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.

 Why do we think they are negative?

 They aren’t comfortable.

 It’s interesting to wonder about why these important feelings are uncomfortable.  Perhaps it is because we need to be motivated to do something about the concerns that are causing them.

 They are associated with behavior that is dangerous.

 It’s important to make a distinction between the emotion and behaviors that are associated with the emotion.  All emotions are valid, OK and potentially useful.  But the behavior that results from emotions can be either helpful or dangerous and hurtful.

 They can make us sick.

 When these emotions are stuffed and repressed, they go inside, put a strain on the body, impair the immune system and cause sickness.

 What evidence is there that these emotions are useful?

 Evolution or Creation

 Whether you believe in evolution or creation, there is evidence that the “negative” emotions are beneficial and useful.  If you believe in evolution, you understand that the human organism has been evolving over the past 30 million years. Any faculty or state of being that wasn’t useful and didn’t have survival value would have been wiped out long ago by the process of natural selection.  If you believe in creationism, why would God have given us a faculty or state of being that wasn’t somehow useful?

 Research

Antonio Damasio

 In his book Descarte’s Error, Antonio Damasio describes his study of people who, due to lesions on their amygdalas, were unable to experience emotions.  He found that such persons were unable to make good use of their reasoning abilities. Unable to feel bad, they couldn’t learn from mistakes.  For example, they would see a stock they owned going down in value but wouldn’t feel bad about it so wouldn’t sell it.

James Pennebaker

 People who write about the most traumatic experiences of their lives have better immune system functioning and are healthier than people who write about impersonal topics.

 Method Actors

The immune systems of actors function better while they are experiencing emotions and it doesn’t make any difference if the emotions are “positive” or “negative”.

 Medical students

Medical students included in the “Bland-No emotions” group were 16 times more likely to contract cancer than those in the “Acting out” group.

 Joseph Ledoux

 Signals that are received through the eyes, ears, nose and skin pass through the amygdala (the part of the brain which processes emotions) before they go to the neo-cortex (the part of the brain which processes thinking, problem solving and analyzing), evidence that the human organism is “designed” to enable the emotional processing and reasoning faculties to work together.

 How are these “negative” emotions useful?

Five basic ways in which they are useful:

 They tell us what’s important, what we care about, what we like, what we don’t like, what we are afraid of, what we want to get rid of.

They help us get clear about our values.

They help us make decisions.

They give us energy and motivation.

They help us understand other people and, therefore, to behave in better ways.

Following are some examples:

Anger: Anger tells us what we don’t like, what we want to get rid of, what is threatening us, what we want to overcome.

Jealousy: Jealousy tells us what we want and don’t have or what we have and don’t want to lose.

Fear: Fear tells us what we want to avoid, what we want to be careful about, what can hurt us, what we must protect ourselves against.

Sadness: Sadness tells us what is precious to us and what we want to nurture and protect in our lives.

Anxiety: Anxiety gives us the energy, the mental acuity and the stamina to do things that we want to do but which are going to be difficult and scary.

Guilt: Guilt tells us what we think is wrong, keeps us from doing things we think are wrong and enables us to make amends to persons we have wronged.  It enables us to act in accordance with our moral code.

What do we have to do in order to use them?

 1. Experience them.

We experience them in our bodies.  We first get in touch with them through bodily sensations.  What we have to do is let them in, sit with them, wait with them, let them work in us. Many of us have been told that these emotions are bad, that they can’t be trusted, that they only lead to no good. So, as soon as we begin to feel them, we find a way to avoid them.  We get busy, we act out, we take drugs and alcohol, we escape.  If we only would let them work in us for five minutes or so, we could take the first step to turning them into positives.

2. Find out what they are telling you.  What is behind them?  What are they about? What is the message?

This is easier said than done. It may take some time to get the message from the emotion.  One thing that will help is to find a quiet place in which to sit.  Sit in a comfortable position.  Tell yourself that you are open to receiving whatever the message is.  Take some time to relax, let the tension out of your body and allow yourself to receive whatever messages come up from inside of yourself.

Here are some other rules of thumb that may be useful in taking this step.

• Anything which gets in the way of you loving the way you want to love and working - expressing yourself and using your abilities - the way you want to work is going to cause one of these “negative” emotions.

• Welcome whatever thoughts come up.  Even if they don’t make sense or seem to be coming out of left field, they may be the start of a useful insight.  If they seem weird, ask them what they are doing there and what they have to tell you. Be open to answers.

• It is not necessary to push yourself hard at this point.  It works better to relax and allow things to come to you – all by themselves – without you making it happen.

3. Take some action based on what you have learned or decide not to take action.

This may be the hard part.  Since these emotions are usually about something which is bothering you or is in your way, something you want to get rid of or you want to confront, it may take some courage to take action.  And since action will often involve confronting other people you will have to learn how to confront without making them defensive.

Here are some rules of thumb for taking action.

• If you are confronting another person, use the rules of assertiveness.

Describe what is going on for you, what you are noticing, how you are feeling using “I” instead of “You”.

Tell the person that you are having a problem with what is going on, that you don’t know what the solution is and that you’d like her or him to join with you in finding a solution.

Take responsibility for your feelings, your thoughts and your desires.

Say what you want – calmly and directly.

Don’t take responsibility for the other person’s feelings.

• If you are afraid, ask yourself what you are afraid of.  When you get the answer, see if it is a fear that you can walk with, that you can manage without letting it stop you.

• Ask yourself what is the worst thing that can happen and see if you could live with that or somehow mitigate it.

• Be aware of the ways in which you habitually stop yourself from taking action.  We often stop ourselves by saying things like:

"I don’t want to be petty."

"I’m afraid if I say something or do something, things will get worse."

"It’s not that important."

"I’ll just let things ride and see what happens."

"Who am I to think I should get what I want?"

"If I do what I want to do, they’re going to think I’m mean and nasty and not a nice person."

Check these thoughts out to see if they really make sense and if you want to let them stop you or not.

What if I don’t want to take action?

After experiencing the emotion and getting its message, you may decide not to take any action.  If so, you need to find some way of discharging the energy that is in the emotion.  Examples of how some people use this energy effectively is exercise, sports, creative activity, talking to friends, writing, playing music, and helping other people.  Any activity which uses energy and is not harmful to self or others will work.

So what is the bottom line?

These so-called “negative” emotions are valid, beneficial and potentially useful.  They tell you what is important to you and what you need to do in order to live more the way you want to live.  If you want to use them, take the following steps:

1. Experience them.  Let them in and let them work on you.

2. Learn from them.  What are they telling you?

3. Take action based on them.  If you decide not to take action, find a way of using the energy in them that is helpful to you and/or others.

Thomas Scheff, Professor Emeritus, University of California, Santa Barbara, Department of Sociology

Many years ago (1894), the noted philosopher John Dewey published a theory of emotions that today might seem peculiar, at least at first glance. He proposed that each emotion is a bodily process like breathing, only painful if obstructed. Dewey’s articles were ignored because, oddly, he provided no examples: he didn’t describe the patterns of obstruction that cause grief, anger, fear or shame to be painful.

Much later Bull (1951) partially responded to Dewey’s theory. She provided one example: grief is painful only if there is too little crying. No attention has been given to these writings; little evidence has been offered to support them. This note describes a small bit of evidence that might be relevant: my own personal experience of catharsis of obstructed emotions (Scheff 1979, 2007).

Some 50 years ago (I am nearing 90), I had a personal experience of removing obstructions of grief, anger, shame and fear. It occurred when I enrolled in a small informal class called Re-evaluation Counseling (1965). Although not mentioned in the class or it’s supportive writings, it seems to be based on the Dewey-Bull theory. After the first class, I cried every day for almost a year. Since at the age of 40 I hadn’t cried since childhood, I was quite surprised and gratified. The crying seemed to remove or at least decrease a substantial amount of pain and doubt.

Similarly, instead of bearing anger for much of a day and night, I saw that my little screams produced a flash of heat in my whole body that ended the anger. After a few minutes. I was no longer angry. A great relief, since in those days I was often angry.

A prolonged burst of happy laughter seemed to remove shame or embarrassment completely.

Unlike the other three emotions, fear was infrequent. But a few moments of intense sweating and shaking removed fear the few times that it occurred.

There is a complication which I can only mention in passing in this brief note: not all crying, shouting, shaking and laughter removes obstructions of emotions. For example, one can cry for many, many hours without removing the obstructions. I would guess that most of the crying, laughter and shouting that we see is like this. To remove obstructions, these actions must be under control, even though the person who is crying, laughing and/or shouting may not know that they have control. But in my experience, there have been moments when I needed to attend to business other than my emotions. To my surprise, I could stop and start the cathartic process at will. I have called this feature “aesthetic distance” because it resembles that emotional reactions of audiences in the theatre (Scheff 1979).

Most people in modern societies seem to have little interest in emotions. They take their beliefs about them for granted. In actuality all emotion terms, especially in English, are undefined and highly ambiguous. For example, most of the emotion research in psychology is not about emotions themselves, but about facial expression of emotions. Facial expressions are visible, without dealing with the problem of emotions, which are partly internal. In this way, they think they are studying emotions, but they only deal with a very small aspect.

Since the public and most of the researchers seem to be certain that the four emotions dealt with in this note are inherently painful, it will be difficult to convince them that they are not. According to this theory, we need not only to think differently about emotions, but research them directly, and also stop hiding them from self and from others so one can experience each emotion directly.

Bull, Nina. 1951. The Attitude Theory of Emotion. New York: Nervous and Mental Disease Monographs.

Dewey, John. 1894. The Theory of Emotion. Psychological Review. 1; 6 (553-568) and 2; 1 (13-32).

Jackins, Harvey. 1965. The Human Side of Human Beings. Seattle: Rational Island.

Scheff, Thomas. 1979. Catharsis in Healing, Ritual and Drama, Berkeley: U. of Calif. Press.

Scheff, Thomas. 2007. Easy Rider, pp 194-195. Lincoln, Nebraska: iUniverse Press.