at the other end of the crisis line about their experiences of violence disturbed and troubled me. So many of these women had stories about how they had been disbelieved by mental health professionals when they had disclosed experiences of sexual and physical abuse. Others, who were clearly having reactions to the trauma they had experienced, appeared to have been misdiagnosed as mentally ill. On occasion, women had mental health problems that pre-existed experiences of violence or which made them more vulnerable to abuse. Violence was not the only thing that marked many of these women's lives--poverty and experiences of racism and homophobia were also evident. I asked myself, how could the material I was learning in my upper level psychology classes be so far removed from the actual lives and experiences of women? More specifically how could the discipline of psychology proceed as though social differences like gender, race, sexual orientation and class were inconsequential "variables" only mentioned occasionally or relegated to small separate sections in one or two of our psychology texts?

Several distinct memories come to mind: a social psychology class where we are told that men experience more violence and crime than women and where the subject of intimate violence is never broached; a class on clinical psychology where sex and race differences related to psychiatric diagnosis are never mentioned much less interrogated for their meanings; a class on the history of psychology where Freud's sexist ideas about women's bodies and sexuality are presented as "quaint" and "outmoded" but never discussed in relation to the unwitting legacy he left regarding the massive denial of the role that childhood sexual abuse plays in the lives of women. One welcome departure from this was the lone course on the psychology of sex differences where those of us who suspected that gender, race, sexuality and social positioning were relevant to one's psychological development and one's experience of illness gathered. It was in this class that I began to suspect more ominously that the disciplines of psychiatry and psychology were not always the concerned helping professions they purported to be and were not based on "objective" science but rather contained deeply held biases that often led them to function in ways that perpetuated social inequity.

This deepening realization caused me to abandon my original plans to become a clinical psychologist and I might well have become a full time activist and advocate for women, except for the nagging sense that crisis work, however grounded in women's experiences, would never allow the reflection required to more fully understand the complex social issues I was now grappling with. I was left searching for a graduate program that might allow for a critical discussion of the ways in which women and men's lives are not just biologically and psychologically, but also socially, determined. It was this that led me to Jeri Wine's office on that crisp fall day and it was in her office that I began to realize that there were individuals who had dedicated their lives and careers to critically appraising the ways in which the psychological professions have pathologized women. Jeri, I soon discovered, was one of those unique individuals. The first gift she gave me was to validate my disquiet concerning the disjuncture between what I had been taught in psychology at university and the experiences of women that I witnessed during my time as a rape crisis worker. The second gift she gave me was the insight that my experience as an activist in the women's movement could not only usefully inform, but was in fact a necessary ingredient in furthering my academic study. This was a firm belief of Jeri's which she practised in her own classroom:
 In my own feminist teaching over the years I have increasingly
 wished to foster the activist efforts of the women in my classes. I
 believe the oft-mentioned gulf between academic and activist
 feminists is a false one.... There is a danger, of course, of
 academic feminists becoming overly committed to the development of
 theory or too focused on a narrow slice of feminist scholarship and
 thereby neglecting the work of women seeking social change. As
 well, activists can become too focused on immediate goals without
 developing a broader framework for understanding change (Wine and
 Ristock, 1991, p. 342).


It was from this base that i started my own graduate work and began to contribute to the growing body of feminist literature on violence against women, mental health and the role of the feminist movement in social change. Most recently, as a result of research I have been conducting on mental health reforms in Canada, I have been examining the links between the feminist critique of the "psychiatric paradigm," which exposed the abuses of psychiatry and challenged its claims to objective knowledge (e.g., Chesler, 1972; Laing, 1969; Penfold and Walker, 1983; Wine, 1989; Burstow, 1992) and the anti-psychiatry and psychiatric survivor movements (Szasz, 1961; Breggin, 1991; Chamberlin, 1978; Capponi, 1992). Specifically, I am interested in how these movements have respectively influenced contemporary debates in mental health with a view to further interrogating what has been identified as a growing absorption of feminist work into the discipline of psychology and the apparent abandonment by the feminist movement of women with mental illness (1) (Burstow, 2005).

Feminism and psychiatry

In the following discussion, I begin by examining Bonnie Burstow's recent observation that despite the fact that feminists played a key role in the critique of psychiatry in the 1970s and 80s and embraced their "mad" sisters as part of the movement, currently the feminist movement, with some important exceptions (Caplan and Cosgrove 2004; Chan, Chunn, and Menzies, 2005), has had little to say about psychiatry, and arguably few inroads have been made in changing psychiatric practice and mental health care for women, especially for women who have chronic mental health problems and do not have access to private therapy.

Using this as a jumping off point, I examine the "uneasy" relationship between the psychiatric survivor movement and contemporary feminism as I have come to understand it through interviews and discussion with psychiatric survivors and feminists actively working to improve both social and mental health service responses to women. (2) Specifically, I take up the points outlined by Burstow (2005) that feminist work in mental health has ignored men and that collaborations between feminist professionals in mental health and psychiatric survivors are difficult to sustain. Using examples from my own research and collaborations, I argue that feminists in mental health should apply an analysis of gender that includes an intersectional approach (3) and a discussion of marginalized psychiatrized men. Further, I look at the challenges and possibilities for bringing together progressive work by activists and those working in mental health with the work of feminists striving to maintain a critical "skeptical" lens on psychiatry. I conclude with cautious optimism that feminism can play a renewed role in mental health if it takes its direction from psychiatric survivors.

Burstow's examination of feminist initiatives that have challenged psychiatry is to my knowledge the most recent Canadian discussion of the relationship between feminism and movements that are critical of psychiatry. Burstow categorizes these movements as either "anti-psychiatry," a movement comprised of academics and professionals (including psychologists and psychiatrists) who expose the abuses of psychiatry, or as "psychiatric survivor" movements. (4) The latter exposes the abuses of psychiatry but from the point of view of those who have experienced psychiatric treatment. I would add a third group that, although perhaps not properly a "movement," involves those engaged in collaborative relationships between psychiatric survivors, academics, mental health care providers and decision makers in mental health. The work of these groups has resulted in a wide variety of activities that reflect a critical stance on the biomedical and clinical focus of the mental health care system in Canada. Members of these alliances work against the dominance of what Trainor, Pomeroy and Pape (2004) call the "service paradigm" in mental health, support active recovery models, and have had significant influence in advancing mental health reform (e.g,, Nelson, Lord, and Ochocka, 2001).

It could be said then that movements that are critical of psychiatry, like the women's movement, have both "activist" and "academic" centres of activity and that, also like feminism, the views and positions expressed within these groups differ and range from those fundamentally opposed to psychiatry to "softer" positions which acknowledge the sometimes useful role of psychotropic medications for people experiencing mental illness, while maintaining a critical stance towards some psychiatric practices. As discussed below, feminists have played varying roles in each of these movements and locales.

The anti-psychiatry movement in North America began with the writings of Thomas Szasz, who was trained as a psychiatrist but launched a critique of the moral and scientific foundations of psychiatry (Szasz, 1961, 1963, 1970, 1974). For Szasz and his followers psychiatry was little more than a pseudo-science and mental illnesses were not really illnesses but "problems in living." Others adherents to the anti-psychiatry movement did not fully reject psychiatry but rather criticized some of its more controversial practices (e.g., insulin shock therapy, lobotomy, electroconvulsive therapy). In recent years the anti-psychiatry "eye" has been trained primarily on the multi-billion dollar pharmaceutical industry of which psychotropic drugs play a major role. While contemporary critics continue to discuss psychiatric practices they also point to the links between profit making by the pharmaceutical industry, drug prescription and the suppression of evidence that some drugs (e.g., Prozac and other anti-depressants) have seriously harmful side effects (Healy, 2004; Breggin, 1991, 2001).

The feminist critique of psychiatry emerged during the resurgence of the women's movement in North America in the 60s and 70s and began with women sharing their stories about their abuses at the hands of psychiatry and with the pivotal publication of Phyllis Chesler's book Woman and Madness in 1972. Chesler's work was the first to comprehensively analyze the ways in which madness has historically been rooted in normative ideas about femininity and exposed the masculinist origins of psychiatry and the ways in which psychiatric treatment was structured to both maintain and enforce women's subordination.

Chesler's work helped to galvanize the feminist critique of psychiatry that was being launched both by activists and academics in the women's and anti-psychiatry movements (Kimball, 1975; Burstow and Weitz, 1988; Caplan, 1987; Penfold and Walker, 1983; Ehrenreich and English, 1978; Showalter, 1987; Broverman et al., 1970; Woolsey, 1977). First person accounts of experiences with mental illness by women were also important contributions that gave further evidence to the literature on abuses in psychiatry (Blackbridge, 1997; Millet, 1990; Redfield Jamieson, 1995; Nana-Ama Danquah, 1999). Lesbian feminists, in particular, were vocal about the role psychiatry played in pathologizing homosexuality and lesbian identity (Blackbridge and Gilhooly, 1985). The fact that Chesler's 1972 contribution was re-released in 2005 attests to the continued relevance of this critique as do essays on this subject and volumes released in the 1990s and 2000s (Chan, Chunn, and Menzies, 2005; Millet, 1990; Ussher, 1991; Ripa, 1990; Caplan and Cosgrove, 2004).

The literature on the experiences of Aboriginal, racialized and immigrant women diagnosed with mental illness is in its nascent stages. However, increasingly, the impact of colonization on the mental health of women in Aboriginal communities is being explored as are the specific concerns of women of colour and immigrant women who come into contact with the mental health system (Boyer, 1997). Specifically, it has been noted that the profession of psychiatry has not responded in any significant way to the substantive evidence that mental distress is intimately tied to social inequities like poverty, homelessness, racism, homophobia and sexism (Morrow and Chappell, 1999; Morrow, 2004) and continues to use diagnostic labeling and drug therapy as its primary forms of intervention (Caplan and Cosgrove, 2004).

Psychiatric survivor movements and feminism

Psychiatric survivor movements developed in parallel and as part of the feminist critique and were at their height in the 1960s and 70s, sometime after the first wave of psychiatric deinstitutionalization in most North American cities. The movement was comprised of diverse activists who went public with their own experiences of psychiatrization and staged protests and activities that publicized mistreatment by psychiatry. In the late 70s psychiatric survivors across Canada were largely isolated from one another with very few avenues for communication. By the early 80s informal networks began to form and Toronto became the hub of the consumer survivor movement with high profile activists (e.g., Pat Capponi), newspapers (Phoenix Rising and Cuckoo's Nest) and the development of some of the most innovative programs in North America, including those that promoted psychiatric survivor leadership.

This included, for example, the development of the Ontario Council of Alternative Business which supports survivor run businesses--the most well known of these being A WAY Couriers (Church and Reville, 2001; Church, 1997). Developments in other parts of Canada included the establishment in 1983 in Quebec of Le regroupement des ressources alternatives en sante mental du Quebec, which is composed of a variety of community organizations that deal with mental health and promote alternatives to psychiatry, and the provincial association of consumers founded in the 1980s called L'association des groupes d'intervention en defense de droits en sante mentale du Quebec (l'AGIDD-SMQ). The establishment of the Second Opinion Society in the Yukon and the Mental Patients Association (now the Motivation, Power and Achievement Association) in Vancouver are two other examples of organizations that began working from the perspectives of psychiatric survivors. In most locales the psychiatric survivor movement was characterized by a degree of interaction between the movement, other activists and mental health professionals. Groups therefore also worked from within the mental health system to promote the recognition that a wide range of resources and supports outside of psychiatry are needed for people diagnosed with mental illness.

Bonnie Burstow (2005) argues that, although feminists in the early part of the second wave were a strong anti-psychiatry force, today although individual women still work to improve the situation for women diagnosed with mental illness, psychiatry is not an issue currently galvanizing the women's movement. She further suggests that the reasons for the "uneasy" relationship between feminism and psychiatric survivor movement is, first, that "mad" women have sometimes felt that they have more in common with "mad" men then with their feminist activist "sisters" and secondly, the fact that some feminists, especially those in the psych professions, have used the tools of psychiatry abusively against women has created mistrust (Burstow, 2005). Additionally, many psychiatric survivors because of their experiences of illness and disenfranchisement have not held social positions of power and therefore feel alienated by professional groups and academics trying to change psychiatry. This is something that Kathryn Church (1996) takes up in her discussion of the clash of cultures between psychiatric survivors and professional groups each of which are guided by different social and behavioural norms.

In the first instance, the fact that much of the feminist work to date has focussed on women and femininity in its intersections with psychiatry has meant that as yet we have an under-developed understanding of men's experiences of mental illness and the role of masculinity. While it is true that much of psychiatry's early raison d'etre (as was the case of western science in general) was to affirm male professional's beliefs about women's (and racialized others') inferiority and greater susceptibility to mental "disorder," it is also true that men with mental illness remain a highly stigmatized population and many (like their female counterparts) have lives marked by poverty, racism, violence and homophobia.

Current feminist work on mental illness tends to ignore men and masculinity or to crystallize it as residing in the authority of "malestream" psychiatry as though psychiatry has not also damaged the lives of men. This is not to deny that sexism is a profound and determining factor in women's experiences but rather to remind ourselves that it is not the only relevant factor. I would argue that there is a gap between developments in feminism with respect to theorizing gender (both femininity and masculinity) and intersectionality, (5) and the work of feminists in mental health where gender has come to equal women and where a discussion of other interacting forms of social difference (class, race, ability, sexuality, gender identity) are rare. This, I believe, has actually impeded our understanding of people's experiences of mental illness. It has also perhaps weakened potentially powerful links between feminists without experiences of psychiatrization and those who have had these experiences and feel some allegiance to their male counterparts.

That said, developing a framework for understanding gender and mental illness while continuing to recognize power differences between men and women is no easy task. Feminists have for good reason feared turning attention away from women because of the historical experience of how the study of gender quickly reverts to the study of men and also because the resistance to looking at women and mental health is still so strong. This is evidenced in the marginalized place that women's mental health has had in virtually all high profile developments in mental health in Canada.

Further, studies that do look at "gender" rather than "women" often simply employ a comparative lens, for example, "women are diagnosed with anxiety and depressive disorders more often than men", etc., and/or take the form of concentrated articles on men and mental health. In my view, while comparative studies can be useful, they do not have the ability to fully comprehend the intricacies of femininities and masculinities in their relationship to one another and in their day to day "naturalized" expressions. Further, if we include the lives of transgendered people in our discussion it helps us to see how gender transgression is a powerful ingredient in what gets defined as "normal" whether you are sexed as female or male.

Gender in mental health

In my own work, I have been attempting to better understand gender and its intersectionalities in mental health. For discussion purposes, I offer the following example (6) from a study where we are currently examining the experiences of men and women leaving Riverview Psychiatric Hospital (7) in BC. These individuals are mostly being transferred to smaller tertiary care facilities in their "home" communities. (8) In my view the employment of qualitative sociological methods are most useful for trying to understand gender in this context. In view of this we are employing institutional ethnography as our methodology which takes the "standpoint of women" as the starting place for uncovering the gendered dimensions of social relations (Smith, 1990; Smith, 2005).

Our study was motivated by two interconnected inquiries: the first was to understand what is needed to ensure community capacity to care for, support and integrate people arriving from Riverview to towns and cities in BC; the second was the fact that, aside from selective first person accounts, almost nothing is known about the experiences of women and men leaving institutionalized care in this context and about the role of gender in these experiences.

In the Canadian context, psychiatric deinstitutionalization began in the 1950s with the shift of care from public mental hospitals to community mental health services (Shera et al., 2002). Deinstitutionalization was and continues to be driven by a number of interconnected forces including developments in psychopharmacology, new psychosocial rehabilitation practices, studies of the negative impact of institutional life, concerns about the civil rights of people with mental illness, and cost-containment (Lesage, 2000). Today, the vast majority of people with mental illness are not institutionalized (only 10 to 20 percent are in hospitals or supervised settings). While only a small population; these individuals capture a substantial proportion of mental health care budgets. Thus, especially in times of restructuring and fiscal constraint, deinstitutionalization garners significant attention. This is particularly relevant in the BC example where deinstitutionalization is occurring in the context of dramatic health and social welfare restructuring, which includes new fiscal pressures and changes to the mechanisms designed to involve mental health care recipients in decision making.

Some of the early assessments of psychiatric deinstitutionalization produced in the 1960s, 70s and 80s reported on the negative aspects of the process, particularly the deterioration of people leaving institutions. Critics argued that governments had failed to fund adequate community supports for people with mental illness trying to reintegrate into communities (Dear and Wolch, 1987; Rose, 1979). However, virtually none of this literature focussed specifically on the ways in which gender or other social variables (outside of poverty) might be relevant to these experiences. It is with this limited understanding of gender and deinstitutionalization that we are constructing our study.

Gender relations are often so normalized as to become invisible not only to the people living and working in the institutional context but also to those attempting to investigate them. Institutional ethnography as a methodology aims to make gender relations visible as well as the institutional processes which regulate and produce gender (Smith, 1990, 2005). Studying this in a setting where the people whose lives you are concerned with are highly regulated and where illness, medication side effects and the long-term impact of institutionalization potentially impedes their ability to discuss their lives and their experiences is challenging.

One of the questions we are grappling with vis-a-vis the method of institutional ethnography, is an epistemological question about standpoint. In institutional ethnography one begins from the standpoint of women, precisely because knowledge in its objectified forms implicitly incorporates the standpoint of men (in this case the form of objectified knowledge is masculinized psychiatry) (Smith, 2005). However, when the forms of objectified knowledge have also worked to disenfranchise some groups of men beginning from the lived experiences of both women and men seems appropriate. This is where our study begins--with the experiences of women and men who have been transferred from Riverview Hospital, to other smaller institutions or other supported living arrangements.

From there our examination includes interviews and focus groups with those working in institutional care, those working in community mental health and individuals supporting family members who are institutionalized. Through this we are attempting to make gender (and other forms of social difference) visible and to identify the institutional practices which may reinforce gender inequities and/or simply ignore gendered realities. Our hope is that including men's experiences in our starting point alongside of women's will better illuminate gender differences and gendered relations as they are reproduced and regulated in psychiatric institutional settings and that this will elevate not only our understanding of gender but also of psychiatrization. Our goal is to build on the understanding of how psychiatric institutional processes shape the lives of women and men in order to inform strategies that will enhance their lives.

Although only a brief example, the intention is to illustrate how by utilizing a feminist methodology we can shift the frame, in this instance so that both women and men's lives become visible in new ways that move beyond traditional comparative studies in mental health or those focussed exclusively on women or men.

Collaborative partnerships

In the late 1990s I became involved in co-chairing a women and mental health discussion group at the BC Centre of Excellence for Women's Health in Vancouver. This group brought together psychiatric survivors, mental health care providers, women's groups, mental health care decision makers and academics to develop and conduct policy relevant research for women. In my second example I want to draw on my experience of developing projects with this group as a way of illustrating some of the challenges and possibilities of collaborative partnerships. The challenges include those related to establishing trust amongst group members who do not all necessarily share the same perspective on mental health, and the power differences inherent in each member's social and institutional positioning leading to differential access to social, intellectual and material resources. The positive outcomes include the knowledge gained from working in alliance with each other (including the deeper knowledge for non-survivors of what it is like to live with mental illness) and in the small inroads made with respect to changes in programs and policy. These examples are not meant to be representative of work in Canada as a whole but rather are offered as a starting point for further analysis and discussion.

The first project that emerged from this group was motivated by the release of the 1998 Mental Health Plan in BC (BC Ministry of Health and Ministry Responsible for Seniors, 1998). The plan was meant to be the template for mental heath service delivery in the province at a time when regionalization was still relatively new. This plan, like others of its kind across Canada, did not substantively integrate women's issues into its framework or discussion. The project, Hearing Women's Voices: Mental Health Care for Women (Morrow and Chappell, 1999) was designed to address this gap by examining women's experiences with the mental health care system and psychiatry in eight towns and cities across BC. The focus was on women who identified as having serious and chronic forms of mental illness that had brought them in repeated contact with psychiatry and the mental health care system. Pressure from the psychiatric survivors on the project advisory committee, and specifically a disagreement over my hiring as the research leader (that is, that employing an academic without a psychiatric history would undermine the goal of honoring experiential knowledge of the mental health care system) led to the adoption of a co-researcher model which paired me with a woman who identified as a survivor and was a community-based researcher. The two of us brought our respective academic and experiential skills to bear on the design and implementation of the research. Additionally, we continued to work under the direction of an advisory committee which included survivors, government decision makers, women's organizations and mental health care providers.

The challenges of partnership or alliance models of this type have been analyzed in the literature (Church, 2001; Church, 1996) and as described in these analyses, we too struggled as individuals and collectively with many issues relating to trust and differential social and institutional power. Despite this, the model proved both personally transformative (9) as well as essential for gaining the trust of the over 200 women we subsequently spoke with throughout the province. Because our larger advisory committee included a well-positioned "femocrat," we were also able to gain some ground in bringing women's mental health to the ear of politicians and policy makers. The latter resulted in funding for further projects--one of which explored the experiences of women in the mental health care system with violence and trauma (Morrow, 2002) and the other which supported innovative program development for women diagnosed with mental illness and included several psychiatric survivor led projects (Morrow, 2003).

Role of Women's Organizations

One of the emerging themes from the work that we pursued on these various projects was the role of women's organizations in working with women whose lives included experiences of violence, poverty and serious mental illness. The role of women's organizations (rape crisis centres, shelters, women's centres) in mental health is generally invisible, under-valued and not seen formally as part of the continuum of care for women diagnosed with mental illness. And yet, women's organizations and front-line workers continue to be some of the most important innovators when it comes to program development and supporting women.

In my research I have found that the mental health system, in part because of the dominance of the bio-medical paradigm, is often ill-equipped to deliver the kinds of services that women identify as important for recovery (e.g., on going counseling for childhood sexual abuse issues, women-only drop-in spaces, advocacy on issues related to child custody, violence, etc.,). Women's organizations where the knowledge of gender issues, racism, homophobia and violence has been built up are therefore, in my view, potentially well-positioned to work with women diagnosed with mental illness. However, the willingness of these organizations to do so has not always been apparent. That is, many women's organizations have come over time to develop screening criteria that often excludes the participation of women diagnosed with mental illness in their programs if they are taking medications, have concurrent substance use issues, and/or have problems that staff feels ill equipped to address. Screening has resulted, in part, from the institutionalization of women's organizations like shelters, many of which, through funding mechanisms, have come to comply with more traditional social service guidelines. Women's organizations (especially women's centres) since the 1990s have also continually been under attack by governments who have removed their resources, forcing many groups to narrow their mandates and be selective in whom they can support. There is also an identified knowledge gap by front-line workers who do not always feel that they can adequately support women with complex needs.

In recognition of this gap, in 1999 the BC Association of Specialized Victim Assistance and Counselling Programs (BCASVACP) (10) in Vancouver held a symposium called Connecting: Mental Health and Violence Against Women to address concerns by their membership about working with women diagnosed with mental illness. This symposium was meant to facilitate knowledge exchange between mental health professionals and women working in anti-violence organizations. During the symposium members of BCASVACP and transition house workers came together with a group of feminist psychologists to share knowledge and discuss the challenges and possibilities of developing better programs for women. It quickly became apparent in the symposium sessions that women in anti-violence organizations were often working from very different assumptions than the feminist psychologists. Specifically, they resisted the psychiatric labeling of women and in feedback from participants later they complained that the knowledge exchange had only been one way--from feminist psychologists to antiviolence workers. The symposium thus highlighted the fact that feminists working within different contexts and with different kinds of knowledge and training had dramatically differing understandings of women's lives and the relative merits of traditional psychiatric treatment. Subsequent work in this area requires more attempts to equalize the knowledge exchange and critical discussion of psychiatry.

Since this event there have been several successful program developments in women's organizations in BC which are addressing the needs of women with overlapping violence, mental health and substance use issues. These programs are built both on Canadian knowledge and programming (e.g., Haskell, 2001; Haskell, 2003) and on programs developed primarily in the US--for example the Seeking Safety Model developed by Lisa Najavits and the Trauma, Recovery and Empowerment model (TREM) developed by Maxine Harris (Harris, 1998; Najavits, 1999). Although these programs differ in their emphasis they all see trauma and violence as central to women's lives and to subsequent mental health problems.

Little is known yet about how the introduction of support and programming on these issues will impact women's lives. In view of this it is interesting to track the progress of the Women, Co-occurring Disorders and Violence Study in the US, sponsored by the Substance Abuse and Mental Health Services Administration. This study was launched in 1998 and involved nine sites developing a services integration intervention to address the multiple needs of women with co-occurring mental illness, violence and substance use issues (Veysey and Clark, 2004). The study is allowing communities to develop integrated approaches across a range of services which are guided by a framework that is "gender specific, culturally competent, trauma-informed and trauma specific, comprehensive and integrated, and involve consumers/survivors/recovering persons (CSRs) in substantive and meaningful ways" (Veysey and Clark, 2004, p. 1). Each component of the program is being evaluated and hopefully will reveal strengths and weaknesses of what is both a partnership and a system change model. In particular, it will be useful to gain knowledge about how working across diverse sites, where presumably providers and psychiatric survivors have differing positions on psychiatric and mental health care, can be accomplished in ways that foster positive outcomes for women.

These examples, although limited, provide evidence of collaborative partnership models between psychiatric survivors, feminist organizations and other components of the mental health system. Although these collaborations are not without their challenges they are contributing to the development of a knowledge base on women diagnosed with mental illness that is vital to improved responses at the service level. What is missing however, are more comprehensive discussions of the wider societal context in which those with psychiatric histories are often marginalized through poverty and discrimination. Feminist service related initiatives must continually raise these larger social issues, even as they attempt to work more effectively at the individual level.

The integration of feminist and psychiatric survivor analyses has the potential to ensure that a gendered intersectional analysis which includes attention to the lives of both women and men is integrated into discussions about mental health and that a critical focus on psychiatry and its practices is ongoing. The challenge will be to ensure that the collaborations that are established are authentic and that the results are taken seriously by key decision makers. Skepticism about this latter point has been fueled in BC with a shift in governance that resulted in dramatic cuts to social welfare services across the province as well as significant cuts and changes in mental health. (11) Some of the most critical cuts have been made to mechanisms and organizations that had been designed to foster the active involvement of psychiatric survivors in decision making about their own treatment and also in the mental health policy process. In the absence of state-supported mechanisms it behooves mental health and women's organizations to develop their own mechanisms to bring psychiatric survivors to the table so that their voices remain central to all discussions in mental health.

Conclusion

As documented by Burstow (2005), currently the lives of women diagnosed with mental illness are not a critical focus of the feminist movement. Despite this there is evidence that some feminists, especially those engaged in front-line work, are establishing collaborative relationships with psychiatric survivors and developing services and supports that take the specific needs and concerns of women into account. At the same time feminists in the academy also continue to theorize the ways in which psychological, medical and legal institutions structure women's lives and to think through gender in the context of psychiatrization (Chan, Chunn, and Menzies, 2005; Caplan and Cosgrove, 2004). Feminism, however, remains on the periphery of the psychiatric survivor movement and feminist knowledge about mental health is rarely integrated into even the most progressive articulations of what is needed in the mental health system.

In the spirit of Jeri Wine and other feminists striving to bridge activist and academic work into projects that result in progressive social change, the work must continue and our analyses of women's lives and the role of gender and intersectionality in mental health must evolve to reflect recent theoretical developments.

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Marina Morrow

Faculty of Health Sciences

Simon Fraser University

Burnaby, BC

Notes

(1.) I use the term "mental illness" in this paper with the knowledge that it is a contested term, rejected by some because of how it has historically obscured social suffering and resulted in stigma and discrimination against those with psychiatric labels. On the other hand, there is no doubt that certain kinds of psychological reactions and symptoms exist for some people and cause extreme distress and that for many people psychiatric labels and treatment has resulted in an improvement in their lives.

(2.) My observations in this paper are drawn on eight years of working in a variety of collaborative relationships on mental health related research and policy projects with mental health service providers, those working in women's organizations, policy decision makers and self-identified psychiatric survivors (Morrow, 2002, 2002, 2003, 2003; Morrow and Chappell, 1999).

(3.) That is an approach which contextualizes women and men in their diverse social and economic circumstances and understands gender as inseparable from other forms of social difference such as race, ethnicity, culture, class, sexual orientation, gender identity and ability.

(4.) People who identify with the "survivor" movement have adopted many different names for illustrating their position vis-a-vis psychiatry and the mental health care system. These include, but are not limited to, "consumer," "consumer-survivor," "ex-patient," "mad" and "psychiatric consumer."

(5.) For a discussion of this issue in the context of women's health research, see C. Varcoe, M. Morrow and O. Hankivsky. "Beyond 'Gender' Matters: An Introduction." In Morrow, Hankivsky and Varcoe, Women's Health in Canada: Critical Frameworks for Theory and Policy (Toronto: University of Toronto Press, 2007).

(6.) This study is called, "Gender, Community Capacity and Mental Health Reform in BC" and is funded by SSHRC and the Michael Smith Foundation for Health Research. My research team members include Alain Lesage, Jules Smith, Lupin Battersby, Ann Pederson, Jill Stainsby and Monika Chappell.

(7.) Riverview is BC's only large psychiatric hospital. It has historically housed people from all over the province (many under involuntary committal orders) who have been deemed chronically mentally ill.

(8.) Proposals aimed at phasing out Riverview Hospital have been made periodically since the late 1960s. The subject of this research is the current phase of deinstitutionalization that began in 2000 and involves the relocation of approximately 600 people from Riverview Hospital to cities and towns throughout BC.

(9.) Sharing my research role with a psychiatric survivor allowed me to discover a much richer and more textured understanding and appreciation for what it is like to have been psychiatrically labeled and to live with mental illness. I am grateful to Monika Chappell, Jill Stainsby, Helen Turbett and the many other survivors who went to great lengths to "educate" me during this and other subsequent collaborations.

(10.) The BCASVACP is a provincial organization that has provided a communication network among Community Based Victim Assistance programs, Sexual Assault Centres and Stopping the Violence Counselling Programs

(11.) The BC Mental Health Advocate position was cut (this was the first position of its kind in Canada and focussed on systemic change issues), the protected envelope for mental health care dollars in health was lost, 70 percent of the staff of the Adult Mental Health Division of the Ministry of Health were laid off and legislative changes to disability benefits ensued.
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Date:Mar 22, 2007
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