Steve Spiegel

In his classical dissertation on scientific paradigms, eminent philosopher of science Thomas Kuhn describes the difficulty in understanding social influences that skew science theory.¹ Popular behavioral neuroscience theory is a classical paradigm; it is a complete world view that is supported by terms with interrelated connotations and contexts that reinforce the status quo. Scientific paradigms are homogeneous; it is difficult to recognize a false assumption of a paradigm from within. In the arduous challenge (and valiant effort) to understand our behavior, it is far easier to theorize about behavior science and neuroscience and their relationship than to theorize about theoretical problems underlying the established paradigm. Eminent philosopher of science Karl Popper understood the difficulty of identifying false assumptions when he advocated the accepted Philosophy of Science principle of “falsifiability.”² Philosophy of Science advocates that real science theories can be differentiated from ad hoc theories by falsifying them — explaining how to disprove them.  The process of describing how to disprove a theory identifies assumptions that are potential sources of error. Unfortunately, the admirable endeavor to understand behavioral neuroscience has not been falsified to identify assumptions of the prevailing paradigm for critical consideration. 

Behavioral neuroscience investigates complex principles of molecular neuroscience, cellular neuroscience, and systems neuroscience while the philosophy of informing sciences implores consideration of simple principles of tissue neuroscience and systems neuroscience. Scientific logic, the philosophy of science, a philosophy of natural science, and the philosophy of physiology beg for consideration of simple binary tissue neuroscience. The philosophy of a science is the science’s most fundamental principle; it defines and frames a science with an unprovable underlying assumption. An anomaly of the philosophy of a science taints all of the science that is built upon it; as information technologists advocate, “garbage in, garbage out.”³ In the following three sections, this thesis addresses scientific anomalies hidden deep in the foundation of the current behavioral neuroscience paradigm. The following sections advocate that popular neuroscience theory contradicts: 1) basic science logic when it assumes complex brain principles and ignores simple binary science, 2) the philosophy of (general) science and a philosophy of natural science when it assumes complex brain principles and ignores simple binary science, and 3) the philosophy of physiology when it ignores tissue neurophysiology — the function of whole nervous tissues and their interaction. Basic science logic and accepted science tenets implore consideration of beautifully simple binary tissue neuroscience to understand behavioral neuroscience. 

First, popular behavioral neuroscience investigations contradict basic science logic while they continue a long tradition of assuming complex brain principles while brain principles are unknown.  Full stop.

Moreover, popular neuroscience investigations continue to contradict basic science logic while they assume complex brain principles while modeling the brain with computers that operate on the simple principle of binary science.  Again, full stop.

It may appear that simple brain principles would be obvious to scholars but appearances are often deceiving. It is extremely difficult to reverse-engineer a system that produces a complex product based on a simple principle especially when the simple principle is not sought.

The first sentence of the recent PBS series on the brain (The Brain with David Eagleman) advocates the common assumption of complex brain principles but scientific logic demands consideration of gloriously simple binary neuroscience.

Second, besides contradicting scientific logic, behavioral neuroscience investigations also continue to contradict the philosophy of science and a philosophy of natural science when assuming complex brain principles and ignoring simple binary neuroscience. All science theory is based on the principle of parsimony — Occam’s razor: “All other things being equal, simpler theories are better science”, or more accurately, “Fewer assumptions make better science.” Unfortunately, accepted neuroscience investigations are comfortable with increasing complexity and a related increase in unidentified assumptions; parsimony and falsifiability are not considerations. Popular behavioral neuroscience research contradicts the philosophy of science while embracing complexity and failing to consider beautifully simple binary neuroscience.

Besides contradicting the philosophy of science while assuming complex brain principles, neuroscience investigations similarly contradict a philosophy of natural science. The philosophy of natural science advocates that our environment is best understood with a singular focus on the natural (physical) world, but there is a secondary philosophy of natural science. Our most eminent natural scientists (Einstein, Brian Greene, Steven Weinberg, Walter Lewin) also advocate that human nature is based on eloquently simple principles that are hidden beneath an appearance of complexity.⁴  Natural scientists contend that simple principles produce the complex manifestations of nature including human nature (binary neuroscience beyond binary neurons).  One hundred trillion neural connections produce complex thinking and complex behavior but do not prove a complex brain principle.  Moreover, only simple brain principles promote the natural science requisite of “functional resilience” (proper operation over time); consistently, maintenance engineers advocate simple engineering with the mantra (acronym) “KISS”: “Keep it simple, stupid!”  Eminent natural scientists advocate simple brain principles; assuming complex brain principles and ignoring gloriously simple binary science is pseudo natural science.

Regardless of a long, painful history of problematic oversimplification in science, it is unscientific to assume that only complex brain principles can produce complex thinking and complex behavior. The philosophy of science and a philosophy of natural science implore consideration of a simple principle of binary neuroscience.

Third, besides contradicting basic science logic, the philosophy of science and a philosophy of natural science, popular behavioral neuroscience investigations also contradict the philosophy of physiology when addressing molecular neuroscience, cellular neuroscience and complex systems neuroscience rather than whole nervous tissues and simple systems neuroscience.  Considering the physiology of simple systems neuroscience and entire nervous tissues (and their interaction) may seem confusingly abstract compared to finite or abstract investigations but the philosophy of physiology implores the focus. The philosophy of physiology explains organisms at different organizational levels of the body with each organizational level explaining the entire organism. Anatomy and physiology texts explain humans at different organizational levels of descending sizes and ascending complexity; they explain organisms at organizational levels of body systems, tissues, cells, and molecules.⁵ Physiology texts explain organs with body systems, explain body systems (including organs) with tissue physiology, explain tissue physiology with cellular physiology, and explain cellular physiology (theoretically) with molecular physiology. The philosophy of physiology completely explains organisms at different organizational levels and explains organs with the organizational levels of body systems (or “organ systems”) and tissues.

Physiologists investigate organisms at different organizational levels of the body and explain the function of all organs at the largest level — the level of body systems (organ systems). The nervous system at the organizational level of body systems is “systems neuroscience.” Consistently, physiology explains systems neuroscience (the brain at the organizational level of body systems) as: the brain receives information about the environment through the peripheral nervous system, processes the information, and sends related information back through the peripheral nervous system to affect behavior towards species survival. Current theory seeks to explain a complex systems neuroscience while physiology explains systems neuroscience with simplicity. Physiology investigates the human organism at different organizational levels and can explain all organs of the body at the largest organizational level of body systems.

Besides explaining all organs of the human body at the organizational level of body systems, physiologists can also explain all organs besides the brain at the level of body tissues. All organs of the body besides the brain are explained by four kinds of tissues: muscle tissues, connective tissues, epithelial tissues and nervous tissues. For example, after explaining the heart at the organizational level of body systems (as a pump that shoots nourishment and draws waste), physiologists explain the function of the heart with the increased specifics of tissue physiology. Physiologists explain the heart with the interaction of (whole) tissues as: 1) muscle tissues create the general structure of a pump while flexed muscle tissues push nourishment throughout the body and pull waste, 2) nervous tissues create a periodic electric spark to flex heart muscle tissues, 3) connective tissues create valves in the pump structure to produce directional flow, and 4) epithelial tissues encase muscle tissues and create pipes to carry nourishment and waste. The organizational level of tissues completely explains all organs with a macro-perspective of tissue physiology that is more detailed than the organizational level of body systems that also completely explains organs.

Physiologists explain all organs of the body except the brain with tissue physiology (the physiology of entire tissues and their interaction) but are unable to explain any organ with a smaller, more complex organizational level.  Cellular physiology explains tissue physiology that explains organs, but cellular physiology cannot skip a “generation” of information about tissues to directly inform about organs. Consistently, investigating molecular physiology to understand an organ skips two generations of information (about tissues and the cells that comprise tissues). Molecular physiology cannot yet explain any cell of the body; it is illogical to believe that it can explain a tissue, much less an organ. Investigating molecular neuroscience to understand the brain is analogous to investigating the molecular structure of steel to understand the purpose (function) of an automobile engine. Investigating cellular and molecular neurophysiology to understand behavioral neuroscience contradicts the philosophy of physiology that explains organs with tissues — the physiology of whole tissues and the physiology of their interaction.

Popular behavioral neuroscience investigations contradict the philosophy of physiology when brain research fails to theorize about a macro-perspective of whole nervous tissues and their interaction.

In conclusion, scientific logic dictates that the tenets of a science are the most important guidelines to follow since everything emanates from foundational principles. Unfortunately, the distinguished endeavor to understand behavioral neuroscience is hindered by critical, long-established scientific anomalies hidden deep within accepted theory. Neuroscience investigations continue to contradict basic scientific logic and the philosophy of (general) science, a philosophy of natural science and the philosophy of physiology. It is illogical and unscientific for accepted neuroscience theory to assume complex brain principles and ignore magnificently simple binary science when: 1) brain principles are unknown, 2) eminent natural scientists advocate simple brain principles, and 3) neuroscientists model the brain with computers that operate through binary science. Equally important, popular behavioral neuroscience theory contradicts the philosophy of physiology while investigating molecular neurophysiology, cellular neurophysiology and complex systems neuroscience rather than whole tissue neuroscience.

Science logic and the tenets of informing sciences implore consideration of binary tissue neuroscience to understand behavioral neuroscience.  For instance, neuroscientists should consider the binary science of “motivated-thinking” wherein the thinking process is somehow separate from the motivation that directs it.  With an example like motivated-thinking, neuroscientists should consider whether nervous tissue structured for motivation (like the limbic system) directs nervous tissue structured for thinking (like the cerebral cortex).  Scientific truth can radically improve community mental health; binary tissue neuroscience is the foundation of a breakthrough theory that explains all human psychology (free at NaturalPsychology.org).

¹ Kuhn, T. (1962). The Structure of Scientific Revolutions, University of Chicago Press.

² Popper, K. (1959). The Logic of Scientific Discovery, reprinted 2002 by Routledge.

³ Eysenck, H.J. (1978). An Exercise in Mega-Silliness, American Psychologist, vol. 33(5), May 1978, 517; Ioannidis, J. A. (2016). The Mass Production of Redundant, Misleading, and Conflicted Systematic Review and Meta-analyses. The Milbank Quarterly, 94(3), 485-514. doi:10.1111/1468-0009.12210.

⁴ Greene, B. (1999). The Elegant Universe, Norton, New York; Lewin, W., N. Buckner & R. Whittlesey (1998). Mysteries of the Universe, A Science Odyssey, (part 1), a PBS film; Weinberg, S. (2003). The Elegant Universe, Nova, a PBS film by Brian Greene.

⁵ Marieb, E. & K. Hoehn (2012), Human Anatomy and Physiology, Benjamin-Cummings Pub. Co, (9^th Edition); Martini, F. et al. (2011). Fundamentals of Anatomy and Physiology. Benjamin Cummings   Publishers, (9^th Edition); Tortora, G. & B. Derrickson. (2012). Principles of Anatomy and Physiology.  New York: Harper and Row (13^th Edition).

Paula J. Caplan, Ph.D.

In Part 1 of “Is There Such a Thing as a Normal Woman?” (ISEPP Bulletin December 2019), I addressed many of the ways that psychiatric diagnoses are used to pathologize women, demean them, challenge their credibility and motivation and feelings, and deprive them of everything from self-respect to their human rights to their very lives.

Mother-blame¹

It doesn’t require a psychiatric diagnostic handbook or even a therapist to pathologize women. The fact that every female either is a mother or can be regarded as a potential mother or at least as mother-like, can be assumed to be hormonally, cognitively, and emotionally preprogrammed to be mother-like, is often all that is needed to cast women as inadequate, inferior, harmful, even grotesque. I will focus primarily in this section on women who have in fact had children, but it is important to keep in mind that nearly everything negative that is attributed to mothers is often also attributed to women who are not mothers, solely because the latter are also female. In other words, what is often considered the essence of femaleness includes inclinations or predispositions toward behaving in motherly ways, and then most of what is associated with that essence is considered negative. Sometimes the lengths to which people go to pathologize anything associated with mothers is astounding.

Early in my career as a psychologist, I worked at a clinic where we had interdisciplinary teams whose members took turns conducting assessments of people referred by the courts. Each team would sometimes watch one of its members interview a family that included a teenager who had been in trouble with the law, and after the interview, the team would discuss what had transpired. I had two young children at the time, which probably led me to observe the following pattern: If a mother sat right next to the teen who was the “identified patient,” the team members would conclude that her having sat next to her child indicated that she was controlling, intrusive, and/or smothering. If a mother did not sit next to the teen who was the “identified patient,” they construed that as evidence that she was cold and rejecting – and if the teen was male, that the mother was castrating. “Hmm,” I asked myself, “where does a good mother sit? On the ceiling?”

I broached the subject of this constant pathologizing of mothers with the psychiatrist who was my team leader (it was always a psychiatrist who was the team leader), and he informed me that obviously, my reason for thinking this was that I was a mother. Did he mean by this that due to being a mother, I was understandably observant about how mothers were being treated? No. He meant that I was distorting the truth because I was a mother.

Mother-blame Research

This was one of those times when I was glad I had earned a research degree. Ian Hall-McCorquodale and I decided to survey clinical journals and see if we found much mother-blame. We developed 63 categories related to mother-blame and classified each of 125 articles according to each category. We found overwhelmingly that mothers were blamed for virtually anything, in fact for 72 different kinds of problems in their children, ranging from bedwetting to “schizophrenia,” from inability to deal with color blindness to aggressive behavior, from learning problems to “homicidal transsexualism.”² In one study, the authors said they wanted to find out whether the fathers’ having been prisoners of war affected their children. They reported that the children indeed had some emotional problems, but here was their explanation of those problems: The fathers were often emotionally distant from their family members, even when physically present, and this upset the mothers and thus interfered with their parenting, which is what harmed the children. Although our research was done in the mid-1980s, mothers are still more likely to be blamed, and this is due to the history of mother-blame among clinicians; the continuing tendency for mothers to do more of the child care than fathers – and thus to be the ones the therapist sees when the child has difficulties, so they are available for study and thus for pathologizing; and the ongoing mother-blame and misogyny in general in society.

The Mother Myths³

That research prompted me to consider mother-blame more broadly, and in the book I wrote about it and how it interferes with mother-daughter relationships (much of which applies to mother-son relationships as well), I recounted the Mother Myths that are widespread and that seep into all of us by osmosis as well as by explicit statements and that pervade the zeitgeist simultaneously. These myths I divided into two groups; Perfect Mother and Bad Mother.

What I call the Perfect Mother myths are those that set standards so high that no human being could ever meet them, thus paving the way for all mothers to be deemed inadequate if not simply bad. These are: (1)The measure of a good mother is a “perfect” daughter; (2)Mothers are endless founts of nurturance; (3)Mothers naturally know how to raise children; and (4)Mothers (and “good” daughters) don’t get angry.

The Bad Mother myths encourage us to take anything a mother might do, including what ought to be considered good things, and transform them into “proof” of mothers’ inferiority or harmfulness. They are: (5)Mothers are inferior to fathers; (6)Only the experts know how to raise children; (7)Mothers (and daughters) are bottomless pits of neediness; (8)Mother-daughter closeness is unhealthy; (9)Women’s power is dangerous; and (10)Both stay-at-home mothers and mothers with paid jobs are bad mothers.

A look at the two sets of myths reveals two pairs of myths that would seem to cancel each other out. These are: (a)That mothers are endlessly nurturant (Good Mother myth) and that mothers are bottomless pits of neediness (Bad Mother myth),though based on simple physics principles of vectors, one can hardly be constantly giving while constantly taking and (b)That mothers naturally know all they need to know about raising happy, healthy children (Good Mother myth) and that mothers need experts’ advice in order to raise happy, healthy children (Bad Mother myth). How can these contradictory myths exist simultaneously?

Consider this: In any power structure, those who have the most power usually want to maintain their position. Choosing scapegoats to whom to attribute any problems that might arise is one way to keep their power, because they can say, “Don’t blame me! It’s their fault.” Mothers have been a convenient group to scapegoat, not only because they have traditionally been held responsible for everything bad that happens to their children but also because they have not tended to come together to advocate for mothers, to try to persuade people to look in a more balanced way at the wide variety of potential causes of their children’s – and thus society’s – problems.

For those in power, it is dangerous if scapegoats do things that are obviously good. So beliefs arise – sometimes consciously and purposefully created – that, in essence, provide a myth for every occasion; thus, no matter what a mother does, there is a myth that makes it easy to cast it as something bad. Thus, for instance, if she is a caring, loving mother whose adult offspring demeans or distances her, it’s easy to avoid concluding that the offspring was in the wrong by claiming that the mother loves being a martyr (this is a form of the myth of women’s masochism that was addressed in my previous essay⁴).

An example of the bizarre transformation of even good behavior into proof of bad mothering is the myth that "Mother-daughter closeness is sick." During my book tour for Don't Blame Mother, women media interviewers often got me alone and confessed, "I talk to my mother every day." When I asked how they felt after those talks with their mothers, they usually said something like, "Great! She's warm and funny, and we trade advice and stories and really enjoy our conversations." I would then ask, "Do you have a best friend or an intimate partner" "Yes." "Do you talk to them every day?" "Yes." "Are you embarrassed about that?" "No!" "Then why," I would ask, "did you confess to me that you talk to your mother every day? Why did you seem embarrassed about your regular conversations with her?" The answer was usually, "Because I know that means I am dependent and immature." Daughters who had been in therapy often said, "It means we are enmeshed or symbiotically fused."  Notice how, simply by replacing a mother-offspring relationship for any other relationship, we introduce pathology.

In light of all this, it is remarkable that mothers ever manage to do a decent job of raising children, since nearly every mother I’ve ever heard from has told me some version of this: “I feel like nothing I do is ever right. There’s always like a little bird on my shoulder telling me I am doing too much of this or not enough of that.”

Mother-blame as Hate Speech⁵

Many years after I started noticing the pervasiveness and poisonousness of mother-blame, it struck me that mother-blame often is hate speech. Consider that hate speech is aimed at a person because of their membership in a particular group and is intended to silence, intimidate, shame, and/or terrify. All a stand-up comedian has to do is say, “Let me tell you about my mother,” eyes will roll, and many people will laugh. If the phrase were, “Let me tell you about my father,” can you imagine the same kind of response?

Mother-blame in the Courts

In the courts, serious problems emerge from the existence of the Mother Myths combined with the misogynist psychiatric diagnosis enterprise addressed in my previous essay⁶. Having served as an expert witness in child custody cases in which the mother alleges that the children’s father has abused them sexually or in other physical ways are likely to be lost by the mother because – though this may sound unbelievable – the very fact that she has reported his abuse is construed as proof that she is “mentally ill” (often, the diagnosis of “Munchausen’s Syndrome by Proxy” is used or others are applied). Thus, her attempt to protect her children is used to transfer custody to the abuser. All this is done in order to allow to hold sway the notion that fathers would never do terrible things to their children.

In one case in which I was an expert witness, there was strong evidence that the father had abused the children, and although the mother was the farthest thing from vengeful, she wanted to protect her children from further mistreatment. In court, the judge transferred their custody from her to their abuser. How could this happen? In part, it was because their guardian ad litem, who is supposed to speak for the children or with regard to their welfare, had told me on the phone that he could not believe what the mother claimed was true, because he himself was a father and would never have done anything like that to his kids. In addition, after I testified that I had conducted a psychological evaluation of the mother and found no indication that she had emotional problems – other than, of course, fear for her daughters’ welfare – and no sign whatsoever that she was inclined to lie or distort the truth, the father’s lawyer began to cross-examine me. Rather than challenging any of my professional, academic, or clinical qualifications, he simply asked, “Dr. Caplan, isn’t it true that you are a feminist?” I answered truthfully that that was true. I had a sinking feeling right then that the mother would lose custody, given that that judge was then going to be likely to discount everything I said.

Lawyers representing abusive parents, who are overwhelmingly likely to be male, often grasp at any chance to portray the protective mother as “mentally ill.” Decades ago, Richard Gardner made up what was presented as a psychiatric disorder he called “Parental Alienation Syndrome (PAS).”⁷ Disproportionately used, with his endorsement of the practice, to use a mother’s report that her child was being abused by its father to “prove” that the mother was fabricating in order to hurt the father and turn the child against him, PAS has come to be used frequently in the courts. What frequently happens, then, is that the judge transfers custody of the children to the abusive father, on the grounds that the allegations of his abuse were surely false and put forward by the mother for the purpose of turning the children against their father. I have seen decisions that claimed that the father was clearly the better parent, because he had no qualms about allowing his children to visit with their mother, were he to have custody, whereas the mother had put up roadblocks about their visits with him.

Some jurisdictions have prohibited use of PAS, a good thing, given that it has no scientific basis and is used in such biased ways. It is poignant, however, that many a mother in such situations have been so upset that their offspring’s abusive father has won custody and turned them against her, that they have chosen to accuse the father of PAS, thereby helping to perpetuate the use of this unscientific, profoundly misogynist term. I urge mothers in such situations to use different words instead of “PAS,” such as saying that the father is turning the children against them.

A case in Canada that drew extensive media coverage illustrates the ways that clinicians who conduct psychological evaluations in child custody cases can base their recommendations on deeply sex-biased and unfounded principles. A couple with four children was divorcing. The mother had been the ideal stay-at-home mother, and the father had financially supported the family but been far less emotionally involved with the children. Over time, the mother and father each connected with a new partner, and a court battle for child custody began. A white, male psychologist was brought in to conduct evaluations of the parties and make a custody recommendation. Hard though it may be to believe – and keep in mind that this is by no means the most extreme example of biased evaluations that I have seen – his report included the following:

(1)   The father admitted the truth of the mother’s allegation that he had physically attacked her in front of witnesses, but no doubt he attacked her because she must be a masochist who somehow got him to do it.

(2)   The psychologist had been about to recommend, based on the history of who had been the primary parent, that custody of all four children go to the mother, but then he learned that she was pregnant and that her partner, an aboriginal Canadian man, was the father. Stating that the more children one has, the less love one has to give them, he said that for that reason, he was recommending that two of the four children live with the father and two with the mother. It’s noteworthy that neither parent had ever suggesting splitting up the children, and the four had very close, loving relationships with each other.

The psychologist’s “reasoning” in (1) was clearly based on the unfounded and deeply misogynist myth that women enjoy suffering.⁸ As for what he said in (2), there was of course no foundation for that claim; it is hard to imagine that he would have said the same thing if the father and his new partner were expecting more children, since men continue to be less often expected to do the lion’s share of childcare; and it is possible that some racism about the stepfather’s race/ethnicity may have entered into the equation.

Psychological theories about personality and interpersonal interactions tend to fall roughly into two categories: For one, there is at least some scientific basis, and for the other, there is no scientific support. A clinician conducting a custody – or other psychological – evaluation thus can choose to justify conclusions on the basis of empirical observations or of a theory falling into one or the other group. Clearly, the psychologist in the above example chose to use unfounded theories, and where there is no scientific basis for judgments, every kind of bias easily swooshes in.

In another such example, a heterosexual couple with two children had divorced. The mother had always been the primary caregiver for the kids and was in fact home-schooling them, based on a decision the parents had made jointly. She went to great lengths to ensure that the children would have lots of extracurricular activities with friends. When the father acquired a new girlfriend well after the couple split up, he sued for custody. The public school system representative had told the mother that her teaching of one of the children was inadequate, and she promised to do exactly what they wanted her to do. However, the father said the children should instead be sent to school. The judge transferred custody from the mother to the father on the grounds that the mother’s decision to persist in home-schooling her children revealed that she was overly involved with them. I have never seen anything like that alleged about a father. It’s not hard to imagine that if the parents’ roles had been reversed, the father would have been praised by the judge for devoting so much time to home-schooling the kids and for his determination to improve in doing so.

Mothers and Other Women in the Military⁹

Increasingly these days, women serve in the military. Mothers whom the military requires to leave their children behind during periods of their service of course miss them terribly and often feel guilty and ashamed for being away from them, since a good mother is expected to be constantly on duty. When they are upset, they may seek or be ordered to seek help from a military therapist, and the stories of such therapists diagnosing mothers as mentally ill are legion. Then, as in civilian life, therapists are very likely to prescribe psychiatric drugs for these women, and though there is some disagreement about this, in at least some cases, the women are in danger of being punished for refusing to follow an order if they decline the drugs. When the mothers return home to their children, there are often understandable problems with readjustment on the parts of all family members, and if there is a separation or divorce and a child custody dispute, the fact that the woman had been given a psychiatric label tends to be used as reason to limit her access to and control over her children.

Something similar happens to women even if they are not mothers but are in the military, where rates of sexual assault against women are high, as is retaliation for those who report the assaults.¹⁰ Once again, the deeply human upset they experience because of the attack and often the fear of or dealing with retaliation lead them to see a therapist, and the terrible sequence described above occurs. When they leave the military or come home on leave, they are subject to all of the kinds of harm that result from getting a psychiatric label that were described in Part 1 of this essay.¹¹

A Brief Note about Psychological Theories and Research

Space limitations make necessary just the briefest description of some aspects of sexism in psychological theories and research.

Language, Research, and Theories of Behavior and Emotions

Dr. Jeri Dawn Wine and her colleagues were pioneers of critical thinking about published research about alleged sex differences,¹² and they highlighted the crucial role that language plays in the interpretation of behavior as positive or negative. Working at a time when it was widely believed (even more than today) that men were innately more assertive than women and women more dependent than men, they carefully studied the definitions of assertiveness and dependency used in the studies. With respect to assertiveness, they found that the studies fell into two categories: In one, the behavior examined was the tendency to interrupt, give monosyllabic responses, and so on, and in the other, the behavior examined was the statement of one’s beliefs or feelings and sticking to it. Men did more of the former, which often amounted to aggressiveness and rudeness, than did women, and women did as much as or a bit more of the latter than did the men. The latter of course would more reasonably be called “assertiveness.” Results of the two kinds of studies tended to be lumped together, and there were more of the former, so it was concluded that men were more assertiveness than women, and often what was also concluded was that that difference was innate. This was a powerful way to cast women as inadequate, even not fit for the public world including the workplace.

Similarly, in their analysis of studies of “dependency,”¹³ they found that what was often called dependency – and said to be more common in women than in men – actually included such things as  attention to and concern with the feelings of others, listening and responding respectfully, smiling, having positive and encouraging interactions with others, and accurately sending and interpreting emotion-related messages. Calling such kinds of behavior “dependency” and noting that they were more frequent in women was another major way of casting women as deficient, even childlike.

In my son’s and my simply written, short textbook called Thinking Critically about Research on Sex and Gender, we examine in brief chapters a wide range of research, from studies of the brain and cognition (including math, spatial, and verbal abilities) through emotions and interpersonal interactions.¹⁴ For each topic, we illustrate how traditional assumptions about sex and gender differences have led to seriously biased definitions, research hypotheses and designs, data analyses, and interpretations of findings. Nearly always, outcomes have been some form or other of pathologizing or demeaning of girls and women.

Pathologizing through Theorizing

To address another vast and important topic briefly, I begin by considering that the traditional theories of human development were based on the notion that the aim of growth and maturity was increasing separateness, individuation, and development of “the self.” Beginning in the 1980s and early 1990s, a number of women created work that ought to revolutionize the entire field. Psychologist Carol Gilligan¹⁵; psychiatrist Jean Baker Miller, and the Wellesley College Stone Center group that included Miller and psychologists Judith Jordan, Alexandra Kaplan, Irene Stiver, and Janet Surrey¹⁶; and social worker Rachel Josefowitz Siegel¹⁷ in various ways drew attention to the strengths that girls and women were socialized to have, leading to the recognition that, as I once heard Miller say in a lecture (but put here in my own words):

"Although it makes sense that – even from the evolutionary standpoint of thinking about who survives – it is important for humans to develop capacities to function on their own, there are a parallel track and aim of human development that is at least as important, and that is to develop the capacity to express and identify a range of emotions and the abilities to form relationships with others and repair problems in those relationships. This parallel track also makes sense from the standpoint of how they enhance the likelihood of survival."

That kind of approach provides a perspective from which it is harder to pathologize and dismiss girls and women and our strengths and from which it is easier to understand the importance of teaching people regardless of sex the skills involving connections with and consideration of others.

¹ Much of this section is adapted from Caplan, Paula J. (2000). THE NEW Don't Blame Mother: Mending the Mother-Daughter Relationship.  Routledge. 

Firstly, the Special Rapporteur, appointed in 2014, is Prof. Dainius Puras, a distinguished Lithuanian child and adolescent psychiatrist and epidemiologist, and a person with the highest international credentials to chair this type of project. As a working psychiatrist, it is not rational to belittle his conclusions as "anti-psychiatry" although it is true that he is resolutely opposed to bad psychiatry. It is also factually wrong to see these reports as open to the "bias" of a single individual. Second, for readers in Australia and New Zealand, his conclusions must be seen in the context of the often bitter criticism of mainstream psychiatry drawn forth by two current enquiries, the Australian Productivity Commission Enquiry into Mental Health (2019) and the Victorian Royal Commission into Mental Health (2019). Psychiatrists who believe they are offering the best of all possible treatments for the best of all possible reasons, and are thus above criticism, urgently need to read the public submissions before delving into the latest UNHRC report.

The intellectual basis of Puras' current report includes many propositions with which there will be no disagreement, as per the following items:

1. ....In the present report, the Special Rapporteur highlights the importance of the social and underlying determinants of health in advancing the realization of the right to mental health...

7. ...States also have an obligation to create supportive and enabling environments that foster mental health and well-being....

21.... States do not invest enough resources in mental health in general...

28. Actions taken to realize the right to mental health must be of good quality, and they require evidence-based data and information that is multidisciplinary....

However, the main thrust of the report will cause angst among many psychiatrists, to wit, that the ever-growing emphasis on a biomedical approach to mental disorder is inappropriate:

1. ...A rights-based approach to the promotion of mental health offers an alternative to the biomedical, disease-oriented model that adopts a narrow, individual focus on the prevention of mental health conditions....

19.... the outsized influence of pharmaceutical companies in the dissemination of biased information about mental health issue...(leads to an) overreliance on coercive, punitive and overmedicalized measures... (which) demonstrate a lack of political will to support, replicate and sustain evidence-based social interventions that foster well-being, prevent discrimination and promote community inclusion.

21.... States do not invest enough resources in mental health in general... a larger proportion of available resources are directed to ineffective systems, reliant on excessive medicalization, coercion and institutionalization, breeding stigmatization, discrimination, disempowerment and helplessness.

28....Responses to mental health conditions that are based on the use of coercion... are becoming the rule. Continued investment in policies and services, with prevailing patterns of coercion, excessive medicalization and institutionalization, are a serious obstacle to the effective realization of the right to mental health. Such systems reinforce vicious cycles of stigmatization, discrimination and social exclusion, and may be more detrimental than the mental health conditions they are supposed to treat.

For the many psychiatrists who firmly believe that biological reductionism is not just the correct approach to mental disorder, but the only conceivable approach, these are inflammatory remarks. The idea that our forms of treatment could, on balance, be inequitably distributed, do more damage than good, at greatly excessive short- and long-term cost, and with dismal efficacy, will be reflexly rejected. This defensive response would, however, be exceedingly unwise. All is not well in psychiatry, as the existence of the above-mentioned enquiries indubitably demonstrates.

If, however, psychiatrists manage to convince themselves the enquiries are just some bothersome window-dressing from which no good will emerge, there is ample, highly reliable evidence that theirs may not be the best of all possible worlds.

1. The Royal College of Psychiatrists was recently forced to acknowledge that, despite its previous attempts to deny the possibility, antidepressants are addictive (RCPsych 2019). This accounts in part for the relentless increase in numbers of people taking these drugs in Western countries (now 16% of adult population in UK). At the same time, there is emerging evidence that people taking antidepressants are likely to have a worse outcome (Hengartner, Angst and Rössler 2018).

2. Antipsychotic drugs shorten the lifespan (Correll et al 2015). That is, people who, for example, are detained and compelled to take drugs against their will just on the basis of potential "reputational damage" (whatever that means) are likely to die younger as a direct result, albeit with their reputations intact. At the same time, recent studies have added to the already strong evidence that antidepressant drugs are neither as effective nor safe as the manufacturers claim. Hengartner and Plöderl (2019) concluded:

The data presented herein suggest that antidepressants significantly increase the suicide risk in adults with major depression.

3. Drug companies in the US have acted unethically and, in at least some cases, illegally, to produce an "epidemic" of opiate addiction which now claims about 50,000 lives a year and shows no signs of abating. As a result, the life expectancy in the US has declined for several years in a row, the first time this has ever happened in a developed country in peace time. This is part of a pattern of scandalously venal and/or illegal conduct by drug companies for which they have been fined a collective $42billion in the US over the past ten years (Gotzsche, 2015; Whitaker and Cosgrove, 2015).

4. The argument that ECT is "essential and irreplaceable" in treatment of mental disorders evaporates under close scrutiny (Read and Arnold, 2017). It should be noted that the recent Guidelines on ECT issued by the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2019) do not address the critical point of whether ECT is necessary. In fact, analysis of readily available figures reveals that it is not, that the main driver for the rapidly increasing use of ECT in Australia is the financial rewards it generates for the private psychiatric industry (McLaren, 2018).

5. The relentlessly expanding list of diagnostic categories of mental disorder has long passed the limits of common sense. What we are now seeing is the medicalisation of normality (Horwitz and Wakefield, 2007; Frances, 2013).

6. Long-term use of drugs with strong anticholinergic effects, such as antidepressants and antipsychotics, is associated with an increased risk of dementia (Coupland et al 2019). Overwhelmingly, these drugs are approved on the basis of short-term trials, often only weeks, whereas large numbers of people take them for decades. Long-term studies demonstrate that their efficacy is grossly over-rated  (Wunderink et al, 2013) while reanalysis shows that many trials are unreliable (Le Noury et al, 2015).

7. With the NIMH Research Domain Criteria project (Insel et al, 2010), psychiatry has committed itself to a project of biological reductionism which is hugely expensive, has no rational basis and can never succeed (McLaren, 2011). This is not a matter which can be countered by claims such as: "They used to say that heavier-than-air flight was impossible, too." It is the case that mental properties cannot be  reduced to or explained away by their physical mechanism (Stoljar, 2010). No psychiatrist has ever argued a remotely plausible case that the ordinary, or even extraordinary, techniques of laboratory science will ever tell us anything interesting about mental disorder, let alone explain it with no questions unanswered, yet the great bulk of psychiatric research funding will now be directed to basic biological sciences.

8. On March 6th 2018, the RANZCP issued a press statement claiming inter alia that:

The prescription of antidepressant or antipsychotic medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits (RANZCP 2018, emphasis added).

This claim was manifestly untrue and it was impossible for those who authorised it to believe otherwise. 

This strongly suggests that even though psychiatrists are very happy with their work and don't see any need for criticism, many people on the receiving end of it aren't quite so enthralled. By effectively abandoning the psychosocial elements in their former mantra, psychiatrists have painted themselves into a biological corner, but there is no Plan B. For anybody who takes psychiatry seriously, I see grounds for despair. Psychiatrists more and more are showing at best, the trappings of a medieval guild (Cosgrove and Whitaker 2015) or, at worst, an ideology or cult (McLaren 2013). Blame for this rests squarely on psychiatry's lack of a model of mental disorder and its adamantine refusal to accept the criticism which is the only path to rectifying that deficiency (McLaren, 2018).

Science proceeds by criticism of the status quo; in the canon of science, not even that proposition is beyond criticism. Attacking critics such as Puras will never conceal the intellectual hole at the heart of modern psychiatry. Indeed, the extreme defensiveness of psychiatrists attests to their intellectual insecurity. As psychotherapist and author Gary Greenberg noted:

It's the universal paranoia of psychiatry that everybody who disagrees with them is pathological. You can't disagree with a psychiatrist without getting a diagnosis... (they) diagnose the critic (Reece 2013).

If and when, by their constant breaching of the most fundamental rules of the conduct of science, psychiatrists succeed in destroying public confidence in their profession, it will be both supremely ironic and a tragedy for the mentally-disturbed.

References:

APC Enquiry into Mental Health (2019). https://www.pc.gov.au/inquiries/current/mental-health#draft.  Accessed July 14th 2019.

Correll, CU et al. (2015) Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry. Jun; 14(2): 119–136. https://doi.org/:10.1002/wps.20204.

Cosgrove L, Jureidini J (2019). Why a rights-based approach is not anti-psychiatry. Australian and New Zealand Journal of Psychiatry 53: 503-504. https://doi.org/10.1177/0004867419833450.

Coupland, CA et al (2019). Anticholinergic Drug Exposure and the Risk of Dementia. JAMA Internal Medicine. https://doi.org/10.1001/jamainternmed.2019.0677. Published online June 24, 2019.

Dharmawardene, V, Menkes, DB (2019) Responding to the UN Special Rapporteur’s anti-psychiatry bias. Australian and New Zealand Journal of Psychiatry 53: 282–283.

Frances, A (2013).  Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. New York: Wm. Morrow.

Gotzsche Peter (2015). Deadly Psychiatry and Organised Denial. London: Artpeople.

Hengartner M, Angst J and Rössler W (2018). Antidepressant use prospectively relates to a poorer long-term outcome of depression: Results from a prospective community cohort study over 30 years. Psychotherapy and Psychosomatics. Published online April 20, 2018. https://doi.org/10.1159/000488802.

Hengartner, M. P., & Plöderl, M. (2019). Newer-generation antidepressants and suicide risk in randomized controlled trials: A re-analysis of the FDA database. Psychotherapy & Psychosomatics. Published online June 24, 2019. https://doi.org/10.1159/000501215.

Horwitz AV, Wakefield JC. The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder.New York: Oxford University Press, 2007.

Insel, TR et al (2010). Research Domain Criteria (RDoC): Toward a New Classification Framework for Research onMental Disorders. American Journal of Psychiatry 167: 748-751

Le Noury, J et al  (2015) Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ 2015; 351 https://doi.org/10.1136/bmj.h4320.

McLaren, N. (2011). Cells, circuits and syndromes. A critique of the NIMH Research Domain Criteria project.  Ethical Human Psychology and Psychiatry 13: 229-236.

McLaren, N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.

McLaren, N (2018). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104

McLaren, N (2018). Anxiety: The Inside Story.  Ann Arbor, MI: Future Psychiatry Press.

McLaren, N (2019). Criticising psychiatry is not ‘antipsychiatry’  Australian and New Zealand Journal of Psychiatry 53: 602-603.    https://doi.org/10.1177/0004867419835944.

RANZCP (2018) Press release March 6th 2018: RANZCP deeply concerned over stigmatising reporting of mental health treatment. Since deleted; available at https://www.MIA.com/2018/03/psychiatrist-writes-ranzcp/.

RANZCP (2019). Professional practice guidelines for the administration of electroconvulsive therapy.  Australian and New Zealand Journal of Psychiatry 53: 609–623

RCPsych (2019). Position statement on antidepressants and depression. PS04/19. Royal College of Psychiatrists, London.

Read, J, and Arnold, C (2017). Is electroconvulsive herapy for depression more effective than placebo? A systematic review of studies since 2009. Ethical Human Psychology and Psychiatry 19: 5-23.

Reece, H. (2013). Interview Gary Greenberg, The Atlantic, May 2nd 2013. https://www.theatlantic.com/health/archive/2013/05/the-real-problems-with-psychiatry/275371/.

Stoljar D (2010). Physicalism. Oxford: Routledge.

The Royal Commission into Victoria’s Mental Health System (2019). https://www2.health.vic.gov.au/mental-health/priorities-and-transformation/royal-commission. Accessed July 14th 2019.

UN Human Rights Council (2017, 2019) Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

(2017) UNHRC Document A/HRC/35/21 , available at: http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/35/21.

(2019) UNHRC Document A/HRC/41/34 , at: https://documents-dds-ny.un.org/doc/UNDOC/GEN/G19/105/97/PDF/G1910597.pdf?OpenElement.

Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.

Wunderink, L et al (2013). Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2013.19. Published online July 3, 2013.

Paula Caplan, Ph.D.

Note: Part 1 is about sexism in psychiatric diagnosis. Part 2, to appear in the next issue of the Bulletin,  is about sexism in relation to mother-blame and psychological/psychiatric theory and research, with suggested solutions for these realms. Portions of this article are based on the author’s September 28, 1999, keynote address of the same title to the Department of Health and Human Services-sponsored New England Conference on Women and Mental Health, Hartford, CT.

Even this far into the 21st century, if one examines psychiatric diagnoses, stereotypes and myths about and expectations of mothers, and classic theories of psychological development, it is hard to find any possibilities for women to be considered normal. Instead, they are usually considered pathological or otherwise deficient.

The ways that psychiatric diagnoses are conceived, constructed, and applied leave the field wide open for sexism and indeed for every conceivable form of bias. Mother-blame in clinical journals and mother-blame as hate speech result in the pathologizing of virtually anything that mothers might do. And classic theories of psychological development and designs of research questions and methodologies have often been profoundly sexist. None of this is surprising, since the vast majority of the world continues to be pervaded by sexism, so it naturally shapes virtually every realm.

Sexism Due to Lack of Science in Psychiatric Diagnoses

The Diagnostic and Statistical Manual of Mental Disorders, often called the therapist’s Bible, is widely used to pathologize all women (and many men). It is a product that is a multi-million-dollar business, because it has been translated into two dozen languages for global use, and it is marketed by its publisher, the American Psychiatric Association (APA), as a scientifically-based document. The APA’s profits come not only from publication of the manual itself but also from sales of a variety of related books and other products. I was a consultant to two committees that produced DSM-IV, but I resigned after learning of the profoundly unscientific way the manual was put together and the dishonesty of its head and many of its members about the lack of science and the harm it causes.¹ What I saw as an insider was that, when junk science can be described in a way that supports the aims of the select few who make the final decisions, it is presented as good science, and when well-done research conflicts with their aims, they ignore, distort, or lie about it. I have said that that process should be called "Diagnosisgate" for these reasons.² (See ISEPP's position on the DSM here).

To give just one rather representative illustration of how unscientific the manual is (for far more examples, see citation in Endnote¹), let us consider how the DSM authors dealt with their idea of creating a category now called Premenstrual Dysphoric Disorder. That category, according to the DSM committee's own published information, would apply to at least a half-million North American women.³ The category first went into the DSM at a time when Robert Spitzer, then DSM head and one of the originators of this category, acknowledged in a press conference that psychiatrists had no cure to offer for this disorder beyond the nutritional, vitamin, and self-help suggestions published in the pages of women's magazines. However, he said that the category needed to go into the manual so that psychiatrists could find out how to help women who suffered from "it". The scientific basis (or its lack) was not really examined until seven years later, when the next edition of the DSM was being prepared. At that time, DSM-IV head Allen Frances had cannily appointed an all-woman committee to evaluate the research, and they were longtime experts on the subject, most or all of whom received money from Big Pharma. The PMDD committee wrote a report approximately 125 pages long and including a review of more than 400 research articles. It looked impressive.⁴ In their own summary, the committee said outright that almost none of the papers was relevant to the question of whether there is a premenstrual mental disorder. Many of the papers were instead related to such premenstrual physical experiences as bloating, breast tenderness, and food cravings -- or even to reports of increased irritability, for instance, but by no means to anything one might conceivably consider a "mental illness". The committee said that the few reports that were relevant were "preliminary" and had many methodological problems. On that basis, one might have expected the committee to tell Dr. Frances that there was no scientific justification for claiming there is a premenstrual mental illness. Instead, they reported that they could not reach a consensus.

Frances then announced that he had appointed two other people to decide the fate of this category, but he refused to name those people. I telephoned him, said the debate about this category had perhaps become unnecessarily adversarial, and suggested that we try together to focus on the welfare of the women who might be given this label, since both his group and opponents of the category were presumably most concerned about those women. I pointed out that I had given his PMDD committee documentation of the harm that had already been caused to women who had received this label. I said it would be reassuring if he could present some evidence at least that more women had been helped than harmed by this diagnosis. He responded, "Well, of course, there's no way of knowing that." But of course, there is a way of knowing that. That is what scientific research is for, and scientific research is supposed to be the basis for decisions about the DSM.⁵

Ultimately, under media pressure, Frances announced the names of the two persons who would decide the fate of the PMDD category. Psychiatrist Nancy Andreasen was a longtime advocate of the notion that all emotional problems are caused by brain disorders and had served on DSM committees with Spitzer, one of the category's inventors. Psychiatrist A. John Rush specialized in research about “depression” and had received Big Pharma funding for research about it. This pair recommended that the category be included in the DSM-IV and that it go not just in the appendix that was said to be for disorders requiring further study but also in the main text of the manual, which is supposedly reserved for well-supported categories. Further, they said it should be listed under Depressive Disorders -- even though, astonishingly, one did not have to be depressed to meet the PMDD criteria. (But remember, A. John Rush received Big Pharma funding to study “depression.”) This was particularly disturbing in view of the fact that it has been documented that women who report feeling upset premenstrually are significantly more likely than other women to be in abusive or other upsetting life situations. Therefore, diagnosing them as premenstrually mentally ill leads us in the wrong direction, away from focusing on the real sources of their problems.

Around that time, the DSM people began to claim – though evidence on this point was appallingly poor, and there was even evidence disproving it – that “antidepressant” drugs were the most important treatment for women given this label, and committee members accompanied Eli Lilly staff to a meeting where they persuaded the FDA to approve repackaging and renaming (in pink and purple) of Prozac to be called Sarafem and prescribed for women labeled with PMDD.⁶

When women tell me they feel badly premenstrually, I believe them. I know that hormonal changes can affect one's feelings. But so, for instance, can a sprained ankle, and sprained ankle is not included as a mental illness in the DSM, nor are the vast majority of other physical problems.

What Allen Frances and his colleagues did with the science related to "PMDD" is just one example of how fast and loose they played with the research, a pattern that leads to other problems. If one imagines the enterprise of psychiatric diagnosis as a sphere, consider that the DSM marketers claim it is filled with good science, but we know that is not true. If one removes from that sphere all of what is wrongly called good science, it leaves a vacuum. What goes into a void where there is no objectivity? Every conceivable form of subjectivity and bias. It is unsurprising, then, that sexism – as well as racism, classism, ageism, heterosexism and homophobia, and others – pervades the creation and application of psychiatric labels.⁷

Harm from Psychiatric Diagnoses

The DSM is probably the single most powerful source of support for the medical model of emotional anguish, with the strikingly similar psychiatric listings in the International Classification of Diseases adding still more force. It  is deeply worrying that use of the medical model for emotional problems increases the likelihood of therapists unthinkingly prescribing psychotropic drugs (inappropriately, without obtaining fully-informed consent and/or without explaining to the person the full range of possibly helpful options), even electroshock, and ignoring the potentially negative consequences of applying a diagnostic label. The vast range of kinds of harm that begin with the labels includes the person's loss of custody of their children, loss of employment, loss of health insurance or skyrocketing of premiums on the grounds that the person has a pre-existing condition (the mental illness), and legal rights to make decisions about what happens to them, such as whether to have electroshock, take medication, and be physically confined, isolated, or restrained. Other adverse consequences of labeling include the dehumanizing of the labeled person and creation of a we/they world, in which therapists are more likely to feel superior to and qualitatively different from the people they are supposed to help. These are not inevitable consequences of labeling, but they are common ones.

Vast numbers of women (and men) who have real but undiagnosed physical health problems are inaccurately diagnosed as having mental disorders instead.  Some physicians are quick to assume that any woman with complaints of any sort is hysterical, dependent, and attention-seeking and thus mentally ill. Other physicians' intentions may be more honorable, but when their training has not included the physical symptom picture presented by a given patient, they mistakenly conclude that nothing physical can be wrong and that therefore the problem can only be psychological. These phenomena account for many women being regarded as mentally disordered.

Many well-meaning therapists tell me that they believe they minimize risk from diagnosis by classifying all of their patients as having Adjustment Disorder, because it sounds so innocuous. However, a lawyer told me the following story about a client of his. The client, a woman who had recently moved to his state to begin a graduate program in psychotherapy, was told during the first week of classes by the program director that any student who had not been a therapy patient should seek some therapy sessions right away, just to see how it felt. The rationale was, "Soon you will be a therapist, so you need to have that experience of being a patient." The obedient student went promptly to a walk-in clinic at the local hospital and explained to the psychiatrist on duty why she was there. The psychiatrist agreed to see her for some sessions, during which they discussed anything that was bothering her, such as feeling lonely after having moved to a new place where she knew no one. Subsequently, the patient was in a vehicle accident and incurred physical injuries, for which she was treated at the same hospital. She was bewildered to receive a letter from her health insurance company, in which she was told they would not pay her medical bills from the accident because she had lied to them on her insurance application form. When she contacted them to protest that she had not lied, they replied that she had denied that she had a mental illness on the form when she applied to their company for insurance. "But I don't have a mental illness," she replied. The insurance company employee said that she clearly did have a mental illness, because her hospital chart showed that the psychiatrist had given her a DSM label. "But the psychiatrist knew I wasn't there because of a mental illness," she protested. That did not matter. The insurance company officials claimed that, simply by virtue of some therapist's having assigned her a DSM label (which the therapist likely did so that the insurance company would pay for the therapy), this woman was now irrevocably considered mentally ill. What power the DSM has! It is far too often erroneously assumed that anything in the DSM is true and that any therapist who uses a label from that manual is using it accurately.

I am aware that some people feel that receiving a label, or receiving a label and then psychotropic medication, has been extremely helpful to them, and I do not question that. But in general, psychiatric labeling tends to narrow our vision of the causes of women's and men's pain and anguish and of the ways we might help. 

Sexism and Specific Diagnoses

The DSM is the most influential basis for how we as a society decide who is normal, but the very foundation of the book is nebulous. "Mental illness" is a construct, and even the DSM authors acknowledge the impossibility of creating a good definition of it. When that overarching construct is ill-defined, how can each of the hundreds of categories and subcategories of alleged mental illness have any validity? Here follow just a few examples of labels that were constructed and/or are applied in sexist ways – Post-traumatic Stress Disorder, Borderline Personality Disorder, Self-defeating Personality Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Premenstrual Dysphoric Disorder.

Post-traumatic Stress Disorder used to be the "normal reaction" in the DSM, because it was described as likely to develop in anyone who had experienced major trauma. However, Dr. Allen Frances in DSM-IV removed the statement that the criteria are normal reactions to an abnormal situation, and the statement was not restored in DSM-5. This is devastating for battered, raped, or severely emotionally and verbally abused women as well as for others, such as people who have been traumatized by war, because it means that deeply human reactions to trauma are classified as mental illness at the drop of a hat.⁸ This is not only inaccurate but also severely damaging, because in addition to struggling with the effects of trauma, the labeled person now has to grapple with feeling something is wrong with them for not being “over it” yet.⁹

Borderline Personality Disorder is a label often given to victims of battering, abuse, and severe harassment -- most often women -- making it another classification that conveys the messages that “You should get over it” and “You are seriously defective, probably with a chemical imbalance in your brain.”¹⁰ From my own experiences listening to many traditional therapists, I have observed that it is a label they often give to patients they dislike.

Self-defeating Personality Disorder appeared in the appendix for categories requiring further study in DSM-III-R but not in subsequent editions. It was a slightly masked title for what was originally called “Masochistic Personality Disorder” and was to be applied to people who, for instance, put others’ needs ahead of their own and settled for less when they could have more. The danger of this category was especially great for women, who are traditionally socialized to fit these patterns, and even more for victims of wife battering, rape, and child sexual abuse, who are more likely to be women.¹¹ The absence of the term from the current manual by no means prevents practitioners from using this label – or even if not using the label itself, interpreting women’s suffering as caused by a sick enjoyment of the abuse, failure, deprivation, or other harm they suffer. In addition, the use in the current manual of terms like “unspecified” or “other” disorders in practice allows the professional to call anything at all a mental disorder.

The sexism in the DSM  is illustrated by the fact that there is no male equivalent in the DSM of either Premenstrual Dysphoric Disorder (for instance, no Testosterone-Based Aggressive Disorder) or Self-defeating Personality Disorder (since Self-defeating Personality Disorder is in many ways a somewhat exaggerated form of traditional female socialization, a male equivalent might be called John Wayne Syndrome or Macho Personality Disorder). Sociologist Margrit Eichler and I decided, for educational and consciousness-raising purposes, to design an alleged mental disorder we called Delusional Dominating Personality Disorder (DDPD), the consequences of a somewhat exaggerated form of traditional male socialization.¹² We designed DDPD using the DSM format and submitted it to the DSM committee for inclusion in DSM-IV. We pointed out that not all men suffer from DDPD and that some women do. We also noted that DDPD is frequently seen in major military and political leaders and the heads of large corporations. For brevity’s sake, I shall only list here the first four of the 14 proposed criteria for DDPD. They are:

1. Inability to establish and maintain meaningful interpersonal relationships.

2.Inability to identify and express a range of feelngs in oneself (typically accompanied by an inability to identify accurately the feelings of other people).

3. Inability to respond appropriately and empathically to the feelings and needs of close associates and intimates (often leading to the misinterpretation of signals from others).

4. Tendency to use power, silence, withdrawal, and/or avoidance rather than negotiation in the face of interpersonal conflict or difficulty

(The full list of criteria is included in Caplan, 1995, cited in endnotes.)

We created the category more than two decades ago, and I began to speak about it in lectures. Every time I read the full list of criteria to any group of any kind, as I read the first few, people would laugh. As I read the next few, they would fall silent and appear to be listening carefully. By the time I would get to the last ones, they were shouting out things like, "I KNOW people like this! Why aren't they considered a problem?!" Needless to say, the DSM committee gave no sign that they even considered it for inclusion in the manual. Although virtually everything that women may do can qualify for "mental disorder" according to the DSM, traditionally-socialized masculine behavior that often causes pain, physical harm, and even physical illness in people who meet DDPD criteria and to the people with whom they live and work is far less often considered pathological by those who create the official diagnostic categories. That is why people laughed when they heard the first criteria of DDPD: They were surprised that anyone might suggest calling hurtful or inhumane "masculine" behavior a mental disorder. It is encouraging that in recent years, there has been increasing recognition of the harm caused by what has come to be called toxic masculinity, though it is important to recognize that this is a widespread social problem and should not be called a mental illness, lest the methods for reducing such social problems be overlooked rather than implemented.

Major Depressive Disorder (MDD) is a category leading to dangers for girls and women, because in a sexist society such as ours, there are a great many causes for grief, sadness, a sense of helplessness or hopelessness, feelings of worthlessness, irritability, difficulties with sleeping or eating, and other emotions, beliefs, and problems listed under this category in the DSM.  Since having such feelings after bereavement or other major loss are deeply human ones and should not be called signs of mental illness, it is important to mention a particular part of MDD’s descriptions in the current and previous editions of the DSM. There has been a justified outcry that in DSM-5, it is said that MDD should not be diagnosed if the person has been bereaved less than two weeks. It is both absurd and dangerous to consider these kinds of feelings pathological as soon as the first two weeks after the loss are over. But what should also be known is that in DSM-IV, Allen Frances’s edition specified that MDD could be diagnosed in a bereaved person as long as the person had any of the following: “marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” Since these are very common characteristics of bereavement, the DSM-IV allowed for application of the MDD label to a person on the first day of their loss, making it in that way even worse than DSM-5.¹⁴ This matters, because in all of the justified outcry about the two-week limit in DSM-5, it is crucial not to render invisible the suffering of all of the bereaved people who were hurtfully diagnosed with MDD based on DSM-IV.

Generalized Anxiety Disorder is similar to Major Depressive Disorder, given that what is called “anxiety” is usually fear, and in a sexist and violent society, there are myriad reasons for girls and women to be afraid.

Premenstrual Dysphoric Disorder’s unscientific nature, described earlier, is not the only problem with the category. Because its name confines its application exclusively to women, who have menstrual periods through many decades of their lives, it has opened the floodgates for the pathologizing of nearly everything about women. Most women have had the experience of their legitimate feelings and concerns being dismissed on the grounds that they must be premenstrual. And as the medical community has joined with Big Pharma, both “peri-menopause” (the time recently delineated for purposes of pathologizing as when hormones start to change when women move toward cessation of menstruation) and menopause itself (the cessation of menses) have been treated as causes of “mental illness,” and there is a long tradition of demeaning and pathologizing older and old women based on the notion that without the hormonal levels typical of women who are still menstruating, they are unfeminine, unwomanly, “dried up,” somehow less than human. I am not being entirely flippant when I suggest that it’s only a matter of time until the APA creates a category of psychiatric disorder for girls from birth till their first menstrual period and attributing it to the fact that their hormone levels differ from those of menstruating women.

In summary with regard to psychiatric labeling, once you add to all who have been or could be diagnosed with the labels discussed above,  plus all the women who could qualify for any of the other hundreds of mental disorders listed in the DSM, is there any chance we could find a normal woman?

As if the ways described here of pathologizing women were not enough, myths and stereotypes about mothers and sexism in psychological theories and research add much to that pathologizing, and some of these will be addressed in Part 2 of this two-part essay, which will appear in the Bulletin’s next issue.