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Gender and diagnosis: struggles and suggestions for counselors.

The field of abnormal psychology has had a troubled relationship with women. Feminists have asserted that "diagnoses such as nymphomania, hysteria, neurasthenia, erotomania, kleptomania, and masochism have served to enforce conformity to norms of female domesticity, subordination, and subservience to men's sexual needs" (Marecek, 1993, p. 115). Feminist theorists have stated that women's anger, depression, and discontent have been refrained as medical or psychiatric symptoms and that, as a result, the often difficult and distressing life circumstances of women have been disregarded. They have stated that it is often forgotten that the roots of women's so-called psychological problems have frequently been social and political rather than individual and intrapsychic in origin (Caplan, McCurdy-Myers, & Gans, 1992; Cook, 1992a, 1992b; Koss, 1990; Ussher, 2000; Wakefield, 1992).

Although feminists initially reacted militantly against the male hegemony they believed to be inherent in diagnostic (and many other) systems, further analysis indicated their recognition that both men and women have been hurt by previously unquestioned diagnostic systems. In fact, many authors have pointed out the stigmatizing effects of diagnostic labels; the classist, sexist, racist, and homophobic assumptions embedded in both the International Classification of Diseases (ICD; World Health Organization, 1992-1994) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text. rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000); the resulting pathologizing of behaviors that may be normative within particular gender contexts; and the underdiagnosing of problematic behaviors (Brown, 1990a, 1990b; Eriksen & Kress, 2005).

In this article, we report gender-related concerns about diagnosis, including those related to the prevalence of diagnoses by gender, sex bias in diagnosis, the problematic impact of particular diagnoses on women, and the impact of socialization and social conditions on diagnosis. We conclude by proposing alternative diagnoses, diagnostic procedures, and diagnostic loci designed to address some of these concerns. It should be noted that, in general, the disciplines of psychology and psychiatry have "owned" the area of diagnosis because of their greater focus on psychopathology. Therefore, little has been published in counseling-related journals on struggles with diagnosis. However, the nearly universal licensure and increasingly reimbursable status of counselors now makes it a market necessity for counselors of certain specialties to provide diagnoses. Thus, counselors need to increase their knowledge of both diagnosis and its challengers, and they need ideas on how to proceed in ascribing diagnoses in the most sensitive fashion possible.

* Prevalence Data of Diagnoses by Gender

From the perspective of popular culture, women have historically been considered to be "crazier" than men. As late as 1993, the first author heard a female expert on women and psychology report that more women than men had a mental illness. However, current research on the prevalence of mental illness by gender has yielded contradictory results. Some authors cited evidence that more women than men had a mental illness and that women's prevalence rates were higher than those for men on far more disorders (Cook, Warnke, & Dupuy, 1993; Gove, 1980; Hartung & Widiger, 1998). Other researchers indicated that men and women experienced mental illness at comparable rates (Bijl, deGraaf, Ravelli, Smit, & Vollebergh, 2002; Horsfall, 2001; see Kass, Spitzer, & Williams, 1983, for personality disorders).

However, research on specific diagnoses rather than overall rates of mental illness clearly indicates that men predominate in some disorders, and women predominate in others. For instance, men's prevalence rates were higher for substance abuse and sexually related disorders, whereas women's prevalence rates were higher for all forms of mood and anxiety disorders (Bijl et al., 2002; Hartung & Widiger, 1998; Horsfall, 2001; Wetzel, 1991) and eating disorders (Hudson, Hiripi, Pope, & Kessler, 2007). Furthermore, women were found to predominate in borderline, dependent, and histrionic personality disorders (although only in the 31- to 40-year age group for dependent personality disorder; Nehls, 1998; Reich, Nduaguba, & Yates, 1988), whereas men predominated in antisocial, compulsive, paranoid, schizoid, and passive aggressive personality disorders in all age groups except 31 to 40 years of age (Kass et al., 1983; Reich et al., 1988).

It is of interest that gender prevalence studies have indicated few gender differences in diagnosis prevalence before school age. Once children begin school, however, boys are more frequently diagnosed in the elementary years and girls in adolescence (Keenan & Shaw, 1997). For instance, McDermott (1996) found no significant female prevalence for any type of maladjustment during childhood but found male prevalence in hyperactive, aggressive--provocative, and aggressive--impulsive behaviors. Although boys' problematic behavior reduced with age, avoidant or diffident behavior, more frequently associated with female children, increased with age. Caplan (1992) further noted that despite the widely accepted wisdom that more boys have learning disabilities than do girls, research has indicated that learning disabilities were equally divided among boys and girls (see also Shaywitz, Shaywitz, Feltcher, & Escobar, 1990) even though more boys were referred for problems in this area.

Keenan and Shaw (1997), observing the rather sudden shift from gender similarity to gender difference in prevalence from before-school-age to school-age children, hypothesized that young girls with difficulties are socialized to channel them into internalized distress that is not as identifiable by teachers and parents. In contrast, they suggested, young boys more frequently externalize problems, which disrupts families and classrooms, resulting in the boys being diagnosed and referred for help early. Caplan (1992) concurred with these notions about "noticing" and "referring" and indicated that, as a result, girls' problems are more likely to be overlooked and underdiagnosed (see also Caplan, 1973, 1977; Caplan & Kinsbourne, 1974).

Clearly, the lack of ability to observe young girls' distress, should it actually be present, would result in young girls' mental health needs not being met (Caplan, 1992). Failure to meet these needs might also result in an escalation of such needs, matching the observed increases in diagnoses as girls reach adolescence. The very apparent needs of boys would, in contrast, result in the overpathologizing of young boys (Caplan, 1992). Because policy and funding decisions are based on observed prevalence rates, diagnostic inaccuracies would result in money being allocated inappropriately (Kimball, 1981), that is, allocated to those whose difficulties are observable (boys) rather than to those in need (both boys and girls). Inaccuracies may also result in unfairly stigmatizing those with observable difficulties (boys) and in greater affinity for those whose difficulties do not disrupt families and classrooms (girls).

It is notable that untreated childhood mental disorders with male predominance, such as conduct disorder, oppositional defiant disorder, and attention-deficit hyperactivity disorder (ADHD), tend to evolve into adult diagnoses of antisocial personality disorder, adult ADHD, substance abuse or dependence, and intermittent explosive disorder (Hartung & Widiger, 1998). Not all of these are Axis I diagnoses (i.e., mental illnesses), which makes their treatment nonreimbursable. Untreated childhood mental disorders with female prevalence may emerge into the entire range of reimbursable mental disorders (Caplan, 1992). One might conclude that young girls' problems more frequently evolve into mental illness whereas young boys' problems seem to evolve more frequently into criminality. Such conclusions might indicate why more women seek treatment than men--that is, Axis I disorders are reimbursed by insurance and criminals are less likely to seek services without external persuasions--and might thus explain some research results in which female prevalence of mental illness is greater.

* Sex Bias in Diagnosis

Concerns also exist about the tendency of clinicians to bias their diagnoses on the basis of the gender of the client. Broverman, Broverman, Clarkson, Rosencrantz, and Vogel (1970), for example, discovered that mental health practitioners were more likely to deem men, because of their independence, personal assertion, and goal-directed activity, to be healthy adults, whereas women, because they are "more submissive, less independent, less adventurous, more easily influenced, less aggressive, less competitive, more excitable in minor crises, having their feelings hurt more easily, being more emotional, more conceited about their appearance, less objective" (Broverman et al., 1970, p. 4), were deemed psychologically unhealthy. If women were to be considered psychologically healthy adults, they had to behave like men and, thus, lose their status as healthy (or desirable) women.

One would hope that the passage of time might have shifted this difficult conundrum to allow men and women out of this clear bind. However, more current research has indicated that the passage of time has not altered such stereotyping (Althen, 1981 ; Angermeyer, Matschinger, & Holszinger, 1998; Brown, 1992; Busfield, 1989; Chesler, 1972; Cook, 1992a, 1992b; Hamilton, Rothbart, & Dawes, 1986; Kaplan, 1983a, 1983b; Landrine, 1989; Pedersen, 1987; Sherman, 1980; Spence, 1985; Usher, 1989). Angermeyer et al. concluded that women who act in unfeminine ways receive very strong negative reactions but that men who behave in ways not judged to be masculine do not. Furthermore, mental health professionals have been found to label people disturbed if their behavior does not fit the professional's gender ideals (Cook et al., 1993). Researchers have also found that simply knowing a client's sex can influence the diagnostic process, even among experienced practitioners (Loring & Powell, 1988). Female and male clients may earn different diagnoses even when they present with identical symptomatology (Becker & Lamb, 1994; Hamilton et al., 1986). As Brown (1990b) indicated,
   The impact of gender is to shape the perception of the assessor
   in ways that can yield quite different outcomes for the
   assessment process, unless the assessor is attentive to these
   potentially distorting influences of nonconscious gender effects
   on her or his judgment. (p. 15)


Of course, men within this context also run the risk of underdiagnosis; that is, they might demonstrate all of Broverman et al.'s (1970) listed characteristics for a healthy adult, but the very bias about these being "healthy" might cause practitioners to overlook men's emotional suffering. Research in fact indicates that well-socialized White men (i.e., those who have adapted well to the expectations of the dominant culture) run the risk of being underdiagnosed for mental disorders with the possible implication that they do not receive the services that they may need to address these disorders (Ganley, 1987; Kaplan, 1983a, 1983b). Men and women, boys and girls are harmed by over-, under-, and misdiagnosis (Becker & Lamb, 1994; McDermott, 1996). As Ritchie (1994) pointed out, beliefs about what constitutes proper manhood and womanhood and related assumptions about what is mentally healthy and unhealthy are used in treatment planning, in evaluating treatment effectiveness, and in test construction. If sex bias results in men and women being diagnosed inappropriately, one would question whether appropriate treatment would be received.

* Masculine Bias in Diagnoses

Feminists have challenged the DSM (APA, 2000) diagnoses and proposed diagnoses that seem to (a) reflect a particularly masculine bias and (b) have greater prevalence rates in women. These diagnoses have included, among others, premenstrual dysphoric disorder (PDD; or late luteal phase dysphoric disorder [LLPDD]) and the borderline, self-defeating, histrionic, and dependent personality disorders. Feminists have been particularly concerned with why the DSM developers have not entertained parallel diagnoses for men (Brown, 1991a; Caplan, 1992; Caplan et al., 1992; Gallant & Hamilton, 1988; Pantony & Caplan, 1991).

The battle over the inclusion of PDD or LLPDD has drawn particular attention to the political and gender struggles inherent in the development of DSM classifications. Gallant and Hamilton (1988) reviewed the research on premenstrual symptoms and concluded that
   the overabundance of methodological problems in this literature
   may simply reflect poor research. However, it is also possible
   that the quality of the research on premenstrual changes
   reflects tacit assumptions about the negative influence of the
   menstrual cycle on female functioning.... Such assumptions
   reinforce focusing only on negative changes, focusing only
   on the premenstrual cycle phase, and studying mood cycles
   only in women. (p. 273)


Caplan et al. (1992) then pointed out that "there is no evidence that [women's hormonal changes] are any more severe than men's hormonally based mood or behavior changes [and yet] ... there is no DSM equivalent for males" (p. 28; see also Caplan, 1992). Caplan et al. thus questioned why women's changes in moods caused by hormonal changes are considered psychiatric abnormalities but those of men are not.

Furthermore, asked Caplan et al. (1992), why do we not simply continue to consider premenstrual syndrome a physical, gynecological problem? As they pointed out, thyroid problems may lead to mood and behavior changes, yet there is no thyroid dysphoria disorder. Such might be considered, according to the DSM, to be a mental disorder due to a general medical condition (APA, 2000), but it is doubtful that anyone would consider a person with thyroid problems to have a mental illness; the person would merely be treated medically to eliminate the hormonal imbalance and to eliminate the mood and behavior correlates. Caplan (1992) believed that it does not require a great leap of logic to move from defining women with PDD as mentally ill to keeping women out of well-paying, responsible jobs. She pointed out that men also experience cyclical hormonal changes that affect their functioning. Yet, because men's cycles are not tied to a marker like monthly menstruation, men continue to work in risky and highly challenging and dangerous jobs even when they are at low points in these cycles. Gallant and Hamilton (1988) thus concluded that women's premenstrual complaints can be sensitively dealt with within the current nosology without having to develop a separate diagnosis for these experiences.

* Personality Disorders Reflect Male and Female Socialization

Personality disorder diagnoses have been examined more frequently for sex bias because they are least likely to represent medical diseases and, therefore, could be likely to reflect social conventions (Kroll, 1988). As mentioned previously, women seem to predominate in borderline, dependent, and histrionic personality disorders, and men seem to predominate in compulsive, paranoid, antisocial, schizoid, and passive-aggressive personality disorders.

Horsfall (2001) indicated that each of the criteria for the disorders in which women predominate could be seen to be an exaggeration of socially promoted feminine characteristics that are embedded in many cultures' beliefs and practices (e.g., excessive worrying, low self-esteem, feelings of worthlessness, overdependence, passivity, seductiveness). Caplan (1992) paralleled the female prevalence personality disorders with the "good wife syndrome" (p. 74), or the ways that North American women are socialized to be unselfish and to put others' needs ahead of their own. She declared that it seems unreasonable to raise women to behave in certain ways and then to diagnose them with a disorder for complying.

In fact, in reaction to what they consider an imbalance in pathologizing, Pantony and Caplan (1992) proposed delusional dominating personality disorder (DDPD) as a challenge to practitioners and diagnosticians to pay attention to those stereotypical male characteristics that harm men and those around them. The criteria for DDPD include characteristics, among others, such as difficulties establishing and maintaining interpersonal relationships; difficulties expressing and attending to emotions; the choice of violent solutions or power, silence, withdrawal, and/or avoidance as solutions to conflict; the need to be around younger women, who are shorter, weigh less, make less money, and are conventionally physically attractive; a tendency to be threatened by women who do not disguise their intelligence; and resistance to efforts to establish gender equity. In fact, some of these difficulties are already reflected in the male predominance personality disorders.

Landrine (1989) proposed a social role hypothesis to account for diagnostic concerns related to both genders. She noted that the personality disorder diagnoses received by men most represent role stereotypes for men of a certain age, class, and marital status, whereas the personality disorder diagnoses received most by women represent female role stereotypes for females of a certain age, class, and marital status. Her research results confirmed her hypothesis, indicating that people who demonstrated the stereotypes of young, lower-class men were labeled antisocial; those with the stereotypes of single middle-class young women, histrionic/hysterical; those with the stereotypes of married, middle-class, middle-aged women, dependent; those with the stereotypes of middle-class men were labeled prototypically normal, or compulsive, paranoid, or narcissistic. Borderline and schizoid disorder descriptions were not attributed to either sex. These results match the epidemiological distributions of the disorders. Landrine concluded, therefore, that the gender distribution of personality disorders does not result from the misogyny of practitioners but from the overlap between personality disorder characteristics and role or role stereotypes of both sexes.

Landrine (1989) questioned why personality disorders should so closely mirror stereotypes of these groups. If personality disorders are merely "a reflection of gender roles that serves to maintain gender stratification, then those [diagnoses] are political" (Landrine, 1989, p. 332) rather than medical or psychological. Landrine and others (e.g., Brown, 1990a, 1990b; Caplan, 1992; Wirth-Cauchon, 2000) asked further, "Why are those who are well-socialized considered mentally ill?" Should not the fact that such socialization causes problematic behavior direct our focus to society's behavior rather than to the diagnosis and treatment of individuals?

* Socialization and Mental Health

Some research and theory have focused on the mental health implications of socialization. For instance, Wirth-Cauchon (2000) pointed to society's contributions to so-called borderline characteristics. She claimed that the "medicalized construction of women as borderline has the effect of pathologizing some of the fundamental conflicts women face in contemporary society, and within which they construct a sense of self" (p. 142). She indicated that cultural imperatives transmitted through families and broader Western culture "manifest in a split or fracturing of self, a split between irreconcilable aspects of being" (Wirth-Cauchon, 2000, pp. 157-158). Women with a diagnosis of borderline disorder, from Wirth-Cauchon's perspective, are those who have lost touch with "any form of being outside of the boundaries of the mask, and thus manifest empty conformity" (p. 159) to cultural mandates about femininity that are superficial and empty. Women with a diagnosis of borderline disorder may struggle because of the blurring of the image and the "real" in a world in which men continually expect women to be, and women try to be, the pornographic ideal of women. Thus, the cultural imperative requires women to be false, disembodied, and doll-like, as though this is "real" womanhood, and as if there are no other imaginable possibilities. Yet, women have the haunting sense that there is something else, an authentic self "whose loss is memorialized in symptoms" (Wirth-Cauchon, 2000, p. 159). Because these women may have lost themselves, they cannot say, "I'm faking it" (Wirth-Cauchon, 2000, p. 159) or "Only a feeling of falsity remains. One may feel empty inside" (Wirth-Cauchon, 2000, p. 159).

Research by Gilligan and her colleagues (Brown & Gilligan, 1992; Gilligan, 1982; Taylor, Gilligan, & Sullivan, 1995) directed attention to another aspect of female socialization. They found that girls silence themselves and their desires, abilities, and interests--that is, give up their "voice"--as they move into adolescence, because they believe that such silence is necessary to make intimate relationships possible. Smolak's (2002) research found that "voice" was negatively correlated with femininity and positively correlated with psychopathology more clearly so for women. Rather than voice being related strictly to being male or female, higher voice ratings were related to higher ratings on masculinity, and lower voice ratings to lower ratings on masculinity and higher ratings on femininity. Gilligan's findings confirmed previous findings that higher levels of masculinity were related to better mental health (Murnen & Smolak, 1998; Whitley, 1995).

Kirsh and Kuiper (2002) noted similarly that gender differences in experiencing depression seemed to begin during adolescence, just at the time when girls' socialization becomes different from that of boys (Sprock & Yoder, 1997; Steinberg, 1990). During adolescence, boys are taught that men are to he "active, masterful, and autonomous" (Kirsh & Kuiper, 2002, p. 77), whereas girls are taught that women are to be passive, compliant, and committed to interpersonal relationships (Helgeson & Fritz, 1998; A. Kaplan, 1987). In Gammell and Stoppard's (1999) qualitative research, women described themselves as having two sides: (a) their relatedness side that was weak and depressed and (b) their strong, confident, individualistic side that was not. McMullen (I 999) concluded from similar research that women may also desire autonomy and that women who are depressed somehow find that relatedness alone is insufficient. Although it is less well researched, such gender role conflict may also exist for men; that is, those men who experience conflict between their socialization into individualism and their desires for relatedness experience greater depressive symptoms (Good & Mintz, 1990). Heifner (1997) also found corresponding themes of high performance expectations, being emotionally distant from others, and maintaining traditional gender roles in men with depression. Heifner concluded, however, that the mismatch generally appears to be much more evident in the case of women, resulting in a much higher overall diagnosis of depression for women, when compared to men.

Bem (1974) indicated that suppression of the non-sex-typed part of oneself was unhealthy and that androgyny resulted in better mental health and adjustment. Helgeson (1994) expanded these notions of balancing individualism and relatedness in her research, which indicated that poor health and relationship difficulties result from a lack of balance (Helgeson & Fritz, 1998). Being male or female thus turns out to be less relevant than the person's degree of masculinity and femininity. Higher femininity scores and lower masculinity scores correlate with higher levels of depression in both sexes. Higher levels of masculinity result in lower levels of depression in both men and women, which supports the mental health need for Broverman et al.'s (1970) list of male characteristics, regardless of one's gender.

What then are women to do about the conflict between their needs to adopt masculine characteristics in order to be mentally healthy and society's demands that they adopt feminine characteristics? How are men to achieve the needed androgeny without losing their status as "healthy adults"? Feminist assertions seem well grounded that answers to these questions are unlikely to emerge from a focus on diagnosing and medically reducing the symptoms of these conflicts, that at least part of practitioners' focus ought to be on changing a biased and unreasonable society.

* Social Conditions

Beyond the typical socialization of men and women and the impact socialization has on the mental health of both are questions about the influences of societal conditions, in particular trauma experiences, on people's mental health. For instance, researchers have hypothesized that numerous environmental factors account for the high rates of depression and other disorders in women (Carmen, Russo, & Miller, 1981; Collins, 1998; Cook et al., 1993; Gove & Tudor, 1972; Horsfall, 1998; Howell, 1981; Jordanova, 1981; Miller, 1991; Root, 1992; Rothblum, 1982; Vance, 1997; Weissman & Klerman, 1981; Wetzel, 1991). Some environmental factors are most likely applicable to men from nondominant social groups as well (e.g., homosexual men and men of color): (a) the greater restrictiveness of roles, which would result in less financial, occupational, or social gratification; (b) the inability to measure up to the standards of women who are held up as examples of those who have "made it"; (c) a lack of social networks and supports; (d) being married, given that married women experience depression at a higher rate than never-married women, possibly as a result of isolation and not having their needs met in their roles as homemakers or as a result of being employed yet still carrying most of the childcare and household responsibilities; (e) being separated or divorced (because women are less likely to remarry and more likely to live longer than men, and women tend to "marry up" in age); (f) single motherhood and its attendant stresses (Rothblum, 1982); (g) more frequent experiences of gender-based discrimination (Cook et al., 1993; Root, 1992); (h) higher prevalence of living in poverty with its attendant ills and stresses; (i) inequities related to marriage, family relationships, reproduction, child rearing, divorce, aging, education, and work (Carmen et al., 1981); (j) work outside the home that is low status or low paying; and (k) women's roles being defined in terms of the needs of others, which serves to leave their own needs in a secondary status and unmet. All of these conditions involve alienation, powerlessness, and poverty, conditions that epidemiological data link with mental illness (Carmen et al., 1981, p. 1321).

Collins (1998) directly examined the effects of living as a nondominant, or subordinate, group member and found that the effects can be generated not only in women but in any subordinate group. In Zimbardo's Stanford prison experiment, in which psychologically healthy White male college students were assigned to be prison guards or prisoners (Musen, 1992), the students designated as prisoners developed symptoms corresponding to DSM diagnoses that are typically ascribed to women: they became depressed, suicidal, anxious, and developed eating problems. The students designated as guards developed symptoms corresponding to DSM diagnoses that are typically ascribed to men: they became verbally abusive, violent, and otherwise antisocial. Collins's (1998) conclusions from the experiment and from research using videotapes of

the Zimbardo experiment were that "even psychologically healthy White males (who are usually perceived as dominants) will exhibit the 'psychopathology' that is typically ascribed to subordinates (women) when placed in a subordinate role, even for a short period of time" (p. 108).

Some authors have indicated that the ongoing experiences of subordination and oppression are a type of insidious trauma (Brown, 1990a, 1991a, 1991b, 1992; Root, 1989, 1992). Carmen et al. (1981) believed that the current circumstances of inequality "set the stage for extraordinary events that may heighten vulnerability to mental illness. The frequency with which incest, rape, and marital violence occur" (p. 1321) suggests that such events approach normative status as developmental crises for women, gay people, and people of color (see also Brown, 1986, 1992; Caplan, 1992; Chesler, 1972; Committee on Women in Psychology, 1985; Lee, Lentz, Taylor, Mitchell, & Woods, 1994; Libbus, 1996; Miller, 1976/1991; Rosewater, 1986, 1987; Russell, 1986b; Walker, 1985, 1986). The results of the more frequent abuse experienced by non-dominant groups can appear as severe psychological distress or psychopathology and may result in diagnoses such as posttraumatic stress disorder (PTSD), depression, anxiety, eating disorders, and borderline personality disorder (Brown, 1992; Busfield, 1996; Gallop, McKeever, Toner, Lancee, & Lueck, 1995; Lego, 1996; Nehls, 1998).

* Alternative Diagnoses and Diagnostic Strategies

As Gove (1980) indicated, it is clear that some mental illness is individual and related to idiosyncratic life experiences, biology, or personality traits. However, as previously noted, many problems presented by female, gay, or non-White clients reflect problematic societal conditions. Awareness of such social conditions must be considered an essential starting point for ethical clinical treatment. It may, in fact, be accurate to conclude, as Russell (1986a) did, that even though some problems may surface most visibly in particular groups of people, the problems are not necessarily located within those people but in the relationships between certain people and those with whom they relate, or between those people and societal norms and demands. Focusing on the individual may fail to "cure" the problem, whereas focus on societal situations may succeed in reducing the incidence of the problems.

Furthermore, the focus on the individual and on ascribing individual diagnoses may result in "blaming the victims" of oppression (Brown, 1991b), encouraging further stigmatization and blame. Caplan's (1992) research found that victims of oppression or abuse expressed that "their therapists told them regularly that they brought all their problems on themselves" (p. 75). She believed that this kind of blame brings on depression in clients, who then figure that there is no way out of living in damaging relationships or situations. Clients who experience such victimization understandably do not make progress in therapy (Kass, MacKinnon, & Spitzer, 1986). Even traditional treatment choices may victimize these clients by assuming an individually located "illness" or "disorder" (whether disordered biology, thinking, relational ability, or past history); that the anger, anxiety, and/or depression are "the problems" to be fixed; and that the responsibility for change or adaptation to the situation is on the individual client. These treatment choices fail to recognize that anger, anxiety, and/or depression are expectable reactions to oppressive societal conditions and that to react differently would, in fact, be "crazy." Brown (1991b) declared, "If we maintain the myth of the willing victim, who we then pathologize for her [or his] presumed willingness, we need never question the social structures that perpetuate her [or his] victimization" (p. 126).

Reframing

A number of options allow counselors to acknowledge societal problems that have a negative impact on individual clients. For instance, Brown (1992) advocated refraining rather than diagnosing; that is, she noted that the behaviors of abuse survivors that have been labeled as passive or dependent by traditional practitioners can be relabeled as quite "skillful manifestations of personal power" (p. 217). Brown (1992) noted that "such individuals are manifesting not a disordered personality, but a normative, functional, and at times creative (although distressed) response to potentially dangerous situations and oppressive cultural norms" (p. 220) because "attempts at what might be considered 'healthy' means of self-expression by members of culturally disenfranchised groups are often met with punitive responses" (p. 221). However, reframing rather than diagnosing may not be a realistic solution from a market perspective, given that both insurance reimbursement and grant funding for mental health services require a diagnosis.

Alternative Diagnoses

Alternatively, some scholars have proposed using diagnoses that clearly indicate external causality for client problems. Becker and Lamb (1994) proposed greater use of an already available diagnosis, PTSD, for clients who have been physically or sexually abused. A PTSD diagnosis is less stigmatizing, recognizes the trauma etiology of clients' distress, and directs practitioners toward interventions that are pertinent to recovery from trauma. A PTSD diagnosis allows for a "reconceptualization of the sexual abuse and its secondary effects without labeling the patient 'crazy'" (Becker & Lamb, 1994, p. 56; see also Brown, 1992; Carmen, Reiker, & Miller, 1984; Courtois, 1988). The difference between "'severe psychopathology' and 'severe distress secondary to a history of a lifelong hostile context' is meaningful ... in that the latter most accurately describes the interactive effects of person and environment in the development of distressed affect and less-than-functional behavior" (Brown, 1992, p. 222).

However, PTSD has limitations as a diagnosis for those who have experienced abuse or other oppressive societal conditions. That is, these conditions often involve ongoing oppression (rather than the single discrete experience that is usually reflected by a PTSD diagnosis) or repetitive traumas that do not reach life-threatening levels (as is required for the PTSD diagnosis). Brown (1990a, 1992), therefore, has proposed a new diagnosis for the DSM--abuse/oppression artifact disorder--to reflect these situations. Specifically describing nondominant group struggles as artifacts of abuse and oppression takes into account the repetitive nature of exposure to the insidious trauma that is an everyday experience for those in subordinate positions in society. It accounts for the effects of "multiple learning trials across many situations, with severe penalties for 'wrong' responses" (Brown, 1992, p. 219). It describes the intermittent reinforcement of behaviors that results in the tenaciousness of difficult behaviors, requiring many exposures to nonexploitive situations in order to relinquish behaviors that have been necessary to "surviving, coping with, or making sense of abuse or oppression" (Brown, 1992, p. 219).

An abuse/oppression artifact disorder diagnosis would also help clients make sense of their behaviors, placing ultimate responsibility for distress on the oppression or abuse that they have experienced. The diagnosis would clarify etiology for practitioners, so that no mistakes would be made by calling the disorder "pathology within the individual client" (Brown, 1990a, p. 57). The diagnosis further points to the need to proactively work to change the beatings and the beaters, to change a society that "values" hierarchies of dominance and subordination, and perhaps, also, to empower the clients to understand their position vis-a-vis an abusive society and to become activists on their own behalf.

Feminist Analysis

The true benefit of accurate diagnosis, however, exists in its ability to guide treatment, rather than solely in its ability to garner reimbursement for services. In most cases, treatment depends on a more comprehensive assessment than merely deciding on the appropriate diagnostic name and number. Because assessment is guided by the practitioner's theoretical perspectives, it raises the question, What theoretical perspectives are most likely to recognize societal influences on men, women, and nondominant groups? As indicated previously, traditional therapies have tended to locate problems within the individual and hold individuals responsible for creating change for themselves. A number of newer psychotherapies (i.e., narrative, constructivist, feminist, family, and multicultural therapies) offer clear alternatives.

Feminist therapy very specifically targets gender issues in assessment and treatment and can be conducted by either male or female counselors for both male and female clients. Feminist therapy offers an egalitarian relationship that counters the usual submissive position expected of women and other nondominant groups in society. It interprets the client's symptoms in terms of her or his sociopolitical context; that is, it takes "into account the lifetime learning experiences of living in a sexist, racist, homophobic, ageist, and otherwise oppressive cultural context" (Brown, 1992, p. 220). Feminist therapy supports anger, assertiveness, aggression, and taking initiative when indicated, even if their expression causes problems with significant others (Brown, 1990b). Feminist therapists inquire into the gender and other related characteristics of the client and the people involved in the client's life. This includes inquiries into the power differentials between them and the repetitive interactions or reality experiences of the client. Awareness of these gender characteristics illuminates the behavioral options available to the client and the limits that result from social roles (Brown, 1992).

Brown (1990b) urged all practitioners to conduct feminist clinical assessments and included pointers for doing so. For instance, practitioners need to adopt a mind-set that continually questions their own assumptions about what is usual or normal with respect to gender and that attends to factors that may influence the expression of gender. They need to purposefully ask about gender issues and experiences. For example, the counselor might question what it means to the client to be a failure or a success as a man or a woman. Practitioners need to include an analysis of gender meanings and roles within the client's milieu and culture (Brown, 1990a). Gender-sensitive assessment also considers and questions deviance from and compliance with mainstream gender roles. The clinician thus needs to assess whether the deviance is functional and serves positive purposes, or if it fails to be useful to the individual in her or his social context (Brown, 1990b).

Feminist practitioners make the effort to be aware of issues, patterns, or behavior that occur with high frequency in one gender or the other, of the cultural reasons for men's and women's positions in a society, and the resultant impact on men's and women's expressions of distress or types of problems (Brown, 1990b). Going beyond awareness, however, they directly inquire into life events whose rates of occurrence are related to gender: for instance, experiences of interpersonal violence, sexual assault, or covert discrimination. Without direct inquiry, men and women rarely volunteer this information, perhaps partially because they may have repressed their memories of these experiences (Bass & Davis, 1988; Brown, 1990b; Bryer, Nelson, Miller, & Krol, 1987). Counselors may also need to be more tentative in diagnosing people from diverse backgrounds and, as part of a more egalitarian relationship, to coconstruct an understanding of the problem with the client, rather than imposing a diagnosis on the client.

When feminists move beyond assessment into treatment, they deliberately create interdependent egalitarian relationships (Brown, 1990a, 1990b, 1991a, 1991b, 1992; Rothblum, 1982) with their clients, thus reducing the impact of society's power differentials, increasing individuation, and reducing stereotyping (Fiske, 1993). Feminist practitioners also actively seek to counter the experiences and the consequent emotional difficulties of women and nondominant group members by "acknowledging the effects of oppression, considering the impact of socially prescribed female [and male] roles, aiming for egalitarian interactions, examining [their] own values, and exploring feelings and views about ethnicity, class, gender, and sexual orientation" (Steenas summarized by Horsfall, 2001, p. 430). The counseling process may include educating clients about gender issues, working to empower clients, and encouraging expanded roles for both men and women (Rothblum, 1982).

Because feminist therapy recognizes the role of the larger community in creating women's problems, it also encourages intervention in the larger community. Therefore, feminist practitioners may use family therapy to involve partners in therapy; to particularly address domestic, child care, and occupational roles of both partners; and to examine more flexible and nontraditional alternatives (Rothblum, 1982). They may intervene directly in communities in their attempts to change the societal conditions affecting their clients, offering education programs in schools, businesses, and community organizations that increase the available information on gender issues. Feminist practitioners may work at changing, consulting with, and advising institutions about factors that do harm to women and other nondominant groups. They may also create programs that bring people together who have similar difficulties (e.g., mothers with young children, women in nontraditional careers, African American men, gay athletes) and may train health professionals about gender issues. These are all steps "in challenging and changing those social institutions that wound and keep wounds open" (Brown, 1991b, p. 119) and toward a vision of relationships "in which mutuality and respect are the norm rather than power and dominance" (Brown, 1991b, p. 109). The personal, thus, becomes the political and the larger society becomes the focus in the attempt to turn painful knowledge into an "ethic of compassion" (Brown, 1991b, p. 120).

* Conclusions

The nearly universal licensure and increasingly reimbursable status of counselors is cause for celebration because the profession can now assert that it is coming of age as a mental health discipline. But coming of age always brings new responsibilities. We propose that the new responsibility of providing diagnoses requires critical reflection on both the ethical practice of diagnosis and the challenges to the current diagnostic systems. The data and the questions posed in this article draw attention to the challenges to diagnosis from a gender perspective and, in particular, to the broader societal influences on DSM development, on diagnostic decision making, and on treatment of those groups in society who have less power. Practitioners, despite their honest efforts to be of benefit to their clients using diagnostic and counseling procedures, cannot extract themselves from the broader social and economic milieus within which they operate. Therefore, constant attention to the impact of these broader milieus on their work and balancing the benefits to multiple stakeholders (e.g., society, professional associations, insurance companies, clients) may be fundamental to ethical decision making.

But attention may not be enough. In fact, counselors may need to reevaluate whether the traditional theories of assessment and treatment to which they subscribe can adequately incorporate the contextual understandings of the oppressive experiences of women, gay people, and people of color, and whether such theories can suggest change strategies that extend beyond the individual client into the broader society. We anticipate that counselors will need to consider integrating narrative, constructivist, multicultural, and/or feminist notions into traditional ways of working to reconceptualize client problems from a contextual perspective and that they will need organizational change skills to participate in changing the societal causes of many nondominant clients' problems. Counselor education programs will need to add to already present multicultural efforts the inclusion of research and literature on gender and diagnosis, more inclusive theories, and system changing assignments. We have herein proposed feminist alternatives to treatment; clearly, many practitioners already incorporate such alternatives into their practices and some counselor educators may include such alternatives in counselor preparation. We hope this article serves as an impetus for others to begin that process.

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Test to Earn CE Credit

Please complete the following test and send your answers (with payment) to the address listed on the form below.

Note: Correctly completing 3 of 3 test questions earns 1 continuing education contact hour.

* Gender and Diagnosis: Struggles and Suggestions for Counselors (JCD, Volume 86, Number 2, Spring 2008)

* Examination Questions
1. Current research on the prevalence of mental illness
   by gender suggests

   [] a. More men than women have a mental illness
   [] b. More women than men have a mental illness
   [] c. Mental illness is equally prevalent in both
         women and men
   [] d. Contradictory results

2. Research on specific diagnoses rather than overall
   rates of mental illness indicate women have higher
   prevalence rates for which of the following:

   [] a. Substance abuse
   [] b. Sexually related disorders
   [] c. Mood and anxiety disorders
   [] d. Antisocial, compulsive, paranoid, schizoid, and
         passive-aggressive personality disorders

3. The authors suggest that many problems presented
   by female, gay, and non-White clients in counseling
   reflect what condition(s) or situation(s):

   [] a. Social or societal
   [] b. Economic
   [] c. Educational


Karen Eriksen, Counselor Education Department, Florida Atlantic University; Victoria E. Kress, Department of Counseling, Youngstown State University. Karen Eriksen is now at Delray Beach, Florida. Some material in this article was drawn from K. Eriksen & V. E. Kress (2005). Beyond the DSM Story: Ethical Quandaries, Challenges, and Best Practices. Thousand Oaks, CA: Sage, with permission from Sage. Correspondence concerning this article should be addressed to Karen Eriksen, Delray Beach, FL 33431 (e-mail: keriksen@bellsouth.net).
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Author:Eriksen, Karen; Kress, Victoria E.
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