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Women and depression Hathaway, Lorraine 1978

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VST 1VV5 Women and Depression Lorraine Hathaway Major Paper University of British Columbia School of Social Work Health Concentration August, 1978 -1-. WJepression is one of the most prevalent and least understood emotional problems which afflicts individuals in North American society Along with feelings of alienation and anomie, it leads the list of the modern individual's emotional complaints. It has been recognized as a problem since antiquity and descriptions of the symptoms of depression have been remarkably similar over time. Despite the general agreement in descriptions of the disorder, modern researcher, like their ancient counterparts, have consistently complained about their slow progress in understanding and treating the problem. Depression has been described as paradoxical, elusive and perplexing. (Beck, 19&7) itfne of the^  most striking and perplexing aspects of depression in | J +W' 0 NoxUi_Aiaj.-rica. is the KG11_ established fact that women experience and are treated,.for depression in far greater numbers than men • (Weissmand and Klerman, 197?) '-Many social workers in the field are well aware of the higher incidence of depression among women as they are frequently con-fronted by female clients who report that they feel sad, hopeless, and unable to cope with their lives. These complaints r,ay range from mild hut pervasive feelings of apathy, fatigue, box-edom and gloom (frequently called the housewife's complaint) to intense and overwhelming feelings of despair which too often lead the woman to a desparate suicide attempt. Both the prevalence and the seriousness of depression in women is a cause for concern among mental health practitioners. Yet, except for research exploring forms of depression which only effect women (i.e. post partum depression) , there has been little systematic research into the causes and treatment of depression, specifically in women. However, the ce have been indications of greater interest in this area vdthirj the past ten years. H^enewed interest has, in part, been sparked by the ad-vent of modExa-£^ mi-ni.sin..a,nd-J.emlrjist critiqj.ies of the mental health sys-tem ' s understanding .of female.psychology and its t:cea.tiiisn±....-o,fa-ixortbled women. Feminists have 10cussed their attention on analyzing women's role in modern society and on explicating the effects which the feminine role has on the emotional difficulties which many women experience. Feminists have challenged many commonly accepted assumptions about the nature of femininity and have attacked the mental health community's acceptance of this traditional view of women. They have criticised treatment pro-grams which are based on what they consider to be a distorted view of women and have proposed alternate ways of helping emotionally troubled women. vfhe feroinist_jchallenge to the mental health system has special rele-vancy for the field of depression, the most common of all of women's psychiatric complaints. Sfie_challenge has raised many important issues for mental health practitioners. has focussed attention the the links between women and depression and has raised questions about the ways in which practitioners analyze and treat depressed ywomen. i^ fhis ..paper is ar. attempt to examine the links between depression and -women, and to look atthe issues involved, in understanding and treating ythe_prQ.bl.em. The first^section examines the problem from the clinician and clinicial researchers point of view. It looks at depres-sion as a psychiatric problem. HOK prevalent is it? How is it defined? i.'hat causes it? How_can_H. be treaiad? The issues which arc dealt with in this section are: findings in the research on prevalence of depression, with particular emphasis on findings of female preponderance; tttf the definition of clinical depression, the assumptions on which the definition rests .-id the problems involved in defining depression; and yzf an examination of the 4 dominant explanatory and therapeutic schemes related to depression (organic, psychoanalytic, cognitive, and behaviorist theories). The emphasis in section C: is on critically analyzing the ma-jor underlying assumptions which each theory makes in constructing and treating the depressed woman, The research evidence on which each theory rest is examined. Feminist and other critiques of the major theories of treatment approaches are presented. looJi£_ilt' t h e feminist view of depression and women. Issues which are examined in this section are: a) feminist analysis and critique of the mental health community's treatment of emotionally troub-led women; b) the feminist analysis of women's role in society and the relationship between women's role and depression; c) feminist approaches to working with depressed women. The focus in this section is on expli-cating the underlying assumptions of the feminist approach. Relevant research findings are presented as well as critiques of the feminist position. The final section suimn^izes.»JJ^ socim which the author sees as significant to social workers who are working with depressed women. This section Includes a discussion of some of the conclusions which the author has reached about working with depressed women in this society, and sugroations for what the author hopes is a more integrated approach to the problem. Vn order to facilitate the pnalysis..jaf„the..j)iaiQ,r, is„sue§ and approaches to working w3,th flfiprfissed-KoroeR, a,..case example is presented in Section I c/-.^  ™ and used throughout this paper. The case study is based on Sylvia Plain's novel The BelWar which chronicles the life of Ester Greenwood, a 20 who tecor.es seriously depressed as she attempts to deiPno hor car: IP.aPP ly as .;•. voir.an and artist in 20th century North A m ef i C a n T h i s semiautobiographical novel can be taken as a do-cument of Plath's understanding and explication of what it means to be a depressed woman. As it was written by a woman, who 'both endured and ultimately succumbed to that experience, it seems an appropriate choice for a case example and one which provides some insight into the desparate struggle which depressed women so often endure. The problem of depression and women Is complex, and there is con-siderable disagreement among theoreticians, researchers and practitioners about how it can best understood and treated. tgfie lack &f clarUjuin thg_field and the .conflicting approaches to the problem have implications f o r t hlJ^j?^o_seek help from the mental health community. ''As social workers, we are.intimately involved in the.problem of depression and women. l4i.a_pXQ£essioar we often, stand at the intexfaca.^ he;t^ aa.n the . wo.- ^ 4 ^aJL^jihin, her social world.>he the psychiatric treatment world. fcecpuent-1XiJLLLs social workers who' help a woman embark on her career as a m e ^ a l P a t i e n t • liLis often.. th^woman 's mental state, and to extract -relevant details of _ h er piLife for presentation to the treatment community. • In some set tings, v:e. may he e gaged i:hibcj,:;i;:,'n,:;.;. .itself. ~ We__are often involved, in the. social ramifications...Qf for the. woman and her family, ^,'e m&ZJ*;, ask,(?d 'to practical or emotional, support for her, and on some_occasians^ w.s are responsible for placing, her children in foster ^njie? extensive professional involvement .with depressed women, It is., impoxtant...far -us to be sensitive, to the many issues, in .the and as a profession, to approach this problejn. with. a? broad and comprehensive an_understanding of it as possible. It is hoped that this paper will be helpful in adding some clarity to this complex and difficult problem. -6-I. The Clinicians and Clinical Researcher's View Issues and Problems j A. Prevalence I W S b 6 g i n a n e ^ a t i o „ of the clinician's view of depression by | examining findings in the research on prevalence of depression. Questions j of prevalence- have been addressed by epidemiologists in their attempt to | isolate the numerous factor that determine the frequency and distribution j of this psychiatric disorder within the general population. Evidence of j the prevalence of depression generally comes from 4 sources. The primaxy j source is clinical observation of patients who come for treatment. Pre-j V a l 6 n C e 1 3 alS° d e t e r m i n e d f r o m immunity surveys of individuals not in j treatment; from studies of suicides and attempted suicides; and from | grief and bereavement studies. (Weissman and Klerman, 1977) Data -from patients in treatment is always considered a n underestimate of gene-| ral prevalence in that treatment is contingent on availability of re-j sources, financial, motivational and other health care factors, j ^f^i£indings in the epidemiology , of depression can be summarized ! ^ ^ ^ i j i f e s t i . a t ^ a i ^ o ^ a n incid,^of depression' | ln_^eNorth ^ ^ o a n population is approximate^ 3 to ; % cf the •g^l^epresseajppulation, it is estimated that 1 in 5 are treated by ajoctor; 1 in jo are hoS£italized; and 1 in 200 commit suicide; 5) av^^various.estimates, the lifetime, expectancy for anyone - the P^'laticn of boac,:::clinically depressed is about 10^; tf the risk o^becoming depressed is about 10 times greater than of b e ^ Z ^ z o -Phrenic; f) an individual who suVfors from r.cu-r.nt mani^depxassive episodes can expect to spend about 5 to 6 yosirn of he, life In a hospital ^^e^eriences_her_ first .clinical depression at 25 and lives, pntfl she is ?0 years .old; 6) finally, the death rate for depressed women is twice the normal rate, and the death rate for depressed males is three times the normal rate. (Lehrnann, I97I) In examining the demographic variables which are significant in depression, we find that the^ingular most striking characteristic is that women^preponderate at a ratio of about 2:1. (Silverman, 1968, .Lehrnann, I97I, Gove and Tudor, 1973, Wei sr.,nan and Klerman, 1977) ^his • fishing is remarkably,consistent throughout the literature. Female pre-ponderance is established in clinical observation and treatment and in community surveys. ^ s f i r ^ J ^ . ^ in.cross cul-i n I n d i a w h e r e depressed males preponderate. (Lehrnann, 1971, Katz, 1971, Weissman and Klerman, 1977) Within the overall statistics of women in treatment for mental 111-'ness, it has been found that nearly 60% are classified as having either •affective psychosis or neurosis. (Smith, 1975, Chcsler, 1973, Gove and Tudor, 1973) Gove,has reported a higher overall rate of mental illness in ^en compared to single, divorced and widowed women and men. 'In a recent study, Brown found that working class, married women with young children had the highest.rates of depression. (Weissman and Klerman, 1977) These findings would all: suggest that a North American's risk of beco^^depressed increases simply by virtue of being born female. Her risk of becoming depressed^ becomes., even higher if she is married and caring for young children. Another demographic finding of epidemiologists is that the likelihood up O'yxdJUtesr'fJs Cj - o -; of becoming depressed increases with age. (Lcnmann, 1 mfWeissman and ^ L - — - 3 ^ — — 1 1 0 © d i - t r - international , trend .towards increased women, (V/eisman. .andJlerrnan, 1 9 ? 7) Depression ; has also been found to be more common in industrialized societies than ; primitive cultures, more common in whites than blacks, and more common • in the United Kingdom than in North America.(Lehman, 19?1, Xatz, 19?1, Zubin, 1971) All of the findings cited above appear to be quite straightforward • and factual. However, beneath this objective facade lie a number of ma-: jor issues in the field. question .with Khich...epide.miplogists ; struggle is whether the differences or trends which they have discovered : within the population or are artifacts as a re-J sult^methods of gathering or interpreting data. As Dorothy Smith I points out, all statistical information is produced by a variety of in-; dividuals interacting in different -ettir,CT nr^ t> -etumg, and eacn number which is re-s' ported,in reality,represents a series of • , fa—ICS o.L absi,rac o.i.on and judgements about ; an Individual and her problems. (Smith, l97l) To put it more concisely, | i n d l V i d U a l' S ^ e a d o not simply fit into the categories which the statis-j tics represent; they must be fitted into those categories. As a result, j there are a variety of disagreements within the field about the meaning I °f statistical findings in depression . | These disagreements can reflect differences in how the categories of ! depression axe defined or disagreements about how to interpret certain behavior as fitting into one category or another. More specifically, clinicians may disagree about what kind of behavior to accept as part of -1605b-dsprer.r.ion r.nd about how to evaluate the subjective reports of their patients. In examining the issues in the statistics of female preponderance, it is clear that each issue reflects a concern about the effect which dif-ficulties in the definition and diagnosis of depression have on -the produc-tion of mental health statistics, 'Ueissrnan and Klerman's article "Sex Dif-ferences and the Epidemiology of Depression" summarizes the issues and evi-dence in the field. Certain investigators are concerned that female proponderance does not reflect real differences in the rates of depression but rather is the result^ of the fact that: (l) women weigh events as more stressful than men which leads them to report more symptoms; (2) women report more symptoms than men because it is socially more acceptable to them to do so; (3) women go to the .doctor more often than men and engage In more help seeking behavior. I,'hat is being called into question is the reliability 0f using patient's subjective reports in the diagnosis of depression. An alternate- explanation-for fc-.male preponderance would, be that women complain more than men and that their complaints are, therefore, more frequently heard, diagnosed and counted in the statistics of depression. VJeissman and Klerman point to studies by Paykel et.al. (1971) and Cannon and Redick (1973) which indicate that th difference in the way women and men"weigh stress, not are there diff in their perceptions of the social acceptability of psychiatric problems. As community surveys also report a female preponderance, Weissman and Klerman conclude that there is no evidence to support a questioning of the reliability °f the statistics supporting female preponderance. * -iere is no : erences Whother as sue- in the statistic:; of ..female,, preponderance ..is., the. idea that men.,us.e .alcohol to mask depression and are, therefore, seen and statistically counted as alcoholi c and not, depressed. *-fhis theory ,.js based on findings that men in.,.treatmenLforalcoholisin have symptoms of depression, however, studies, in this,. axea have been unable to. deter- ^ mine whether jth.e symptoms of depression. preceded the use of alcohol or c°n sequence of, alcohol use. Weissman and Klerman, therefore - \ > V ' conclude that the links between alcoholism and depression have not vet been established and must await further proof. It must be noted, however, that the issue raised above is related to how depression is seen or defined, and that modifications in the instruc-tions of how clinicians are to diagnose depression would alter even the most well established 'fact' that females preponderate. Thus a set of instructions which told clinicians to view alcoholism as masked depres-sion would virtually eliminate the sex differences found in the disorder. ?indi.ng tha.t does not seem to be alterable is that women, are S^ .nJ„.._di-a.iri0Sed-and treated for depression by the North American health ca£® system twice as often as men and that when women do'come in contact , 1/ with the,..mental_lie.alth system, they are fitted into, affseti-ve-and. neuro-tic disorder categories 60% of the time. ' As we have seen in the above, the major issues in the epidemiology of depression revolve around problems in the definition and diagnosis of the disorder, felljjuasiions of prevalence ultimately hinge on,the .que.s-ttffl, Pf hQW-xlijoical,...depression is defined. ''The criteria which are used ^determine what kind of behavior will be taken to indicate that an individual is clinically depressed will greatly, effect the prevalence -12-of depression within the general population. All researchers agree that the definition and diagnosis of depression is one of the most trouble-some issues in the field, lie must, therefore, turn to this issue in order to gain a better understanding of the sources of the difficulties. B. Issues in the Clinical Definition and Diagnosis of Depression There is no other issue in the field of depression which is more difficult for the researcher and clinician than the question of the de-finition and diagnosis of the disorder. In opening a symposium on de-pression in the ?0's, Ronald Fieve state, "It might he said that the priniciple reason for our lack of understanding about depression has been the lack of agreement in diagnosing it. Furthermore, our lack of of agreement in diagnosing it may be based on conflicting sets of in-structions that have been handed down to us by psychiatrists." (Fieve, 1971, P-l) Similar sentiments have been echoed by many others in the field. Indeed, Silverman states that, "It appears that the clinical diagnosis of manic-depressive psychosis and other depressive conditions is made no more consistently than would occur by chance and that observer varia-bility is the principal element in diagnostic, discordance." (Silverman, 1968, p. 24) In approaching this thorny area, issues in the definition and diagnosis of depression will be examined as representing disagreements about how to construct the person as depressed and what meaning to give to her problem. Furthermore, It will be shown that many of the issues in the definition of depression as a clinicial syndrome and mental Ill-ness are actually embedded in issues in the field of psychiatric classi-fication and that the disputes can be taken to represent difficulties in the way psychiatric classification is organized to deal with depression. basic_PRQ.bJem. in. the...definition of clinical depression., is the fac -Vi that feeling depressed, sad or gloomy is a verycommon human experience. We have all probably experienced times in our lives when we felt hopeless, apathetic, dejected and questioned whether the struggle was really worth it. These feelings may have emerged in us after some loss, disappoint-ment or during a period of uncertainty and agonizing self evaluation. As these feelings are common and considered a normal part of the human experience, it is relatively easy for us to empathize with some who tells us that she feels depressed. We feel that we intuitively know what she means when she uses the term and usually don't requite an elaborate definition. Psychiatry, also recogniz.es that depressed feelings are common, ^foteM*'M*1 ' ' ' (jUjuu-vx^ normal and appropriate..feelings^in humans and as such do not constitute a problem whjshJ&JJg.within the. scope of aits .expertise. '-"'What It seeks to address itself to are those feelings which fall outside of the. boun-dary_ of normal f eelings and constitute, a. psychiatric disoxd.er or mental i™ n e s s" t%_a.result, in defining depression, psychiatry attempts to -identify those features which distinguish depression as a psychiatric disorder from its normal counterpart. 'However, In trying to define clinical depression as distinct from a normal mood state, clinicians arrive, at their first set of definitional dilemmas. ATs^clinical de-• pression best viewred as an intensification of a normal mood or a quali-tatively different experience? y'-Does It represent a biological derange-> mer^2fi"thin the woman, an illness of psychogenic origin or a response t0 !*S'hould it be defined as part, of a continuum of affective res--' ! P o n s e s which spans from normal-no o.d to--a complete- withdrawal, from .reality, ~ 1 > or is it best understood as a number of discrete illnesses or syndromes each of which reflects a qualitatively different state? Despite the many efforts to resolve these definitional problems, the problem today is essentially unresolved and "continue(s) to defy our most energetic attempts at resolutions." (Zubin, 1971, p. 7) Zubin notes that part of the difficulty in resolving the problem of definition lies in the nature of depression itself. He states, "The reason for"this slow progress Is not a lack of methods and techniques but rather that the basic feature of depression is an inner feeling of sadness and dejection; the rest is epiphonomena. As we have been unable to determine the cause for this inner sad-ness...., we are left with a subjective intuitive feeling which manifests itself, If at all, by verbal report and indirectly by such different types of behaviors as tearfulness, diminished ap-: petite, psychomotor retardation and a host of others. Added to this basic problem, we have such additional problems as deciding whether depression Is a transient mood state, a sympton, a syndrome, an illness or a combination of all or some of these. " j (Zubin, 1971, p. 7-8) ; Zubin also points out that efforts to resolve find answer these de-finitional questions will depend on the vantage point which is taken in approaching the question. Thus, the researcher may approach the question < by looking at those aspects of depression which he finds amenable to measurement or objective assessment, adopting, a speculative approach which allows him to test a wide variety of hypotheses. The clinician who Is charged with alleviating the individual's actual suffering, will probably want to decide . which definition will be most helpful In treating the patient and relieving her distress. His role may not afford him the 1 opportunity to speculate on definitional Issues, as he, in practice, must ! act. While he may recognize the the whole definition of depression pre-. sents serious problems, his role as helper will force him to make.a series -16-of decisions about how depression will be seen and treated. This role must lead him to act on the basis of vague and incomplete knowledge as .^/>/pJ04i he decides to prescribe medication, to undertake psychoanalysis, to ad- ij _ minister electroconvulsive shock therapy. In part, his role calls on him to act as if he understands the nature of clinical depression as it expresses itself in the individual patient. His task is to fit what she presents as her problem with what he understands about depression, and to treat her on the basis of that understanding. As the clinician is faced with the task of diagnosing depression within an Individual patient, the Issue which must be addressed Is how he arrives at that diagnosis. In order to gain some understanding of this process, it is important first to look at how psychiatry defines and classifies clinical depression for those engaged In the practical task of diagnosis. While it should be noted that psychiatry is not the only discipline which deals with and treats the depressed woman, it is important to focus on psychiatric definition and diagnostic process be-cause psychiatry, more than any other discipline is authorized by North American society to deal with and treat depression as an abnormal be-havior, and it accepts major responsibility in this area. .As we examine the ways in which psychiatry diagnoses and classifies clinical depression, the focus will be on the underlying assumptions 'upon which the diagnostic process rests. ; j^ Fbere is agreement among psychiatrists that "disturbed feelings are generally a striking feature of depression." (Beck, 196?, p.6)Hence, ! depression is classified in psychiatry as a primary mood disorder or an -17b-affective disorder. ClinicalJiopxessicm.JLs "believed to manifest itself throug]x.-au-vaxlety._Qf affective., vegetative and cognitive symptions. Beck summarizes these as follows: "l) specific alteration in mood: sadness, loneliness, apathy; 2) a negative self concept associated with self reproaches and with self blame; 3) regressive and self punitive wishes: desires to escape, hide or die; 4) vegetative changes: anorexia, insomnia, loss of libido; 5) change in activity level, retardation or agitation." (Beck, 1967, p.6) These traits taken togetlier are believed to constitute the sympton complex or syndrome of clinical depression. Within this broad, description, clinical psychiatry makes a number of sub classifications.• The first is to estimate the intensity of the af-fective state (mild to severe). Clinicians may also classify the depres-sion as either a reaction to psychological stress or conflict (reactive) or arising from some internal or biological state (endogenous). Tied to this question is the idea that a depression may represent a neurotic con-dition (one which implies that the Individual maintains contact with or-dinary reality) or a psychotic condition (one which implies that the in-dividual has lost contact with reality). - It must also be decided whether the depression is marked by mood swings (bipolar) or a singular depressed mood (unipolar). An estimate must be made of whether the depression con-stitutes the woman's main problem (primary) or whether it is secondary to some other major problem. Finally, an attempt will be made to pinpoint the depression as one of a series of discrete clinical entities i.e. manic depressive psychosis, psychotic reactive depression, neurotic reac-tive depression, etc. Such classification assumes that-each type of -18-depression can be distinguished from all other types by a number of dis-crete signs or symptoms which are consisten throughout the population. Furthermore, these types of depression are thought to have a specifiable onset, duration, and outcome and to be amenable to certain forms of treat-ment. (Beck, 1957) In its most ideal and simple form the process of psychiatric assess- U^JCfij^  fiW^L ment, diagnosis and treatment of the depressed woman should proceed along '//£/"/ '-/ . H. pp&Wli the following lines. The depressed woman is interviewed by the clinician and in the process of the interview responds to a series of questions a-bout her emotional and physical state and her tKought processes. KJn the . basis of her responses, the clinician makes a series of judgements which seek to match her symptons with known clinical syndromes. 'The discrete /j •'/ - ' •". • clinical entity which best fits her condition will determine her diag-nosis and treatment will be selected on the basis of th: diagnosis. 1 ! This entire process rests on the medical model..of ..assessment, diag-: r nosis and treatment. The medical model itself rests on a number of as-sumptions. A key^ssumj^tion which the model makes is that symptoms are manifestations of an underlying unitary disease process which occurs /•. within the individual. 'Symptoms are assumed to provide clues to the nature of that underlying process. -'•The healer's job is to correctly in-• ( terpret those clues...on. the basis of known facts and diagnose and treat the underlying problem. If he has correctly assessed and diagnosed the • ( problem and an effective treatment Is known, the .patient will be cured - and their symptons will vanish; . Therefore, accurate assessment "and di-• aeno®is a r e essential for proper treatment. As the medical model presumes that the disease rests within the in-divid£a1' t h e symptoms of the disease will not be greatly affected by en-vironmental or cultural variables. Hence, smallpox is assumed to present the same clinical picture regardless of differences in sex, race or cul-ture. T h i s .inode.Lhas, of course, served medical science well where the assumption of an underlying unitary disease is more readily verified by observable evidence. It is, however, open to more serious criticism when it is applied to emotional problems and problems which are considered to be psychogenic in origin. ^ Homas Szasz Is one of the most outspoken critics of the uno of the medical model in psychiatry. ^He points out that the analogy between physical and mental illness is tenuous. Under-lying psychopathology must be assumed as it cannot be proven by direct evidence. Symptoms must be taken to represent clues to an underlying illness process and that illness must be assumed to rest within the in-dividual. Once these assumptions are made, the search for clues is turn-ed inward to the intrapsychic life of the mentally ill or depressed woman. In addition,l'iih!LJaod^Lplac_e£^ role of arbitrator or judge of what is healthy and normal behavior and what is sick behavior. His views of normalcy and proper adjustment to life thus become very im-portant in the diagnostic process. -'Furthermore the...iaodeLimplies.a deter^stic and universal view of the nature of an indiyidualls.psycho-logical development, and therefore, is not sensitive to the role which the^in^yidual's^interpersonal relationships and culture can have on the problem. (Szasz, I96I) -20-If we consider the problems involved in the diagnosis of depression, it is clear that the diagnostic process may be effected by a variety of' A ' clinical expectations. The diagnosis may be affected by whether the wo- ' ' ' m a n Wh° 1 3 ^ts into the dominant psychiatric model (stereo- ^ type) of the depressed patient (a white, middle aged, middle class, mar-ried female). This stereotype which was determined to be important as • a result of clinical findings can also be seen to influence those same • findings if the stereotype influence thP • jp ajuxuunc^s the clinician's expectations and subsequent diagnosis. The clinician'^ ^ clinician s diagnosis may also be effected by Past psychiatric diagnoses of the patient, m addition, the clinician's • assumptions about what he believes is normal and healthy behavior for a woman in this culture will also influence how he evaluates the patient. V As the clinician has no back up system with which to objectively test his r diagnosis and has no physical evidence with which to confirm it, his diag-nosis will be highly subiective '-pW - n , J uojecti\ -sain, as .?mith has pointed out, patients rdo not just fit into categories; they must be fitted into them. All of •the above would lead to the wide differences i, the diagnosis of de.res-'sion which are reported in the literature. i that^hatj^„cllfliclan diagnoses . in. the patient will, 1 ... Aet.exmine£L..hy.. his., expec tat ions, then, we can also assume that !,hiS * * causes depression will influence the signs he looks f0r-in..the.Patient and what he finds . , ^ to t h e ^ s , example of Ester ^ ~ ^eenwood the main character in Sylvia Plath's novel T h e M U a r . To fiefly summarize the known facts in Easter's background, we find thet at -21-the onset of her depression, Ester was a 20 year old college student who was attending a private girls college on a scholarship. She was an excellent student, bright, creative and well liked by her peers. She had^  an active social life and was involved in student affairs. She wanted t0 a writer and poet and had several poems published in a woman's magazine. Ester was an only child, raised by her widowed mother. Her father died when she was 8 and her mother, with whom it appeared she got along well->. t a u5 h t in a community college in order to maintain the family's middle class life style. Ester had no prior history of depression and had no contact with psychiatry prior to this depression. Immediately preceding her depression, Ester had won a literary ' P r i z e and spentja. month in the summer as a guest editor for a leading - magazine. She returned to her New England home to prepare for a sum-mer school course, but found that she had not been accepted into the : course. She remained at home for the rest of the summer. Quite rapidly, she began to feel sad, gloomy,apathetic and lethargic. She was unable to sleep, eat cr read and had little hope for the future. • --^^oT^would Ester's condition be defined and diagnosed? If we exa-mine the question of whether her depression represents an endogeneous , , U. , or a reactive depression, we find that a clinician who assumes that de- ' pression is primarily an organic disorder caused by chemical imbalance , - ' '{J | could find ample evidence to support his view in Ester's case. He would point to a successful and well adjusted young girl, with no prior i mental history who become suddenly and rapidly depressed for no apparent reaj .son. While it was true that she had suffered nn academic setback in being rejected for the summer course, this minor event would not ac-count for a major depression. As a result, from this point of view, the depression would be clearly classified as endogeneous, and the case would be seen as providing evidence for the validity of that construct. However in reviewing the facts of the case, a clinician, who assumes psychogenic causes for depression, would also find ample evidence to support his theory. He would point to the psychic shock which the rejection from summer school had on Ester, the blow to her self esteem which she suf-fered, and the childhood loss of her father as prime indicators that the depression was reactive. Thus the diagnosis of reactive depression would be made and again, the case could be seen as providing evidence for the validity of that construct. ±nt inciting this example is not to decide which causal theory best explains Ester's condition, but rather to show that both the organic and _ the..psychogenic theory are plausible and the facts of Ester's case can be fitted into either theory, 'ihe way in which the actual fit is ma£liho1! h e r dePression would be defined and diagnosed) would at last P!fl^lly--dePend 011 t h e Position which the clinician adopted about the etiology of the disorder. To sum up, we can see that the definition and diagnosis of depres-sion as a psychiatric disorder depends on a number of major assumptions. The fundamental assumption is that depression represents an underlying unitary psychopathology which rests within the patient and expresses it-self through a complex of symptoms. This central assumption has been -23 questioned by Szasz and others, who point out the tenuous nature of the analogy.between physical and mental illnesses. The process of diagnosis rest on the assumption that the underlying psychopatbology can be dis-covered through the symptoms and classified as one of a number of dis-crete clinical entities, by matching symptoms with categories. However, it has been argued that such a classification system fails to recognize the complexities of the diagnostic process, which relies on a tremendous amount of interpretation by the clinician. Clinical interpretations may be influenced by many factors including: the clinician's assumptions a-bout normal and abnormal behavior, his clinical stereotype of the de-pressed patient, his exposure to previous psychiatric diagnoses of'the patient. Finally, it has been argued that the clinicians assumptions about -the etiology of the depression would also have impact on his de-finition and diagnosis of the disorder. C. Assumptions and Issues in the Etiology of Depression ft A$ we have Sf?en>..the in which depression is defined and diagnosed G&OU POJ.K1 understandings, of the causes of clini-caldepresssion, explanatory theory wilL. provide him with instruc-aoout what to look for in the depressed woman, how tojniterpret what he sees, and how to treat the problem. )fs with all otherj^ssues^in depression, there is no concensus within the field as to •v;hicb theory of depression best explains the problem, nor is there agree-ment^bput__yne_mosi effective method of treating the depressed indivi-duaL- (Zubin, 19?1, Beck, 1967, Silverman, 1968, Beissman and Klerman, 197?) The question of causation has been aproached from many points of view and reflects the wide array of opinions and controversies in the field. In approaching the question of causation or etiology dominant _of_d_.epression will be examined. They are the organic, psychoanalytic, cognitive and behavioral theories of depres-sion. H5ach_ of .these ..^ theories will be briefly outlined and analyzed. The analysis will explicaterthe.major assumptions on which each theory rests; ^ he degree to which the theory accepts the underlying^assumptions ofJB:e modi cal model; what position, if any, each theory takes about the nature of femininity and the relationship of women and depression; the evidence which is cited to support each explanation;^e treatment of.depress.;or which each theory can be taken to support; a^ .d the.role, which (;ach theory assumes the therapist should take vis a vis the woman. Finally, major criticisms of each theory will be reviewed and discussed in relationship to the treatment of depressed women. -25-^gaiii^ Theories of Depression As we have already seen,a clinician ,who„assumes an organic, cause fo5^i®?£e£sionJTOuld.._see in Ester Greenwood's situation some of the In-dicators of that disorder. He would note the lack of stress factors or trauma which preceded the depressive episode and would probably conclude that the depression was endogeneous. His theoretical position would make_the assumption that the cause of clinical depression can be found M 0 C h e i n i C a l ° r genetic makeup of the depressed woman. An organic theory of clinical depression assumes that the depression is caused, by., a biochemical^ imbalance within the individual or is the result of an in-herited, genetic predisposition to the disorder. Organic_:theorists work within the medical model and more than any other-group fit most appropriately within that model. This is because organic theorists and researchers, unlike their psycho -lytic collea-gues, do not rely on the assumption that illnessses of ihe r,-lr.d a n d emo_ tions are analogous to illnesses of the body. They_attempt_to .find • th® .eraotional„st.at.e. ,o.f depression, within the actual bio-logical substrate...of the depressed individual. Like the physical sciences, their work relies heavily on the scientific method of inquiry, as theo-rists attempt to find objective, verifiable evidence for their causal hypotheses. stC // r^t-0^-K)rg^Jheoi:iJt§_a.ddress the issue of female preponderance in de- C*6*"1* "o pre.s.sion..and .suggest two main hypotheses to explain it. The firshypo- /JffA**^ *" " thesis..i^tdepression can le linked to changes in female .endoQXine physi ology. ^ TJieyuanieja^greater prevalance of__.depression in women •i(J , f o U m j a Q ^ s ^ ^ , menopause ^ d u r i n g , ihe. .PrP^struai period, and ^ypothosiz^^^xdil^^einale. hormone may be implicated in mediating the.depresgion.^e second,main theory to explain the link between w ;omen t h e hypothesis that there is a genetic, factor operating in Repressions j s sex-linked to-thai chromosome. (Vfeissman and Xlerman, 1977, Winokur, 1971) As stated above, organic theorists seek objective, verifiable evi-dence for their theories and there have literally been many hundreds of studies investigating organic factors in depression. Among the biological factors which have been explored are the effects of: blood glucose, acidity and alkaline reserve, serum calcium and phosphorous nitrogenous substances, lipiodal substance, chorides, steriod metabolism, thyroid function, blood pressure reactivity, salivary secretion and levels of brain activity (EEC) in sl4ep and state of arousal. (Beck, 1967) No attempt has been made to review all the findings on organic factors. Instead,summaries of available evidence presented by Beck(l967), Peissman and Xlerman(l977), Cole(l97l), Marshall (1971), and Shepard(l97l) have been relied on in reviewing the evidence. Beck finds that experimental tests of organic hypotheses suffer from a wide number of methodological problems'; Among the sources of error which Beck cites are; diagnostic methods of dubious reliability and validity; inadequate, heterogeneous samples; inadequate control for varia-bles such as sex, diet, age, state of nutrition and activity level. Beck finds a consistenPpattern in depression research in which early positive findings are not confirmed by later, more careful studies. He reports that there is some consistency in positive findings associating depression with changes in sleep ERG patterns, sodium retention, and excessive levels of steriods. However, theresultson steriod levels are not specific to de-pression "but rather appear to be associated with many different states of emotional arousal. Sodium retention studies are limited in number. In sum, Beck finds the evidence for organic causation of depression to be incon-clusive and in need of further and more tightly controlled research. (Beck, 1967) ftm Mmwpvd q Ikc-^fa/^ ffawf Ma^Jctfy j&nj&dwd Mc xfauj?/ Within the organic theory of depression, considerable interest has d afi&dX/Mtrt'^ irf . J, n ffLtdUfittGti to * been shown xn the calecholamine hypotheses of affective disorders and in ^HiKM fa' the efficacy of antidepressant medication. The calecholamine hypothesis makes the supposition that depression results from a depletion of the ac-tlve supply of norepinephrine within the depressed Individual. ff>e two maj^r antidepressant medications, the MAO inhibitors and tricyclic anti-deP£®ssants'_,are b o t h thought to act to increase the availability of nor-epinephrine. (Beck, 1967) Therefore, ••.:porimenters, attempting to vali-date this hypothesis have directed their attention to studies of the ef-fects of MAO inhibitors and tricyclics on experimental animals and studies of the efficacy of these antidepressants in humans. Results from studies of the efficacy of antidepressants in humans have found their effective-ness to be limited when compared to the use of placebos. (Cole, 1971, Raskin, I971 , Marshall, 1971, Shepard, 1971) ^  reviewing the findings on^the^antidepressant medications, Cole finds that, "on the average, the superiority of these.drugs over placets is not impressive, particularly in the case of hospitalized patients with depressive illnesses." (Cole, 1971, p. 82) Evidence supporting the catecholamine hypothesis which is derived from animal studies must be viewed with some skepticism as the results may not be conparable with human subjects. (Beck, 196?) While tests continue to be made, it must be concluded that at present this hypothesis has not been validated. ?\A review of the available evidence to support organic hypotheses explain female preponderance finds that the evidence is also inconclusive. Weissman and Klerman conclude that the evidence shows that "the pattern of the relationship of endocrine to clinical states is inconsistent" (Weissman and Klerman, 1977 > P- 106) and that supportive evidence is not sufficient to account for the differences in prevalence which have been found. The evidence which is reported on the possibility of X-linkage and depression in women is conflicting, and based on small samples. Weissman and Klerman conclude that "evidence from genetic studies is In-sufficient to draw conclusions about the mode of transmission or to ex-plain the sex differences. (Weissnan and Klernan, i977) From all of the above, it can be concluded that the available evidence in support of a biochemical or genetic theory of the cause of depression is inconclusive and that further proof would be needed to con-firm such theories. Theories of organic causation are generally taken to support thera-peutic intervention which acts on the biological substrate of the depressed individual. Available chemical treatments of depression include the use of tricycylic antidepressants, MAO inhibitors and lithium carbonate. The other major physical treatment in use is electroconvulsive shock thera-py, which has been found to offer rapid symptomatic relief in some cases c~ j of severe, retarded, endogenous depressions. (Cole, 19?l) Physicians who prescribe antidepressant medications generally use them to treat individuals with endogeneous depression, where the cause for the sad feelings is not readily understood by the clinician. While this may be taken to be a rule of thumb, it is not universally accepted. (Shepard, 1971) Lithium is used in the treatment of manic depressive disorders and is considered the medication of choice for that disorder. (Cole, 1971) Thus, the clinician who adopts an organic causal model for at least some forms of depression attempts to differentially use the available treatments to maximize their effectiveness. Of course, all these efforts will be subject to the inconsistency of diagnosis that plagues the field. As we have seen, one man's endogenous depression is another man's reactive dis-order is another man's manic depressive psychosis. Beyond this diag.ostic problem in the organic treatment of depression, is the question which lsoraejesearc;hers raise about the efficacy of anti- ^ M u f ' \ depressant rotations. ^Cole beUej^s Jjmt J.f^y^.^ptldepressants were ''italiM> ; 811-taken off the market they would not really be .missed.. (Cole,._ ^ ePard questions..the widespread use of these drugs, in view of findings ' 0^i i m i t e d. efficacy, and the belief among practicing physicians that antidepressants have established.,that.depression..is a...physical illness «'^iSll^tfeata1316 by physical means. (Shepard, 1971) In view of the limited success of antidepressants which the literature reports, one ; must question why they are in such widespread use. ^Shepard suggests that the reason for their popularity rests in the physician's role, his t exP^£t^t^_ns and his interaction with the patient. He cites the -30-foliowing_remark by an eminent contemporary, physician: "If you admit to yourself that the treatment you are giving ! is frankly inactive, you will inspire little confidence in your patients (unless you happen to be a remarkably gifted actor), and the results of your treatment will be negligible. But if you be-lieve fervently in your treatment, even though controlled tests show that it Is useless, then your results are much better, your patients are much better and your income is much better too ... (Shepard, 1971, p. 107) So again, we can see that the physician,in his role as therapist, is expected to act as if he^junderstands the nature of clinical depression expresses itself in the client, and that his assumptions will in-fluence the therapeutic process. Researchers engaged in clinical drug trials also recognize the importance of expectation on the effectiveness of antidepressants, and find that placebos can be seen as effective in ^study by Schapira .showed, that yellow placebos were found to be more effective than red or green ones in treating, de-pression. (Shepard, I97I) Of course, organic theories of depression cannot explain this effect, they must simply acknowledge it as one of : the many confounding variables with which their experimental studies must ; contend. In evaluating the organic position on depressive disorders, it is important to look at both organic theories and the supporting evidence as explanations of the etiology of depression and at the application of ' arL°rganic- ^ g^ -gl j:Q..,the. treatment of the depressed woman. Organic theories of depression rest on an assumption of a biological j cause for the disorder. As we have seen, the evidence upon which they rest is largely inconclusive. There is some support for the notion of I ' increased biological suseptability but no clear understanding of the mode -31 -of transmission. The organic theories do not deal with nor explain many findings in the area of depression. Among these findings are: cultural differences in the incidence and symptomatology of depression; higher rates of depression in industrialized society; age factors in the incider of depression; higher rates of depression among married women; the the ef-fect of life stress on depressive disorders. What these explanation omit is an understanding of the depressed person in her social world. Shepard and others acknowledge the importance of social factors and most researchers expect that a comprehensive understanding of de-pression will have to address social facotrs. There is also an acknow-ledgement that current biological theories are undoubtedly overly sim-plistic . (Beck, 1967) In a sense, what organic researchers aim at JLs not a complete understanding of depression but rather a more comprehensive understanding of biological factors in its etiology. While they do make the fundamental assumption that depression will have a biological com-ponent, they seek validation of this assumption in experimental studies. As such, their work falls within the more demanding framework which scientific inquiry requires, ^owever, it must be concluded that despite a considerable amount of research, "there is still very little basic kflowledge_of_the biological substrate of depression." (Beck, 1967, p. 125) '' ^critically evaluating the application of the nygarnn. model to the treatment of depressed woaen, it seems clear that many of the un-certainties ' which are acknowledged by theoreticians and researchers cannot find expression in the actual treatment situation. i>fn his inter action with the woman, a cllnica;: who prescribes drugs or .EQt is called -3Z-uP°n to....act o n thS-pxcsumption that these treatments will he effective. It is a presumption that both he and the patient have a vested interest in believing. (Shepard, 1 9 7 1 ) - c a u s e . . £ o x . . t h e . p r o -blem of depression, the clinician,leads the. patient to see her depression as^  caused by something in her physical nature rather than by her life si-tuation. J^fo_th£j2xtent that the treatment is seen as., and experienced as helpful_by the patient, ^ both she and the clinician will.be satisfied. tajug therapies and BCt are clearly the most simple of the available treat-ments for depression, Kand there is much in North.American culture which encouxagesjthe^use of drugs to cure all manner of ai.lm-ents. Drug com-panies spend millions of dollars annually promoting and advertising chemi-cal cures for depression, and encouraging the widespread use of anti-depressants. However, as we have seen, research on the efficacy of drugs and ECT indicates that while such treatments produce dramatic improvement in some patients, they are largely ineffective in treating many others. »se_j>£. antidepressant medication has the interactional consequenceof encouraging many women who feel.depressed to see themselves and Jo...ipok for the. causes of their illness within. ...theirinternal makeup.1- Given,the lack of evidence to support such a simplistic notion, ^ is open to criticism on . the basis that _it diverts the wo-^ J r ° m e x a m i n i nS other possibilities which might better explain her sad and hopeless feelings. I (}, I ii. Psychoanalytic Theory of Depression and Women O W l^inicia^SjWho adopt a psychoanalytic model to understand depres-. a s s u mP t i o n t h a t depression is caused "by intrapsychic con-flietp within jt-he depressed woman. Psychoanaly tic theories of depression have devolved from the basic Freudian., theory of human behavior and develop-ment^ and they cannot be understood without some understanding of the assumptions which the Freudian view of humanity entails. Therefore, this review will briefly outline some of the basic assumptions of Freudian psychology, with special emphasis on the Freudian theory- of normal fe-male development. It will also outline some of the basic assumptions upon which psychoanalytic theories of depression rest. Freudian psychology rests on an assumption of psychic determinism, in that it Kyiews _ hujnan. behavior ,a,s, determined by lawful universal.psycho-logical processes. Freud viewed the human organism as a complex energy system and saw psychic energy as derived from metabolic processes, with body energy and energy of the personality converging in the id and its instincts. He assumed that instinctual energy is quantitative, displac-able and, like all other energy forms, is governed by the laws of conser-vation. Freud also viewed Instinctual energy as subject to transforma-tion and use in a variety of activities. Freudian psychology attempts to discover the many ways in which this basic and limited source of psychic energy can be transformed in 'the course of human,development and tries to outline the lawful process by which these transformations occur. Freud postulated a tension reduction model of personality. He be-lieved that the aim of an instinct is to achieve satisfaction by reducing sources of tension or need. He theorized that the tension reduction drive is guided by the pleasure prinicipal but that drive directed acti-vity is determined by the object of the instinct, which may change many times as psychic energy is displaced from one object to another. Freud recognized that there are times when a drive cannot find gratification in an appropriate object. He assumed that,in these situations, defensive structures are erected to block attempts at immediate gratification. The •dynamics of personality for Freud become the "interplay of these recipro-cally urging and checking forces." (Hall and Lindzey, 1957, p. 44) In this view, human intrapsychic life emerges as an ongoing battle between overwhelming and insatiable hedonistic1 drives and the defensive structures which operate to tame those drives. (Deutsch and Krauss,1965) Fr.eud hypothesized that personality consists of a dynamic tension between 3 main structures: the id, the source of psychic energy; the ego, the mediator between the id and the extern*1 environment and the superego, the internalization of social norms and expectations. His theory of per-sonality is developmental and assumes that the individual must progress through a number of stages to achieve a mature, fully developed personality Stages of development are assumed to be universal and unaffect by differ-ences in language, culture and race. F^eud postulated 4 stages of develop-ment (oral, anal, phallic genital). Each stage Is associated with a dif-ferent body zone which becomes invested with sexual energy. The Oedipal stage of development (phallic) is considered crucial in both male and fe-male development for its resolution is believed to result in the inte-gration of the superego. In males, the oedipal situation can be briefly j,e summarized in the following way. The Infant male forms a love bond lath his mother and is angry and resentful of his father. He notices that females do not have penises and assumes that they- are castrated males, lie fears that he will be castrated by his powerful father for his desire 1 for his mother. He, therefore, identifies with his father to protect him-iseif from castration and gives up his mother but eventually seeks other wo~ fsien as love objects. The oedipal situation is this resolved and the super-feg0 is formed. This relatively direct and simple theory is used to explain "^both male sexual identification and the development of the superego. | Unfortunately, such a simple and direct theory will not work for ifemales. Like her brother, the infant girl also takes her mother as the i primary love object. The problem, therefore, becomes one of construc-ting a series of events which will lead her to give U-P h e r mother and I | form an attraction for her father, so that she, like her brother, can i I 'progress through the oedipal situation. As a result, Freud and his dis-j ciples were particularly Interested in the pre-oedipal period in female | 'development. The theory which was constructed to deal with the corapli-I cations in normal female development can be summarized in the following way. |The young girl has a primary love attachment to her mother. She becomes I''aware of the fact that her brother has a penis and she does not. She ^ believes that she once possessed'.a penis but was castrated. She regards1 herself as inferior and is envious of the male for his possession of a , , 'penis. She recognizes that her mother also lacks a""penis and blames I ::her mother for her castration. She turns away from her mother and to-! wards her father in hopes of regaining the lost object and enters the -36-, oedipal situation. She gives up her wish for a penis and puts in its place a wish for a child and "with that purpose in view she takes her father as a love object." (Freud, 1974, p.23) Eventually, 'her love for her father must come to grief but she abandons her father reluctantly and incompletely. Thus in women, the oedipal situation is never completely resolved. As a result of this series of events, the normal woman fails to acquire a highly developed superego, and is more narcissistic, de-pendent, has lower self esteem, and more inhibited hostility than her male counterpart, for she can never really get over her loss of a penis except , by bearing a -male child. Such is the Freudian view of the normal woman's ; personality and development"., (Horney, 1974) : Freudian theory asserts that the normal progression through the ^ stages of development may be distorted by excessive frustration or gra-tification at a particular stage with a large amount of libidinal energy fixed at that stage, leaving an insufficient supply for further develop-ment. Under extreme frustration, libido may be taken from a pain zone and regress to an earlier one. Psychopathological symptoms are determined % the developmental stage to which a particular individual is fixated or regresses. , Psychoanalysts, generally agree that depression .is a.. symptom .or ^ ^ L 0 1 1 .°f a Psychopathological process in the development of the lH0WeIer'. t h e r e i s a w l d e sPread.of PI>i^ ons.a>out..,th.a4»;o-type of symptomatic distress, and the psycho- " 'anal?tiC.P°Sition o n depression is not a unified one. (Mendelson, 19?4) •^hile' all the theories rest on the general framework which has be Deen -37-described above,theorists differ in their descriptions of the exact mechanisms of depression. Therefore, some of the central ideas and assumptions which Freudians and neo-Freurlians make about depression will be summarized. H&gufl viewed depression as a raant^n to an Imaginary and vaguely perceived loss which depriygs,the ego. MThe lost object Is introjected or incorporated into the individual!s psyche and the anger over the loss is, therefore, directed inward. ^ his incorporation of the object.re-presents a regression to the oral stage of development. (Freud, 1917) ktifahm also believed that the depressed Individual is fixated at the oral stage and associated it with both dependent personalities and with th®J?£i^tive hostility of oral expulsive fixations. 'He saw it origins in disappointments in the pregenital stage of development compounded by disappointments in later life. Rado saw the depressed per-son _as having intense narcississtic needs and poor self esteem, reacting to the loss of his love object with anger and self punishment. Melanie < K l e i n "believed that the origins of depression are in the first year of •^i&.and. jt®1^  that depression... is. rooted in the lack of mother's love du-ring infancy. Bibering identified the fall of self esteem as central to depression. There are,of course, many other views;however, the pic-' ears to emerge from all of the above is that the depressed individual's personality is marked by dependency, narcissism, hostility, i loVi. seif esteem, deprivation of love and a highly punishing superego. (Mendelson, 1974, Beck, I967) One cannot help but note.the striking paral-' ^ et w e e n the psychoanalytic understanding of the normal female and -30-' Psyghoanalytic view of depression, as Weissman points out. (Weissman and ' Klerman, 1977) The great difference between the two profiles might well be that one individual is supposed to he happy while the other is supposed • to be unhappy. work within the medical model but apply :i that model by an^og^jpsychological processes,The individual Is seen • ^ ggycholoSically ill and her symptoms are manifestation of an under-> lylnf-^!L0lfih°l0Sy- T h e ^ a s k. o f the clinician is to correctly., inter-" t h e S e g.1^!:^1,^"086.the underlying personality disorder and treat t h e P^sonality„has been, restructured (treated), the symptoms y will spontaneously remit. Evidence to support the psychoanalytic interpretation of depres-{ sion comes largely from reports of successful analyses and hence rests ' °n a V S r y s m a 1 1 numl3er o f cases. '"Objective verifiable evidence for the • V ^ ^ 1 ? 1 1 0 . m o d e l i s sparce (Weissman and Klerman, 1977) and indeed, Pthe psychoanalytic model, with its emphasis on intrapsychic events, does "not lend._"self to objective studios. Friedman did a study on hostility vfactors and clinical improvement and found that depressed patients ex-I hibited less hostility than normal controls both during and after depres-sion. (Friedman, 1 9 ? 0) However, as Friedman notes, his study would not ?!be acceptable as a disconfIrmation of the psychoanalytic theory of hos-tility and depression since psychoanalysts would argue that the hostility 'I ^ ists at a deeper level than the-survey can measure. Indeed, it seems pat it is necessary to be immersed in the psychoanalytic model in order -Ho see evidence of its validity. As a model, it has been" very difficult I -39-to confirm or dlsconfirm by standard objective measures, and there has been little enthusiasm among psychoanalytic practitioners to engage in this type of study. (Hendelson, 197^) We now must look at how a psychoanalytically oriented clinician would understand and treat Ester Greenwood's problem. Of course, the understanding would vary from clinican to clinician depending on each clinician's view of the problem, but one fact with which they would all agree is that the symptom only provides a clue to the underlying persona-lity disturbance. Ester's problem would probably be viewed as a reac-tion to an imagined loss of love object. Her depression would be seen as triggered by her rejection from her summer school course. This blow to her self esteemwould be understood as triggering repressed ancLun-concious unresolved conflict in early childhood, probably revolving a-round early maternal deprivation. Ester's personality would be seen as fixated at the oral stage. Her dependency could be seen in her tremen-dous reliance upon external supplies of love, attention and affection In order to maintain her self esteem. This, of course, would "make Ester's drive to overexcel in school understandable. It would also explain her compulsive attitude towards work. Her aggression towards her mother and her reaction to her father's death would have been, turned inward to pro-duce the fuel for her self punishing behavior. Due to her fixation at this early stage of development, Ester would not have been able to suc-cessfully resolve her oedipal situation. As a result, a central part of her^problem would be seen as her difficulty with gender identification and her unresolved penis envy. This can be seen in her choice of a ••>1-0-masculine career, her intense striving for success, her rejection of marriage, her uncertainty about wanting children and her generalized an-ger about being treated unfairly because she is a girl. Given this analysis, Ester would undoubtedly be seen as in need of ^ treatment. The focus of that treatment would not be on removing or curing the depressive symptomatology, but would aim at structuring Ester's personality so that she could be freed of her oral fixation, resolve her oedipal problem and accept her innate feminine role. The treatment would take the form of frequent analytic sessions extending over a long period of time, which aimed at exposing the repressed and unconcious material, perhaps through a detailed analysis of her dreams. Ester would be en-couraged to enter into a transference relationship with her therapist and through that relationship gain insight into her unresolved intrapsychic con-flict. Successful analysis would lead to an acceptance of the mature fe-minine role, a restructuring of the personality and would result in com-plete and permanent symptom relief. It is, therefore, clear that an un-derstanding and treatment of Ester's problem relies not only on an un-derstanding of depression but also on the psychoanalytic theory of per-sonality and normal feminine development. Psychoanalytic theory has been questioned, criticized and attacked from many points of view and on many grounds. Many of the critics of psychoanalytic theory direct their criticism at the basic assumptions which the Freudian model of human development makes. As we have seen, Freudian analysis assumes a universally determined course of personality development. Critics argue that this fundamental assumptions fails to address the role which culture plays in the formation of personality, nor does it recognize cross cultural differences in the development of personality. The general argument is that psychoanalytic theory grew out of an understanding of European middle class culture at the turn of the century and takes the very ethnocentric position that the experience of growing up in that culture should teen seen as representative of the universal human experience. (Mead, 1974) Allied to this criticism is the argument that Freudian theory overemphasizes the role of sexual stages of development (because it reflects the experience of a sexually repressed society) and fails to take cognitive development and other non sexual sys-tems Into account. In postulating a tension reduction model of develop-ment, it fails to adequately explain exploratory behavior in .humans and as the theory is limited to the development of personality in early child-hood, it ignores the effect of later social - xperience on personality development. (Deutsch and Krauss, 1965) Ultimately, psychoanalytic theory rests on the assumption that the analogy between physical develop-ment and Illness and mental development and. illness is valid, and Its ties to the medical model are central. This view assures a search for the explanation of the disorder within the 'ill' person and does not deal with interactional and situational components which may be relevant. Finally, as psychoanalysis relies on interpretation of intrapsychic life, it does not allow for confirmation or disconfirmation by objective measures, and bases its unversal conclusions on a small number of cases. It has been severly criticized by behaviorists and others for its narrow and restricted vision which is based on sounprovena theoretical position. - h z -The therapeutic aspects of psychoanalysis have been criticized on the grounds that they are ineffective, rely too heavily on insight and require too much of the patients time and money. This therapy system has also been criticized for imposing its therapeutic aims and goals onto the patient. For in psychoanalysis, although the patient may approach a psychotherapist for relief from the symptoms of depression, the psycho-analyst's aim will not be to relieve her symptoms but to restructure her personality. (Tennov, 1975) As a result symptom relief may not be a measure of treatment success. Psychoanalytic based therapy has been cri-ticized 1; Szasz and other on the ethical grounds that it adopts a nar-row and unproven view of psychological difficulty and elevates that view to the level of science (proven fact) without meeting scientific criteria of validity and reliability. The psychoanalytic theories of the etiology and treatment of depres-sion are subject to all of the criticisms which have been raised above, as these theories rest on the same assumptive base. In addition,theories of depression are not unified, and there is considerable disagreement among practitioners about which of the many interpretations is correct. Despite these disagreements, Mendelson finds that all too many practitioners are prepared to offer definitive statements about the nature and causes of depression. These practitioners "mistake partial insights for uni-versal statements." (Mendelson,. 197^, p. 291) As we have seen, the nature of the general theory encourages such universal pronouncements. Finally, psychoanalytic theories of depression have been criticized for heing overly simplistic and not addressing findings in other related fields. -43-Again, the parochial and narrow views of many practitioners are con-sidered to be responsible for this problem. (Mendelson, 1974) eo-^j- .a-s it relates to women and mental ill-ness,has been most strongly attacked by feminist writers. As the ma-jority ofjforaen who receive psychiatric help are diagnosed as depressed, ' t h e feminist critique is relevant to the understanding and. treatment of the depressed woman. Feminists agree with the other critics in asserting thalJBsychoa".alXtlc .theory .represents an ethnocentric view of the human co"d:ition" T h e y a d d o n e important factor to that criticism, for feminists believe that Freudian theory is essentially a male view of.human develop-m.ent" T h u s tics^argue that Freudian theories of both nor-mal development ^ ^ pathological states represent an understanding of h o w a. m a l e w o u l d, 5 e e these processes based on his position in the world. Karen Horney's critique c-f the Freudian view of female development points out that each critical stage in the pre-oedipal period can be taken to represent how a male might feel if he were castrated. (Horney, 1974, Person, 1974) What so enrages feminist critics is that this male con-struction of-female development is taken to represent a universal, scien-tific and factual analysis of female development, not the biased ac-count which they believe it to be. All this leads to an understanding of the normal woman which indicates that she Is passive, somewhat maso-chlstic and morally inferior to males and further asserts that this is the way she is meant to be. Her psychological task is to accept her femininity which means that she must accept her inherent inferiority and give up her penis envy. Treatment for her pathological condition, ) depends on helping her to gain insight into her problem and accept her normal feminine role. Feminists argue that ...feminine traits, which FreudianPs_ believe to benormal, in. fact, reflect the oppressive social conditions ^nd cultural stereotypes under which women are raised and exist: , and that feminine development can best be understoood through an understanding of these social conditions. (Janeway, 1974, Kovel, 1974) Feminists point out that the psychoanalytic therapy process in-volves long term analysis and that this analysis is predominantly done by males. (Tennov, 1975, Chesler, 1972) During this process, the woman must learn to accept the analyst's construction of her character and de-pression. She must depend on his interpetation, as her problems are seated in her unconcious which her analyst can see but she cannot'. The feminists argue that what she is asked to do is to accept a negative, male,cultural stereotype of femininity and to allow a male view to con-struct and define her. As we have seen, this entire process of con-struction is open to serious criticism. A final question which must be ..addressed in reviewing the psycho-'•: , analytic theory of women and depression..is. oddly enough why look at the rFreudian position at all. After all, criticises of the Freudian view i.s are now well accepted, among clinicians and fewer and fewer patients are J being treated by traditional analytic techniques. While It is true that .. S Freudian therapy as a whole is currently out of favor among, clinicians, r..;.;'; many parts of the Freudian view of both women and depression, axe in common use- Perhap:^ the r.o:P, widely accepted aspect of Freudian theory in use er view which is favored is that depressed women are really very depen-dent and needy people.1*" S U a n o t h e r view is that depressed women have an underlying personality which is obsessive compulsive, and of coarse, the term' castrating female still survives in some circles. These un-derstanding of depression and women are outgrowths of the Freudian view and are dependent on all of the assumptions of that view. Yet, for many clinicians, they have become well established clinical 'facts'. Just*like the statistic which is taken to represent hard, objective evidence, these views stripped from their assumptive base take on an aura of fact. It is, therefore, Important to reconnect these well known facts with their theoretical base in order to gain some under-standing of them. r -P6-iii. Cognitive Theories of Depression Clinicians who adopt a cognitive model to understand depression make the assumption that depression is primarily a thought disorder which is characterised by specific cognitive distortions of reality and is caUsed2l. t h e ^pressed woman's early childhood experiences and the reflected aPPraisal of others. (Beck, 1967) Aaron Beck, the leading pro-ponent of a cognitive theory for depression, identifies a triad of ne-gavtive cognitions which can he activated in the predisposed or susceptible ' WOma"A^Llre_ate t h e n e§ a t i v e o r depressed affect. This triad of cog-nitions is thought to be Construing experiences in a negative way; vietagjself in a negative way; viewing the future in a negative way. This conception presupposes that the depressed woman's actual experience J • in the world is not negative; it is merely constructed as negative. ] /Beck's theory also rests on the assumtion that depression Is e-.ur.cd by/ ' I ' / ^ distorted perceptions and that it does not work the other way around, j f . | -Beck's theory shares the basic assumptions of the medical model. I Depression is viewed as an illness within the woman. The specific af-fective and vegetative symptoms are clues to the underlying psycho-Pathology which lies in the thought processes." Depression., is.,., therefore, seen as similar to schizophrenia in that both are assumed to . involve distortions of reality. Indeed,..Beck.speculates that "a thinking dis-order may be common to all types of psychopathology." (Beck, 1967) -fieck also shares some of the assumptions of the psychoanalytic school, j'nthat he_offers a psychological .explanation for the etiology of depression -hr-; In fact, Mendelson includes a discussion of Beck's theory of depression in his review of psychoanalytic theories. Like psychoanalytic theories, Beck's theory.locates the causes of adult depression in early childhood experiences. Unlike his psychoanalytic counterparts, he is interested in a more detailed and empirically "based understanding of the symptomatology of depressive disorders, and he'has been criticized by psychoanalysts for offering a superfiscial understanding of the problem. (Mendelson, 197k) Evid ence to support Beck's theory generally stems from studies whichBeck and his colleagues have undertaken. Beck's studies found that depressed patients differed significantly from non-depressed con-trols in what Beck terms idiosyncratic thought content. This thought content is characterized by themes of 'low self-esteem, self blame, over-whelming responsibility and desires to escape." (Beck, 1967, p.230) These cognitive distortions were measured by an analysis of dream con-tent, and other psychological projective tests and were found to be re-latively successful in differentiating depressed patients from other clinical groups. These findings led Beck to adopt a continuum hypothesis to explain depression with' psychotic depressions representing more severe cognitive distortions. His theory of causation in depression has not been subject to the same empirical tests and rests on the as-sumption that cognitive distortions precede depressed affect and have their origins in early childhood. Beck's findings can be criticized for their reliance on projective tests which require a great deal of interpretation by researchers. Furthermore, his contention that depression is preceded - by cognitive distortion is not well supported by evidence and does not explain those cases in which depression is rapidly alleviated by psychphaniocological agents or EOT, (Mendelson, 19?4) Beck does .address the issue of depression and women. In his article "Cognitive Therapy with Depressed Fomen", Beck expands his ideas about causal factors in depression to include cultural Influences which may lead women more than men to perceive themselves as negative and worth-less . ftfe maintains his belief that when these negative self evaluations become severe or disabling, they represent a thought disorder and require therapeutic involvement to help the woman 'gain a more realistic and less distorted view of her experience, her self and her future. (Beck, 1974) In looking at how a cognitively oriented clinican would understand and treat Ester Greenwood's problem, it is clear that he would concen-trate on understanding those thought processes which led Ester to have such a negative view of herself and her environment. He would Immediate-ly be struck by the paradox between the facIts of Ester's situation (that she is a bright, gifted young woman with a promising future) and the way in which Ester interprets those facts (that she' Is ugly and stupid and that her future is without hope). He would see the discrepancies be-tween the objective facts of Ester's situation and the subjective-expe- ! rience which Ester reports as representing evidence of a thought dis- I \ order. He would assume that Ester's rejection from her summer school 1 course activated her already established but dormant idiosyncratic cog-nitive schema which had probably been formed in her childhood. He would B -I'O y note the tendency for these activated schema to dominate her thinking and produced depressive affective and motivational phenomena. (Beck, 1967, Mendelson,1974) The severity of Ester's symptoms would indicate a diag-nosis of psychotic depressive reaction, and Ester would clearly he in j need of treatment. i Ester's treatment would consist of two parts. During the acute • j phase of her illness, the therapy would aim at alleviating her symptomatic distress by helping her to gain some objectivity and control over her negative automatic patterns. When the acute symptomatic distress sub-sided, therapy would be directed at modifying the underlying causes of the disorder, the Idiosyncratic thought processes. This would be ac-complished through the use of insight oriented therapy. The aim of the therapy would be to' review the patient's life history, and to demonstrate to her the ways in which she distorts certain situations and events. She would be helped to see how these distortions were learned in early child-hood. (Mendelson, 197;0 H o re specifically, the therapist would challenge the patient's generalizations, deletions and distortions in her construc-tion of reality,and hope to give her insight into how these misconstruc-tions are produced. This therapy would attempt to give Ester mastery over her experience and allow her to recognize her overreactions. In this way, the therapist would hope to prevent future depressions. The role of the therapist is that of a teacher as he helps the patient to dearn to identify and correct her cognitive distortions. Beck's theory of depression- has generally received favorable re-view, however, in evaluating it, certain problems are evident. As we • 30-have seen, the studies which Beck cites to support his theory are "based, on somewhat unreliable projective tests and. subject to a range of inter-pretations. His assertion of the etiological primacy of cognitive dis-tortions does not rest on extensive evidence and does not explain the successes of organic treatments of depression. Furthermore, cross-cul-tural studies have failed to confirm the universality of cognitive dis-tortions in depression, and the cognitive symptomatology of depression has been found to present . different clinical pictures among different cultural groups,(Katz, 1971) These findings would tend, to support a theory which stresses cultural factors in the incidence and prevalence of depression rather than one which stresses early childhood experience. While Beck's discussion of women and. depression does acknowledge cul-tural factors in higher incidence of depression in women, the weight of his theory and therapy tends to mitigate those factors. Thus Beck speaks of the paradoxes, in...depression, and in his major work, Depression, pre-sents case example which.exclusively highlight these paradoxical com-ponents.'. He cites examples of the rich man who believes he is poor, the beautiful.young woman who believes that she is ugly, the gifted young scholar who believes that he Is stupid.' In such case.s..)...it..makes sense to assume that the problem lies not in the person's experience in the world but In their construction of that experience. But,of course, we must ask what of the poor man who feels useless and incompetent because he cannot find or hold a job; or the homely woman who believes that she is unattractive and unloved; or the poorly educated woman who believes that she has no opportunities in life because she has no skills t0„.0:f:fcr' A 1:L t h e S e P e oP l e may also feel depressed and experience the world as negative and hopeless. Are there feelings best understood a s_a^tortion of reality? Would they be seen as clinically depressed? Maj^ r_f©Bii|^ sis would argue that women feel depressed because their ex-perience in the world Is more negative,and because they are less valued and esteemed than their male counterparts. (Chesler, 1972, Tennov, 1975, Smith, 1975) They would argue that a therapy which tells its patients to look on the bright side, to construe reality as more positive, implicitly tells women to accept their situation and to.change, the way that they think about it. Thus, Beck's cognitive therapy can be criticized for its overemphasis on seeing pathology in the way the patient perceives herself in the world, and deemphasizing those societal and interaction components which participate in this ongoing constructive process. : Behavioral Theories of Depression Behavioral theories of depression assume that depression is an unadaptive response to psychological stress rather than an illness, and see depressed-Behavior as caused By inadequate, insufficient or ineffec-tive reinforcement, (McLean, 1976, Orr, 1977) Behavioral theories are generally concerned with explaining and analyzing observable behavior based on an application of learning principles without recourse to intra-psyc)ai£_strri^tures. This approach relies on rigorous experiental methodo logy and finds its support In research in both animal and human behavior. Behaviorlst theories rest on three underlying orientations; the methodo-logical outlook of behaviorism, the structural prinlciples of association alismj and the motivational priniclple of hedonism (the pleasure prin-ciple in Freud). Thus, behaviorists are concerned with the association between observable behaviors, and use the concept of conditioned res-ponse as the basic unit of analysis. Like psychoanalytic theories, be-havioral theories rely on a tension reduction model of human behavior, and place emphasis on the role which 'rewards', 'drive reduction', rc-inforcers' play in establishing and strengthening the connections between stimulus and response. As Romans states, behavioral theories rest on the assumption that "human behavior is a function of its payoff; in a-mount and kind human behavior depends on the amount and kind of reward and punishment it fetches." (Deutsch and Krauss, I965, p . 79) As with the other theories of depression, there are a number of behavioral theories of depression, which while sharing the' same assump-tive base, stress different aspects of depression and offer somewhat -iJ-,iiffcrent interpretations to explain the phenomenon. This review will briefly consider the theories proposed by .Lewisohn (l??l). and Seligman (l is their theories can be taken to represent the dominant positions in boh doral theories of depression. l i k S h ± S c o l l e aS u e s Lazarus and Ferster, postulates that l^sion^results from inadequate, insufficient or ineffective rein-forcement. He assumes that a variety of life events or stresses (loss -etc.) can disrupt the Individual's usual pattern Reinforcement and result in a low rate of positive reinforcement. Ms low rate of response contingent positive reinforcement will elicit JE£22^tioned response of certain depressive features (i.e. fatigue, •^B^^SJ. ) and negative verbal statements. As the person receives •ess positive reinforcement which is contingent on her behavior, she becomes less behaviorally productive. In behavioral terms, she is on an xtenction trial. (Orr, 1977, McLean, 1976) Lewisohn hypothesizes that the occurance of such a situation depends * 3 factors. The first factor which must be determined is thb number of ••*ents which are potentially reinforcing to the individual. This will * subject to individual differences and will therefore be expected to vara or each individual. The second factor is the availability of potential Enforcers to the individual. The third factor is "the extent which (s)he has the skill to emit the behavior which will elicit re-m a n e n t . " (Orr, 1977, p.80) To put it more simply, does she possess social skill to get the rewards which she requires? ! ^ i l 5 n t r a l i s s u e s ^ the development of depression are the amount 0£.rciPonse contingent reinforcement, and the degree of social skill W*£gj,the PJ;^on.Possesses. ^The individual must experience praise or b i a ^ 5 e i I a r d o r Punishment, a s dependent on her behavior and not on S o r n^ xi r a n e o u s factor. She also must have access to reinforcers and social skill necessary to gain those rewards. If some of these,,central factors are not in operation, . then the woman is likely to become_depressed. Seligman's theory of depression assumes that depression can be ' besjt^understood in terms of learned helplessness. Reinforcement is critical in Seligman's theory, and the theory stresses both reinforcemen contingency and prior learning experiences with respect to mastery. Ac-cording to Seligman's theory, if a person learns that she has little con trol over the conditions under which she is rewarded or punished, she W i l l. l e a™.i h a t s h e i s helpless. When this person encounters events .nich^are aversive (loss of spouse, job or money), her learned belief in h eL^ n a b i l i t y t 0 exercise control or mastery over these events will re-sult in depressed feelings, cognitions and behavior.( Seligman, 1973) Behavioral theories of depression reject the assumptive base of the medical model. , They do not make the assumption that the woman is b u t r a t h e r t h e y s e e t h e P r o b l e m a s c a u s e d b y p a s t l e a r n i n g 3,14 P£?sent enviromental circumstances. Behavioral theories do not specifically speak to the issue of the bteatPv prevalence of depression in women. However, behaviorists have recast ' some of the findings of feminists and others into behaVoral &lif terms. Thus, one can find many examples of behaviorists using feminist explanations to support their analysis of depression and vice versa. For instance, '...findings that married women with young children have the highest incidence of depression, can be explained in terms, of these worn err'.s. are- . lative social isolation and the lack of availability of positive reinfor-i -cement in an isolated setting. Findings that 70% of all depressed in-dividuals experience marital discord can be explained in terms of the lack of positive reinforcement by the spouse. (McLean, 1976) ^Eehaviorist theories of learned helplessness find support in the feminist position that TOmen_are culturally conditioned to be more passive and to lack assertive-ness • As stated previously behavioral theories rest on research in both human and animal behavior. Studies by Lewisohn, Costello, Klerman, McLean, .Seligman and other are cited, to support these theries. Behavioral research relies heavily on animal research. Seligman's study of learned helplessness was generated from experiemental studies with animals, and tehaviorist1s findings have been criticized for drawing a false analogy between animal and human behavior. (Deutsch an'i Xrauss, 1965) Another major critique of behavioral studies has been the circularity of its defi-nition of reinforcement. All behavioral studies rely on an operational definition of reinforcement, for they measure the degree to which de-pression is associated with the lack of response contingent reinforce-ment. However, behaviorlsts have yet to develop an adequate understanding of what is reinforcing, and they can only establish" reinforcers with cer-tainty after the fact. This difficulty creates problems in their lneasure-ttent of behaviors and is thought to effect the validity of their results. (Deutsch and Krauss, 1965) As we look at how a behaviorially oriented clinician would explain ffy'lf and treat Ester's problem, it is clear that he would understand her de-pression as an unadaptive response to stress. In hearing the facts of Ester's situation, he would see her rejection from her summer school course as critical in setting off the chain of behaviors that led to her depres-sion. He would note that the rejection from the course had the behavioral consequence of cutting Ester off from her usual pattern of reinforcement which had been associated with her academic environment and school friends, :Ester would have been left in an isolated environment with few poten-tially reinforcing events available to her, since she had little interest in the people and events in her home town. Ester might be seen as lacking 'the social skills and experiences of mastery to remold this less than re-warding environment into one which would be more satisfying. As a result ofjiex^lack of assertiveness and her general lack of response contingent reinforcement, her behavioral productivity would decrease. With this de-crease In productive behavior, there would- be even less behavior availa-ble for reinforcement, and. in this way, a downward spiral into depression would be produced, : Ester would be seen as needing behavioral therapy to help her break this downward spiral. The treatment for her depression would focus on hel-ping her develop more effective methods for coping with stress and on changing her era-rent pattern of reinforcement. The focus of the treat-ment would be on the depressed behavior rather than the thoughts and feelings a-ssociated with depression. The changes in behavior would be expected to Produce changes In thoughts and feelings. If Ester were treated as a -5?-single person, she would he expected to learn certain self management strategies to cope with her depression. Her behavioral productivity would be increased with the introduction of small- graduated tasks which she could successfully complete each day. Her goals would be examined and reduced to prevent frustration. She would be expected to plan a number of social contacts for each day to decrease her Isolation and increase the availability of social reinforcement. She might undergo specific beha-vioral training to help her become more outgoing and assertive in social situations. She might be trained, in decision making and problem solving to help her achieve mastery over some of the issues in her life. She viould also be taught how to monitor her thoughts to prevent the intrusion j of depressive thoughts. However, behaviorists".have found that their thera-pies work most effectively if the depressed woman Is reinforced by others. As a result, Ester's mother might be involved in the therapy as a collabo-rator with the therapist, and would be trained in ways to more effectively i | reinforce Ester for her positive, non depressed behavior. I I In evaluating behavioral theories of depression certain problems are evident. Behaviorism, as a whole rests on a tension reduction model of I human behavior and is subject to the same criticism as Freud.ian theory in that it fails to adequately explain or deal with exploratory or purposeful • behavior in humans. Behavioral theories, therefore, do not offer very I satisfactory explanations for the cognitive and affective components of depression. They assume that these components result from depressed be-havior but are unable to prove primacy of behavior in the etiology of de-'i pressive disorders, nor can they adequately explain the Interaction between cognition, affect and behavior as they rely on an overly simplistic causal model. There have been some recent attempts to incorporate cognitive and and behavioral components (self-regulating models), but these theories are broad and offer a simplistic explanation for what is generally con-sidered to be a complex process.(Orr, 197?) In emphasizing behavioral components, behavioral theories also cannot explain the effectiveness of organic treatments of depression nor explain instances in which there jappears to be rapid spontaneous remission of symptoms. Since behavioral theories rest on an assumption of precipitating stress, behaviorists have generally been successful in locating stressors in the depressed person's background history. With the introduction of the concept of microstressor. the concept has become even more elastic. The difficulty is that many peoples"history would reveal a rather large number of microstressors in their environment, yet not all these people become depressed. To "c.te, behavioral theories have been unable to successfully predict when a per-son will become clinically depressed, rather they can offer an explanation after the fact. Part of the problem is that "behavioral theories rest heavily on the concept of reinforcement, and. as we have seen, behaviorists 'are unable to define this concept. The - in definition stems from the fact that what is taken to be reinforcing will vary from individual ,> individual and may vary as a result of who provides the reinforcement, ;how is is provided and the context in which it occurs. Therefore, what is reinforcing to one individual may not be reinforcing to another. In addi-jtion the value of the reinforcement may alter depending on the context in "which it occurs. To reframe this in social Interactionist terms, the meaning of a particular reinforcement must be created by participants in social interaction. As behaviorists have no method of establishing before the fact how this will be done, they are forced to rely on a retrospective explanation of the process. The difficulty which behaviorists have in defining and understanding reinforcement creates serious problems in the application of behavioral theories in a therapy situation. The normal way in which behavioristr- \ \ surmount the problem of definition is to accept the consensus of opinion \ about what is generally taken to be reinforcing in this society and to assume that it is also true for the specific individual in treatment. Behaviorist have been critized for their acceptance of a consensual de-finition of reinforcement and critics have charged that behavioral therapis use their techniques to enforce social conformity on individuals who are'' relatively powerless. In treating depression, some feminists and other 1 would criticize behaviorists use of husbands and other relatives to I 1 ! treat the depressed women. They object on the grounds that those in- I dividuals in concert with the therapist might try to manipulate the j woman into conforming to culturally stereotyped and socially discrimina-tory roles (i.e. the husband systematically reinforcing his wife for ! performing household and child care chores) and behaving in socially ac-ceptable ways. However, others In the field point to the value free base of behaviorism and argue that behavioral techniques can be used for good or ill depending on the goals to which they are applied. •6o-v. Summary and Conclusions In reviewing the k theoretical positions on the etiology of do- I presslon, it Is evident that each theory rests on its assumptive base I j about the nature of the disorder. Furthermore, the psychoanalytic, cog- i nitve and behavioral theories also rest on their assumptions of what is normal and desirable behavior, thoughts and feelings. Thus for the psycho-.' analyst, normalcy for women Implies a 'mature acceptance' of their Inhe-rent femininity and passivity. For the cognitive clinician, normalcy implies that the woman perceives the world as basically positive, that she perceives herself as worthwhile, and sees her future as hopeful. For the behaviorist, normalcy implies the capacity to adapt to most types of stressful situations, and implies an ability to conform to her environ-ment. 'All of these positions represent normative or moral statements, although they are not usually specifically idci A ed as such. Three of the four theories rest on the implicit assumption that clinical depression represents a pathological condition or illness which resides in the woman and assume an underlying unitary causal desease process which Is manifest in the depressive symptomatology. The behaviorist position rejects the illness assumption and assumes that depressed behavior can be understood as a reaction to stress. ^ All of the theories rest on a base of evidence which can be taken to support the theory. However, the evidence upon which each theory rests differs in the degree to which the research base conforms to the expecta-tions of scientific inquiry (from subjective case analysis to rigorous double blind experiments) A review of the available evidence indicates that none of the theories rests on conclusive evidence, and the forerr" st researchers in the field are quick to point out the difficulties in making definitive statements ahout a disorder which to this day defies definition. Clinicians who operate on the "basis of any of the k models may be •aware of the confusion within the field, but their position vis a vis the I depressed woman may lead them to act with more certainty than the c-videuce ! would allow. Given the same case example, clinicians operating under the ^assumptions of each of the theories presented vrould. select out those aspect which their theory believes to be primary In depression. However, none of the theories can predict whether or not a specfic individual will be-come depressed nor can any of the theories establish a priori what set of biological, psychological, or enviromental variables will necessarily cause an Individual to become clinically depressed. While some research on life stress claims to "be able to predict some form of physical and emotional difficulty as a result of an accumulation of life stress, this research is unable to predict what specific type of difficulty will occur. Thus, all theories of depression fail in their predictive ability and , rely on retrospective accounts and explanations. As we have seen, all of the theories can explain what happened to •Ester Greenwood with relative ease and offer a coherent and logical account of her depression. That is her experience can be fitted into thejmodels. explana.tax.¥-±i.ypatJaeses. once their basic_assujnptipns are ac-cepted. They all start ..with the depressed individual and look backward to explain what is wrong with her personality or behavior. Each theory places the clinician in a central and powerful role In interpreting what is wrong with the woman, and in helping to remedy the situation. The organic position will lead the clinician to construct the woman as "biologically ill and prescribe a chemical or organic remedy. The psychoanalytic position will lead the clinician to focus on the wo-man's inner mental life and to interpret for the woman the meaning of that life. The cognitive position takes a wider view of the problem in that it is concerned with the woman's current''perceptions of her self and her world, but places the clinician in the role of teacher or judge with res-pect to the correct interpretation of that world.. The behavioral position takes a still wider view in that its analysis includes both the woman and her environment, but it may place the clinician in the role of helping the woman to adapt or conform to that immediate environment arid measures success in adaptive terms. Each or all of these orientations will have impact on the clini-cian's definition, diagnosis and treatment of the woman and the way in which he interacts with her in a therapy situation. In addition, the clinician's assumptions a"bo«t normal female adjustment, mental illness, and psychiatric diagnosis.will effect his Interaction with the patient and the meaning which is created.. Finally, the clinician's expectation that it is his role to assess diagnose and treat the patient may create in him an expectation that he must be more knowing than the patient and that his perceptions of reality ought to be more objective, and sensible than hers are. For he is expec-ted to speak from his role as an acknowledged authority, while she is expected to speak from her role as a mentally ill or maladapted individual. In addition, if the clinician is a male (and if the therapist is a psychia-trist or psychologist, this is very likely), he will "bring with him his socially conditioned sex role and his experience in the world as a male. The male sex role may include a definition of self as actor, protector and provide. It will, of course, coalesce with the expecta-tions of his role as a therapist, and the assumptions of the model of human behavior which he has adopted. " " "' X t /I-.-!<l[lhiiti j /V' -6 i-i II. "The Feminist's View - Issues and. Problems , Having completed a review of the 4 dominant theoretical approaches to understanding women and depression, it is important to examine an ap-proach whichraoes not attempt to discover what is wrong with the depres-sed woman or- to understand how her personal history produced her depres-sion. The modem feminist approach to women and mental illness repre-sents such a view. MotalJteminisrj can he understood, as a political and social movement, an ideologicalposition about women in North.American so-ciety, and a theoretical position on female behavior and development. It attempts to analyze, criticize and change the nature of western society. The feminist approach to women and mental illness does not repre-sent a single unitary theory, but an amalgam of various approaches to un-derstanding the problem. However, feminists who write about this Issue do share a basic orientation to the problem. This orientation seeks to locate the source of the wornan' s difficulty in the construction of the SCi£iSl..order-rather t h a n i n t h e biological or psychological pathology of the^ndividual. It takes sox^role as the central variable in how an in-dividual JLs constructed by that social order. It also takes sexual iden-tity as the most crucial element in personal identity and makes the as-sumption that sexual identity and sex role are products of ongoing social construction rather than the innate characteristics which they .axe.often ..to "be • ^ t assumes that men and women_e.ncounter...the world from dif-fororrt exunr" on i-a'i lams as a result of differences in the way their sex roles are divided. an ^individual' s experience ofjbgprftssion (sadw^s&r-^&s-of-gelf••«st4>«»vliQpelefisne5s) -66-cannot "be stripped away from her experience as a woman in North American culture, for the two are seen as inextricably ..linked .-furthermore, a woman's experience of depression as a clinically diagnosed entity cannot te-JSdfrftood i n isolation from the psychiatric system which produces such diagnoses. V^us, women, society and. the mental, healthy system must all be considered if depression ..and the treatment . of depression as a mental illness in women is to be understood. (Smith, 1971) As a result, this analysis of the feminist position on women and depression will include; a review of the feminist critique of current .approaches to understanding and treating 'mentally ill' women; the femi-nist understanding of female socialization and societal attitudes towards women, and feminist theories of depression and women; feminist alternatives to the present methods of treating depressed women. The analysis will outline the major assumptions upon which the feminist position rests and the evidence which is cited to support this position. Major criticisms of the feminist position will be reviewed and discussed in relation to the treatment of depressed women. -6?-A. The Feminist Critique of Current Approaches to Women and Mental Illness The feminist orientation to women and mental illness must he under-stood. in the context in which it developed. The'feminist position developed as a reaction against the Freudian position on women and as a reaction a-gainst the institution of psychiatry as it exists in North America. (Strouse, 197^) The feminist critique has special relevancy to an understanding of the treatment of depressed women, because as we have seen, depression is the most prevalent complaint of women who are undergoing psychiatric treat-ment. As we have seen, '"the profession of psychiatry rests on a medical model of mental illness. '"Psychiatry also rests on the assumption that its findings_ in humar. behavior represent objective facts and are free of cultural and other forms of bias, ^Feminists and other radical therapists specifically challenge this assumption, and with ih's challenge strike at the foundations of the mental health system.i*"Tfie feminist orientation does not accept psychiatrists and. other mental health practitioners accounts, interpretations and reports of what they do, but rather looks at the in-terpersonal consequences of psychiatric treatment.for women. (Smith, 1975) i^Tpsychiatry is a male dominated profession,, feminisis...look at., the psychia-trist' s ^ interaction with the woman not only as reflecting a. doc.tor/patient relationship, but also as reflecting a relationship between a male and fe-male and seek to understand the relationship on that basis as well. ; By placing sex role at the center of the analysis, feminists ask some very different questions about the relationship of psychiatry, mental •illness and women than the profession itself has addressed. In this respect the feminist orientation to the problem falls within the definition of a sensitizing theory as outlined by Blumer and Scheff for it directs "attention towards new data or to new ways of perceiving old data which challenge taken-for-granted assumptions and shatter "the attitude of everyday life," (Scheff, 1975) The feminist orientation directs attention to a number of these common sense societal and psychiatric ideas about women,and mental ill-ness. Specifically, it questions: 1) psychiatry and allied profession's claims that they speak from an objective and factual basis; (Smith, 1975) 2) the psychiatric assumption that mental illness is -rooted within the inner mental life of the individual; (Tennov, 1975) 3) societal and psychiatric ideas about normal female development and mental health practitioners attitudes and belief about mental health in women. (Strouse, 1974) With respect to the practice of therapy, the feminist orientation questions: ; 1) the power relationship which exists between the patient and the therapist, and specifically, how that power relationship ref-lects the relationship of men and women in larger society;' (Tennov, 1975, Chesler, 1972) 2) the taken for granted assumption that it is the individual's responsibility to fit into his/her place In the society, and that the function of therapy is to help the individual to adjust to prevailing social norms; (Chesler, 1972) tfeny feminists and critics of modern psychiatry take the position that mental illness as a separately defined clinical entity does not exist, as "mental illness can't be separated as sr. thing, ohjec.t.,stated disease entity (or what, have you)_from the social operations. of .psychia-try." (Smith, 19?5, p. 89) As we have seel^Szasz^oints out that mental illness rests on an unproven..analogy^ .^with-.p.hysical. illness. He finds that people come to psychiatric agencies with various kinds of problems and that part of the work which the mental health system must do is to reformulate and sort these problems to fit its diagnostic categories. mental ..health system, is... authorized, to f it„p.eaple7.s_..-e^ perien_c.e ..into Illness categories. While the system does not create the many forms of suffering and despair which humans experience,"it packages these.ex-periences as mental illnesses, U?hus, in Szasz' view, "the mentally ill are the people upon whom this v.:.-~k is done." (Smith, 1975. P- 90) Thomas Scheff's work arises out of a similar orientation. He suggests that mental illness can be better understood as a violation of social rules. Scheff asserts that society uses many standard categories to deal with violations of commonly accepted social rules (i.e. viola-tions of legal statues, violations of etiquette etc.). There are, how-ever, rule violations which do not fit into standard categories and axe conceived of as residual rule violations. The category mental illness is like a miscellaneous file which is available for use in cases of re-sidual rule violations. Usually, these violations are not categorized or labelled. However, when they are treated by the mental health system, then the category mental illness is attached to them,- and the vague -70-social deviations and violations become symptoms. If the individual who is categorized accepts the mentally ill label, she will be encouraged to conform to the societal stereotype of mental illness and to see her behavior as a product of that illness. Thus, in this view, mental illnes. is a social construction which is produced by the patient ahd therapist In the context of the treatment setting. (Scbeff, 1966) ^coming mentally m M§^mY..iroT)licationS. and c < - — b e i n g . labelled, as_ raentalljr^ill has for women, ^^fk^^understamding thejrocess is.that it is cir-c u l a r ^ reflexive. The woman comes to the therapist with a. series of dif!l£±L!ies- L"These difficulties are reframed as symptoms and lead to a di2§^ s i s ° f i l l n e s s' bnce the illness has been diagnosed„ these same difficulties are explained by the illness, 'lo put it more simply, she is C r y i ^ i h e r e f o r e t . s h e J i s depressed. Why is she crying? Because she is depressed. AsJSmith points out, this process really involves separating the person's problem from the context in which the problem occurs. As problems are stripped of the contexts which give""them meaning, they become sensible only as 'sick', 'crazy', or 'mentally ill' behavior. Rosenhan's study shows how the act of writing can be transformed into 'writing beha-vior' and a symptom of mental illness. (Rosenhan, 1973) During this Pr0CffiiJheaWoraan i s 6 i v e n a new set of instructions to understand her P!!2_:Land th°Se instructions tell her to "locate her problems arising in ™I, r e l a t i 0 n s t 0 h e r situation inside herself." "(Smith, I975, p. ?) In depression, she is given a further instruction to locate the problem in herself in the way that she feels. St fa fa -71-Smith offers a set of instructions which tell us how to treat someone who is mentally ill. Such treatment will ensure that they are produced, as sick. They are summarized as follows: "l) Find out how to see this person's "behavior as not making sense... 2) . .Separate the person's behavior from situations in which it belongs...Lift pieces of behavior out of context.. 3) Don't relate to this person as if you could look at the world from the same place., 4) Don't take what she savs seriously. (Smith, 1975, P- 92) Smith believes that this set of instructions will seal off people who are labelled mentally 111 from ordinary social participation. They will not be able to speak with authority or to offer their own under-standing of their problems. As we have seen, 3 of the k major theories of depression instruct practitioner to locate the problem within the wo-man, either in her biological makeup, the structure of her personality or her thought processes. These instructions may lead practitioners to see the depressed woman as mentally ill and to seal her off from ordi-nary social participation, and feminists assert that this labelling pro-cess is damaging to women who seek help from the mental health system. (Chosier,'72) MDf course, one need not be a woman to be labelled as mentally ill and treated as sick. ^ 'However, feminist's argue that women are par-ticularly vulnerable to this process and are more greatly harmed by it. Their argument rests on a number of factors ---4 Feminists take the position that the mental health system,is domi-nated by men and has a negative stereotype of women. Feminists see psychiatry as part of the larger patriarchical structure of society and believe that psychiatry mirrors that structure. Their argument is supported by statistics that show, the 90% of all psychiatrists ancl of all psychologists are males and that women predominate only in ..social work a and nursing, the least prestigeous and powerful of the mental. hea.lth professions (Tennov, 1975) ^ "fhey^ conclude...that the mental healt.h._.system is dominated by a male point of view and that that point of view has.a negative stereo.iyps..oi .woraerr,. Inge Broverman's study of sex role stereo-typing among mental health practitioners supports this contention. The BrovermarP study found that the practitioner's stereotype of normal healthy women indicated that they were "more submissive, less indepen-dent, less adventurous, less aggressive, less competitive, more excitable in minor crises, having their feelings more easily hurt, more conceited about their appearance, less objective, and disliking math and science " than the average healthy male. The study also found that the clinician's views of normal healthy males and normal healthy individuals were con-sistent but that their profile of the normal healthy wromen was not. The • study indicates that practitioners subscribe to the traditional negative feminine stereotype and that the stereotype represents a double bind for women. Women can be healthy adults but not healthy women or they can be healthy women but not healthy adults. They cannot be both. (Broverman, 1970) Thus feminist conclude that even before she enters into a relation-ship with a therapist, the female client is at a disadvantage. /••Feminists arguejth&jfc..the traditional therapeutic relationship can be damaging to women. They point out the the therapeutic relation-ship mirrors the traditional relationship between men and women. Chesler sees it as replicating the husband/wife and father/daughter relationship. Szasz sees it as mirroring the master/slave, oppressor/oppressed, re-lationship. All this highlights the great difference in potential power "between the woman/patient and the male/therapist. In interactional terms he is one up and sheis one down, feminists contend that a woman is particularly vulnerable to the power of the male, therapist because she has been socialized to accept male authority, and therefore, has had little opportunity to speak with authority or to define herself. Fe-minist believe that the process of therapy can be harmful to the woman because her socialization leads her to more readily accept the therapist' interpretation of her problem. As that interpretation often tells the women to see the problem within herself, she is encouraged to turn in-ward. This inward turn is believed to reinforce her passive, and help-less stance towards the world. She does not a.ct in the world; she talks about her feelings. Thus, in following the therapist's instruction to change the way that she feels, she is given the implicit instruction to accept her existential situation and change her view of it. Feminists and other radical therapists interpret this instruction to accept her situation as one of the ways in which the mental health system acts as an agent of social control. They believe that this system acts to main-tain the status quo and to help women adjust to it.(Chesler, 1972) This critique has particular relevancy for the treatment of depressed women because feminists believe that the depressed woman's passive and powerless stance towards the world is at the root of her difficulties. Th^^therefore^believe that a system of therapy, which encourages that passivity and holds a negative stereotype of women will, be detrimental to the depressed woman. ,3. Feminist Theories of Depression in Women Feminist theories of depression in women are based on the ideological position which feminist take about the nature of women's position in vres-ltern society. It should be noted that other theories of hujnan behavior also rest on ideological positions; hoi/ever, feminist are more explicit in out-| lining the value stance upon which their analysis rests. ? Feminists_take the basic position that western society is patriarchical land is oppressive to women. They see the relationship between men and wo-ijien as the fundamental problem in society and believe that while society's jrigid sex role stereotyping is damaging to all its members, it is especially damaging to women. Feminists /view women's emotional^difficulties as an ex-I Impression of their relative oppression, and see the ultimate solution to men-j talJLllness and emotional problems as political. They believe that such a ? solution can only come from a reevaluation of sex role stereotyping and j.a redistribution of political power between women and n o . (Friedan, I963, |Greer, I97I, Chesler, 19?2, Smith, 1Q?5, Tennov, 1976 etc.) f Feminists describe women's experience in North American society as I [on in which women are systematically denied mastery over their lives. {(David, I975, Smith, 1975, Tennov, 1976) Feminists believe that women are i . - • • • • • • - -I " socialized to accept a narrow and restricted sex role. To support this | _ _ -| contention, they ^ ite studies in early childhood. socialization,patterns [which find that female children are less vigorously handled and are kept closer to their mothers for longer-periods of. time than .male....children. •These studies also find that young girls are not encouraged to explore .or initiate activities and are more likely to ask for help when confronted -75-with an obstacle than their male peers.(David, 1975) Later socialization teaches women that their role is expected to compliment the,mals^EQlg• Women are encouraged to view their success in terms of the reflected achievement's of their husbands and children, rather than on their own accomplishments. They are discouraged from ! becoming economically independent and are often denied equal access to opportunities in education and employment, The traditional female I role teaches women that their ultimate fulfillment in life is to marry, I bear and raise children. Women are taught that their role is to be pas-; sive supportive and nurturing to their husbands and to find their hap-; piness in their families pleasure. Women are seen as the providers of ' caxe and their role is to meet others needs, Women also learn that the work that they do in caring for their fa.mili.es is not highly valued within society, and they are encouraged to accept this low prestige as • part.of, their contribution to their family. Women are taught to value self sacrifice, to place their families needs ahead of their own and ; to depend on others for their definition of self and for their self > esteem. The above represents part of the cultural stereotype of femininity to which women are expected to aspire. It does not represent a complete explication of the female role. However, the key elements which feini-r nist's point to are there. Women's roles are largely defined in rela-tion to men, to serve the needs of men and are dependent on men. Women's i happiness, security, fulfillment and success are all defined In terras of husband and family. There is little room in the traditional female -76-role for an independent definition of self, or for experience of mastery in the world. .-Ijfv The combination of female socialization and societal attitudes towards women will, in the feminist view, lead to feelings of self doubt and worthlessness, frustration, anger, helplessness, and hopeless-ness. Feminists argue that this combination of socialization and socie-tal attitudes roughly approximates the conditions which behaviorists outline as leading to the behavior of leaxned helplessness, a.nd to the symptoms which many clinicians take to indicate depression. Feminists differ from a bebaviorist explanation in that they do not take this learned helplessness to indicate a rnaladaption within the individual woman hut ra.ther see it as an adaptive response to oppressive societal conditions. Women's feelings of hopelessness, helplessness, and despair are seen as a direct result of the'r r-.seialisation and their ongoing interaction in a society which roaintains that socialization. Some feminists view depression as an intensification of normally socialized female behavior. (Bernard, 1971. Baxt, 1971) Bart makes the point that female socialization teaches women to suppress their anger and subju-gate their needs to the needs of their family. Women are led to be-lieve that they will be rewarded for this self sacrifice with the life-long love of their husbands and children. Bart believes that depres-sion in middle aged women occurs when women realise that the antici-pated rewards are not forthcoming, and discover that their lives have lost meaning. (Bart, 1971) Higher rates of depression among married women are understood in terms of the effect which the ongoing monotonous experience of "being a housewife, mother, and wife can produce in women who have little experience or opportunity to do anything about their situ-ations . It Is clear that the feminist understanding of depressed feelings in women closely approximates the behavioral analysis of depression, as it outlines the precipitant stressor and learned helplessness which are seen as produced by traditional feminine', roles. However, feminists de-part from behaviorists in the interpretation which they give depressed feelings and behavior. Feminists consider those feelings to be an act of protest against the oppressive conditions under which women exist. (Chesler, 1972, Smith, 1975, Bart, 1971) Thus feminist theories of depression share some similarities with psychoanalytic understandings of the phenomena in that they accept the idea of suppressed anger in \ depression. They differ from psychoanalytic interpretations in that they locate the source of that anger in the oppressive societal con-ditions, and believe that female socialization, not innate characteris-• tics, has inhibited women from expressing their anger in more direct and assertive ways. f While feminists who address the question of women and depression tend to agree that depression can be understood as a protest and see depression as related to both sex role and stress, they are not unified in how much emphasis to place on each factor. As we have seen above, Bernard and Bart see depression as an intensification of normally so-cialized female behavior as a reaction to stress. Chesler, one of the most strident voices in feminism, downplays the role 'of additional stress in depression and other mental illnesses, and focusses on depres-sion as a rebellious act, Chesler's basic position is that depression and all forms of mental illness in women are caused by societies op-pression of woman. This oppression causes women to become mentally ill in greater numbers than j-,sn. Mental illness is reinterpreted to mean a rebellion against sex roIe> j n depression, it takes the form of a com-plete acting out of sex role stereotypes.(Chesler, 19?2) Feminist theories cf yromen and depression rest on evidence from a wide range of sources. They share the same base of evidence as be-havioral theories, for ao w e have seen, they have much in common with behavioral explanations, Feminist theories like other explanations are not predictive and rely cn retrospective interpretations. They do not specifically address cross cultural variations in depression, not do they explain why some wo; ,.n a r e helved by chemical and electro shock treatments. Chesler's ajgument that women become mentally ill in greater numbers than men is not ;,9ii supported by evidence. As Smith points out the statistics which Chesler cites in support of that conclusion have been edited to elim^te some categories in which males predominate. When these figures are reintroduced, there is virtually no difference between men and women in the treatment of mental illness. (Smith,1975) The alternate explanations of depression.which argues that women are handicapped both by their socialization and social discrimination, and are therefore less prepared to cope with life stress in an active asser-• tive way, stands on firmox ground. Feminist analysis of women and soci-ety rests on an analysis 0f images of women in the media, statistics on differences between men and women in edcuation and employment, studies on the socialization of young children, subjective accounts of individual women, interpretations of myths etc. It is, of course, not a scientific theory but an Ideological position. A-. an ideological position, it reflects the values, beliefs and attitudes of its proponents. As a social-and Intellectual movement, mo-dern feminism has been articulated and has found it prime support among -white, middle class, well educated women. Just as Freudian psychology can be seen to represent an interpretation of conditons in 19th century European society from a male's position within that society, modern femi-nism can be seen as representing an interpretation of modern societal conditions by middle class women from their experience of that world. T This is not to say that the feminist's explication of the female role is incorrect, but it does reflect the proponent's experience of that role and therefore, must be taken as a statement about mid 20th century society from her position within that society. The women, who have articulated the feminist position (that is who have had books pub-lished and widely distributed) have primarily been successful products of the liberal western system of higher education. That system highly values success and individual achievement. It also relies on a belief that suc-cess will be based on an individual's achievement not on their ascribed characteristics (i.e. sex, race) A woman who at some point accepted that liberal democratic belief and experienced some recognition for her academic accomplishments, would be far more sensitive to the disjunctures between that belief and the role which women are expected to play in larger society. As she moved from the academic world, where an idea is supposed to rest on its own merits and an individual's achievements are supposed to receive recognition on the basis of merit alone to the'real' world, where she found that her ideas were not really listened to with equal interest and her recognition was dependent on the reflected achievements of her mate j and .children, that disjuncture would have powerful impact. It is pre-cisely because this woman Is white and middle class that sex emerges as a central concern. If she was black, she might explain the disjuncture in.terms of race prejudice. If she was poor, she might seek a class analysis. But she is neither, so her sex role becomes central. It is not being argued that what she sees is not important or meaningful, but rather that the lack of other complicating factors (race, economic de-privation) allows sex role discrimination to emerge in high relief. She can see its effect precisely because she doesn't have those other fac tors.with which to contend. The feminist ideological position accepts the widely espoused value of equality among people and seeks to extend that concept to the relationship between men and women. Feminists also accept the widely held belief that self actualization is a desirable end, and place • high value on independence and self assertion. This emphasis on In-dependence undoubtably reflects'women's recent experiences In a society which is both highly mobile and rapidly changing. Under such changing and stressful conditions both independence and assertiveness are V ah -01-necessary and useful qualities. Given this experience in society, it makes sense for feminists to highlight "both women's lack of equality and their lack of assertiveness and independence in their explanation of why so many women feel sad, helpless and hopeless. The feminist understanding of depression does not represent a universal or 'completely 'objective' view of the problem, and therefore may not be applicable to other cultures or other times. However, it does represent the ideas, observations,__and conclusions of women within this society, who are considering a^problem in which women predominate, and s,s such, it offers insights and understanding which other views lack , G. Feminist Alternatives to the Treatment of Depressed Women As we have seen, feminists have foeussed on analyzing and under-standing women's oppression in relation to her sex role and have attempted to explicate hew that sex role oppression is reflected in women who are treated for mental illness and in the nature of that treatment. Feminist therapy represents an attempi^j^ithin the woman's movement to define how women 'ought' to be gnd to elaborate certain therapeutic principles whiph will^Jbe_liel]xful^o women in reaching that goal . Feminist therapy, there-fore, is prescriptive in nature. It relies on much of the analysisof women's role and feminist criticisms of traditional therapy systems which have emerged from the woman's movement, and offers feministthera-py as an alternate way of helping women. It does not establish its therapeutic priniciples only for women who are experiencing emotional distress, for it believes that to some extent all wom^n and men have been damaged by sex role stereotyping in this society. Feminist thera-pists believe that sex role stereotyping causes Individuals to have a narrow and. restricted, definition..of self and produces a;_fra_gmentati9n of the_p.e.rsonallty • Therefore,., it follows that therapy should help individuals to reintergrate those fragmented j>arts of their personality, and many feminist therapists share a gestalt\>rierrtation to therapy. (Sprei-Ott, 19?6) Anica Mander, a feminist therapist, defines feminism as "integrating the subjective/objective, rational/intuitive, the mysti-cal and scientific, the abstract and concrete aspects of the universe and considers them harmonious parts of a whole rather than In opposition to one another."(Mander and Rust, 19?4, p. ld)Therapy Is seen as healing thorough integration. F e i n i n i i p i e s. It believes in the natural goodness of humans and sees that goodness distorted by ex-perience in society. It takes the position that self^ctualizatASS_ inherently good for people and believes in each woman's potential to self actualize. It also believes that each woman knows what she wants a and what is best for her, although she may have had little experience in articulating her needs and wants. (Thomas, 197?) "Feminist therapists "believe _ thai.jpisy.chQ.1 ngl cal Jaealth-is-the samp for both males and..Xe.iaales. They contend that there is not one psycho-logical profile for a healthy.woman ancl.another profile for a.healthy male. (Sprei-Ott, 19?6) They see balance as the key to psychological and emotional maturity. The Feminist Counselling Collective sees the healthy person as both strong arid vulnerable (Feminist Counselling Col-lective, 1975) Feminists believe that among the characteristics jihich healthy people share are: self acceptance and the acceptance of others; spontaneity; involvement in deep interpersonal relationships; personal autonomy; a wide range..of interests; an approach to life which calls for individuals to be"ruled by the laws of their own character rather than the rules of society." ( Sprei-Ott, 1976) Thus feminist therapy shares a similar view of health with many self actualization psycholo-gies and the human potentialrp.oyjgnent. feminist therapy is not* hpnever,.a.restatement of humanistic psychology. Its principle difference is that it does not focus on how an individual is blocked from self actualization as a result of personal problems, -8'+-but would focus__on problems within society v;hich block self actuali-zation. It tries to reestablish the connection between the personal and the political. It addresses and. explicates the ongoing societal constraints which result in fragmentation on a personal level by analy-zing sex role stereotyping within the society. Therefore, feminist's understanding of society is an inherent part of therapy. In addition, unlike humanistic schools, feminist therapy incorporates a belief in political and social action as part of personal solutions. A central understanding within feminist therapy is that women have been d.enied the right to speak with the authority of their own experience. Feminist believe that that experience has been d.evalued within society, and disconflrmed within psychiatry. Therefore, feminist therapy wants to help women gain back this -power to speak.(McDonald and Smith, 1975) To make this point more clearly, let us look at how a feminist therapist and traditional therapists would d.iffer in under-standing self punishing behavior in a depressed woman. How would each interpret the actions of a depressed woman who remained in a bad and even brutal marital situation? The traditional therapist would probably interpret the woman's failure to leave her husband as an indication of a personal problem with-in her personality. As Smith points out, there is a psychiatric maxim that if an individual stays in "a punishing relationship when they could leave, then that individual must like the punishment. This traditional approach would transform the woman's problem in her marriage, into a per-sonal problem- namely her masochism. Feminists see this as a tendency within psychiatry to hlarne the victim. They helieve that this pro-cess would deny the woman's right to speak with the authority of her experience. (McDonald and Smith, 1975) Feminist therapy would reject this approach. Instead, it would help the woman to examine all of the social and personal pressures which cause her to remain in a situation which is painful for her. It would help her to paint a full portrait of the trap that she is in as she experiences it, and would accept that it is a very difficult trap to get out of. The therapist would help the woman to make the connec-tion between her personal experience and her situation. Beyond this, the' therapist would help her to see the pressures in her life as part of the pressures which women face in this society. Her experience of , being trapped, unable to act in her situation is unique, but the trap itself is common to all women. Essentially, the therapist tries to help the woman see her behavior as sensible by helping her reestablish the context in which the behavior occurs. She encourages the woman to speak with authority, However, the therapist also acknowledges that i the woman finds her situation to be painful. Once the woman has gained authority to speak, then together, therapist and client, begin to find j solutions which are 'actionable'. (Smith and McDonald, 1975) The process of feminist therapy rejects some commonly held psychi | atric beliefs. It rejects the idea that: l) the problem rests within the woman and can be diagnosed and treated by the" therapist; 2) the woman's experience can be fitted into a particular model; 3) the role of the therapist Is to Interpret and reformulate the experience for the vroman. Instead, feminist therapy asserts that equality between therapist \ and client is essential. It believes that inequality within the thera-peutic relationship leads the woman to feel one down. This one down situation enhances the woman's already strong feelings of powerlessness | j and undermines her ability to speak with authority and self worth. This j is particularly relevant for depressed women who often e>^erienc_e_intense feelings of helplessness. Fjeminist.. thea?ap4^ ts.lbelieMje that the therapy situation should enhance a woman's sense of her own power rather than intensify her powerless feelings. ^ Feminist therapy promotes equality in the therapeutic situation in a number of ways: 1) the therapist shares her values and beliefs with the client; 2) the therapist acknowledges that she like the client is strug-gling to self aetiialize and emphasizes the commonality of the experience; 3) the therapist works to demystify the process of therapy; k) the therapist sees the client as a consumer of a service, encourages her to shop around, and to complain if she doesn't like the service which she is getting; 5) the therapist sometimes uses contracts to specify mutual ex-pectations of therapy and to evaluate how the therapy is progressing 6) the therapist shares her own conflicts and difficulties where this is appropriate; 7) the therapist emphasizes the strengths not the weaknesses of the client. (Sprei-Ott, 1976 ) -8?-Feminist therapy emphasizes changes rather than adjustment, and encourages women to express anger which they feel about their situation and their position in society. Feminist therapy also encourages women to learn self nurturance. It does this by encouraging the woman to see how she has been devalued and then to learn to revalue herself. It helps her to recognize that her needs do count, that she has a right to be selfish, that she does not have to assume responsibility for other peo-ple's feelings, and that she has a responsibility to take care of her body. It encourages her to take responsibility for her life while still recognizing all of the societal blocks which she must face. (Sprei-Ott, 1976, Iiander and Rush, 197^ Williams, 1977) . Feminist therapists use a wide range of therapeutic techniques and borrow from other schools of therapy. Feminists see conciousness raising^roups as an essential tool for both societal anal, ' s and personal redefinition. Griffith states that conciousness raising is not "therapy, nor is it counselling, nor is it political in the tradi-tionally defined manner. And yet it is all three and more." (Griffith, 1975, p.151) They also provide training J ^ ^ s e ^ learn to overcome learned passivity. They use;body work; to help women in^grate body and mind and to deal with negative feeling about, their own. body and their sexuality (iiander and Rush, i9?*0 Feminist therapists p r e f e r group rather than individual therapy as they believe that women . can learn from each.other. The above represents a summary of some of the principles and tech-niques which are associated with feminist therapy. The summary is incomplete as feminist therapy is still in its early stages of develop-ment and written descriptions of the process are relatively scarce. It is important to look at how a feminist therapist might_under- ,, stand and treat a depressed woman. To accomplish this task, we will again turn to the case example of Ester_Greenwood. Feminists would^roderstand Ester's depressi_on._as..an_ inten sixic.atlon ofjiorroftl female sop.ia1i,g8.tion and a protest against^ the restrictions of her societalfly_defIned sex role. Like other theories of depression, feminists wouldprohahIy.s^ e..,E.st-ex.ls..dep.X-easio.n-,as,-_txlggered hy her rejection from summer school. They would understand that for Ester school represented a place where she was,free to express herselfto pursue her own interests and. to "be rewarded for hex own achievements. However, when Ester was cut off from this protected environment, she found herself unable to cope with the 'real' world' of women. Feminists would see Ester as having to face a world which expected her to marry, to have children, to..-limit her vocations,1 interests to traditionally feminine areas (i.e. working for a fashion magazine) and which pro-vided little support for a female who wanted to be a poet, not a sec-retary and who was not, sure that she ever wanted to marry and have chil-dxen. Ester's depression would be seen as an expression., of.-her inability to adjust to that narrow sex role and as an expression of her feeling that she was helpless to change the oppressive conditions which her sex role imposed upon her. Her .feelings__gf .helTtlassne.sa, would be un-derstood as a product of her socialization as a woman since that sociali-zation taught her to accept a passive and nonassertive stance towards the -89-world. Her feelings of worthlessness and self doubt would also be seen as a product of her socialisation in a society which taught her that because she was a woman,she was of less valued than her brother. Ester would be seen as blocked from self definition and thwarted In her attempts at self expression. Her depression would be seen as her protest against conditions which she felt were both unfair and insur-mountable . In attempting jto helpJEster, a feminist therapist would not try to impose her understandings of depression on Ester's situation. Instead, she would help Ester to develop her own understanding of her situation. She would begin by assuming that Ester had inherent strengths and had the potenti.al to both define her distress and to know what would be best for her. For her part, Ester would probably c-nter the relation-ship believing that she could do neither. I:he task of the therapist, therefore, would be to help Ester find her -,oice. The therapist would not try to make sense out of Ester's experience but rather to help Ester to see her own experience as sensible. She would do this by helping Ester to understand, her feelings and behavior in the context of her experience in the world. The therapist would try to help Ester make some of the connections between feelings and situation, between herself and other women, and between herself and her position in society as she experienced it. All of Ester's experience would be relevant. Her feel-ings about her rejection from summer school, her concern over her fu-ture as a poet, her refusa.l to learn to type, her uncertainty about marriage and children, her anger over the double standard which society sets' for men and women would all "be considered, In a sense, Ester would be allowed to _see_her; many..good reasons for feeling depressed, and her norm alcy would be confirmed. This would only be a beginning because Ester would also be helped to make connections between her si-tuation and the situation which women face in this society. The thera-pist would try to establish equality within her relationship with Ester and might share some of her own feelings of uncertainty, anger and power-lessness. She would let Ester know..what-her values, wexe-and_Jao.ii. she understood the process of therapy. She would, encourage Ester to par-ticipate in evaluating the therapy experience. Ester would be encouraged to join a conciousness raising group so that she could share her experi-ences with other women, to help and be helped in the group, and to recognize the commonalities in women's experience. As Ester was helped to establish her feelings and behavior as sensible (related to her situation), Ester would be helped to express her anger over her situation and her position in society. Since Ester's depression immobilized her, therapy would aim at reestablishing her capacity to act. Expression of anger about her situation would be seen as one step towards a more ac-tive and assertive stance. Ester's desire to change would also be re-cognized and she would be offered help to unlearn some of her socialized sex role (i.e. assertiveness training etc.) She would be helped to revalue herself through self nurturance. The aim of therapy would not be to help Ester to adjust to her situation but to change and she would be encouraged to become socially and politically active in bringing about societal changes. -91-All of the above repres ts some of the ways in which a feminist therapist would offer help to a depressed woman. The strength of this approach is that it rejects the idea that the depressed woman is sick and that her behavior and feelings are reflections of her illness. Furthermore, this approach asserts that human behavior, requires its context to make sense and supports the idea that the depressed woman must be^given,,the . right,to,,speak with authority and to act., in the world. Despite Its strengths, feminist therapy is not a panacea., and has both limitations and difficulties. One limitation of feminist . •'(/ therapy is that it, like all insight therapies, does not deal well with acutely depressed or suicidal women, ar.d these women..are. usually referred to psychiatric facilities. (Sprei-Ott, 19?6) Feminist thera-py does offer help following hospitalization to mitigate some of the negative effects of that experience and to assist women in reaffirming their strengths and sanity „ An important concept in feminist therapy is that the therapist does not impose her definition of the problem on the client, but rather helps the client to define her problem for herself. This concept presents some difficulties, for the feminist therapist does enter the therapy situation armed with her ideological position about women and society and with her own system of values based an her ideology. To - some extent, she will use these resources to help the client to formu-late the problem. While it is true that a feminist therapist is ex-pected to openly share her values and assumptions with the client, -92 they will nevertheless effect how the problem is defined and under-stood. It is unlikely that a woman emerging from successful feminist therapy would decide to adopt a traditional feminine role nor that the therapist would, see that choice as a desirable result. Another issue in feminist therapy is the question of equality between therapist and client. Some feminist believe that equality is impossible in a therapy situation, and therefore, reject the notion of feminist therapy. (Tennov, 1975) Others assert that it is a difficult but reachable goal. It seems to me that while feminist therapists do mitigate the power relationship between client and therapist, a differ-ence does and must exist, A woman comes to a feminist therapist be-cause she is experiencing distress and wants help. In approaching the therapist, she acts on the assumption that the therapist may have some-thing to offer which she herself does not. While it may be true that the woman has strengths and has much to offer to the therapist, it is still the case that the woman comes seeking some answers and the therapist comes with some ideas and tools which she believes will be of help. It seems preferable to acknowledge that difference than to deny it. As Jo Freeman point out.differences in power exist in all relationships. If they are denied, then they cannot be addressed^, and problems In this aspect of the therapeutic relationship cannot be dealt with. Freeman calls this the tyranny of structurelessness.(Freeman, 1973) It seems preferable therefore to acknowledge and specify power differences, so that difficulties which arise can be addressed. -93-Another criticism which can he made of "both feminism and feminist J , „tf M ? ~ ~ ' fa r , I therapy is that they offer an overly simplistic understanding of the ^ | , male role within this society. It appears that in order to more fully jf f explicate the woman's role in this society, feminists have held the male role in a fixed position, and have left it relatively unexplicated. Feminists do recognize that "both males and females,suffer from sex role stereotyping, but contend that since the male Is in a dominant position, he suffers less and causes women to suffer more. I do not argue with the position that males dominate. The evidence is clear. However, even dominance has its costs, and these costs have not been examined to any extent within feminist literature. Feminists have strong reasons for their refusal to deal more ex-tensively with the male role. They argue that virtually all of human history has loan written from the male point of view, and therefore, males views are already well documented. They believe that it is the female view which has not been heard,and they want to focus their at-tention in this area. Finally, they state that if males want to look at the negative implications of sexism for males,, they should do it them-selves . Despite the internal adequacy of the reasoning of feminists on this issue, the limited explication of the male role may present problems for feminist therapists who are working with depressed women. An unexpli-cated and stereotypical view of the male role may lead to a distortion of how women do experience their relationship with males and male domi-nation, and may not fully equip women to understand or deal with the complexity of their interactions with men. Given the high inci-dence of depression among married women, and the finding that many depressed women report significant marital conflict (McLean, 1976), therapists working with depressed woman are frequently asked for help in this area. Therapists working, with married couples may require a deep understanding of how sex role stereotyping affects hoth the male and female and the ways in which hoth stereotypes are mutually main-tained . The limited analysis of the male role presents another difficulty for feminist therapy. This problem is related to the goals of therapy and the image of a balanced, healthy person. The image which feminist therapy portrays of the healthy individual is very attractive, and the idea of balance between masculine and feminine traits certainly makes sense. It is, however, not very specific. What is a balanced view? How much assertiveness is enough? How much is too much? How much aggressiveness is desirable? It seems to me that while balance -is clearly the goal, feminist therapy helps women to add to their concept of self (or reown parts of themselves)traits which have traditionally associated with males. While these additions may be desirable in ac-hieving a more balanced stance, they may also have some costs. Indeed, in the 1920's, women considered their right to smoke in public a symbol of their emancipation. Today,' some of us axe paying the price for that particular emanicipatory gesture. What kinds of costs can women expect to pay for a more aggressive stance in the world? What are the priveledges which she currently enjoys that she will have to abandon? -95-Weissman notes that recent statistics indicate a rise in female alcoho-lism and criminality - difficulties which have predominantly affected men. (Weissman, 19??) Despite their dominance, the males existential situa-tion can hardly be called idyllic. High rates of heart disease, alco-holism, drug addition etc. speak to some of the difficulties. A more complete explication of the restrictions and ramifications of sexism on males and females may he helpful in assessing some of the hazards to he avoided. As the goal of feminist therapy is change, it is im-portant to have as clear an understanding as possible of the implica-tions of that change, '1 Feminism has been criticized for failing to acknowledge women as responsible. The argument which has been presented is basically that feminism encourages women to blame society and males for their problems and discourages women from taking personal responsibility for their situation. (Beck, 19?4) While this may be a valid criticism, of the position of some feminists(Chesler in particular), it Is not a valid criticism of feminist therapy. Feminist therapy asserts that there is a difference between accepting responsibility for problems a,nd accepting ones position as a responsible adult in society. The first notion of responsiblity can quickly be turned Into blaming the distressed individual for whatever problems she may be experiencing. Feminist therapy avoids this pitfall. However, in openly affirming the woman's right to speak with authority, and by encouraging the wo-man to take an active role in society, feminist therapy treats the woman as a responsible person. It does not infantilize her by offering -96-pre-packaged psychological explanations for her problems, but rather : legitimates her right to participate in society as an adult and strengthens her view of herself as a responsible person. In summary, feminist therapy offers an alternative view of helping depressed women. The alternative is based on "both a feminist analysis ' of women and society and feminist critiques of current therapeutic ideo-logies and techniques. The core of the feminist approach._is_t.o.. affirm the_basic .strength- and ^ competency...of .the woman and to reject the idea that sheJLs_a_sick and helpless individual. Feminist therapy seeks to • help women by establishing therapeutic relationships which are based on j' equality and mutual respect, and by helping women to see the difficulties | which they are experiencing in a larger social and political context. j. Itsaim is to help women see themselves and their behavior as sensible and to view themselves as competent and responsible ' •.dividuals who can ' act_j_n_the world. Feminist therapy does have both limitations and i difficulties. The prime difficulties lie in the problems inherent in ! establishing equality In a therapeutic relationship and in feminisms incomplete analysis of the implications'of sexism on both sexes. It i must be noted, however, that feminist therapy is in its early stages of development,' and that some of these difficulties may be more fully ad-dressed as it continues to develop and grow. Despite its current 1 limitations, feminist therapy represents the most .geniunely sympathetic /approach to understanding the depressed woman and her problem. Given the self doubt, self blame, and lack of self esteem which so often ' accompanies depressed feelings, It seems to me that a truely sympathetic , ^^VfofukUto'tUU klip*. M U t ^ u j Ufach jUhMMt -Ifofaft ccm mrnh ton ; - mU he trur* Juty iAtomt m M M Jwk &t tonckutcm m I ty /'• fl 't > Ill. Conclusions and Implications for Social Work -99-Now that we have completed an examination of the dominant traditional approaches to understanding and treating depression in women and the fe-minist alternative, we are left with the pressing question of what conclu-sion to draw. frTow are"we~to understand and work with depressed women?! ^ Which theories or parts of theories should we adopt in understanding de-pression? What therapeutic principles should we follow in_ offering,-.help tojier? These questions axe pe^tieularly relevant to social work as in our work, we ,are often. intimately involved in the lives of depressed women'. Let us begin ty reviewing the__'facts' about^depression.to see what we can say with certainty atout the problem. Hfe_can say that depressed feelings are common feelings in people and that depression represents a feeling of innex sadness and despair, beyond this much is .asserted, and little is known with certainty. All serious researchers agree that depxession is a complex problem which has defied many attempts at defi-nition. Definitional problems have created difficulties fox both diag-< nosticians and epidemiologists. Researchers have found that there is lit-tle agreement among clinicians in diagnosing the problems. Difficulties in diagnosis present problems for epidemiologists as they rely heavily on clinical findings in generating the statistics which they study. If the diagnoses are unreliable, then their studies must reflect that un-reliability. Even the most wide.ly supported finding that females pxe-ponderate has been questioned on that basis. ^One finding which car^be established with certainty is that females are treated for depxession . twice as often as males, and that when..females come into contact with -100-psychiatxy t-.hf»y. fitted into, affecti,ve^nd neurotic categejdSSJBSPX^ -than 60% of the time. As we examined the process of psychiatric diagnosis of depression, ;Be found that it relies on an illness assumption. We also found that t the diagnostic process depends on a number of assumptions which the cli-I nician makes about the nature of depression and the way in which he inter-prets his interaction with the patient. Psychiatryis not an_exact or ob-jective science, and the art of psychiatric diagnosis represents the,ways .in which psychiatrists abstract and fit people's experiences into illness l categories. lft is important.for-social workers to.understand this, for j;, I: nany things 'fhlrtl «ppp*a'r ^xim! _aM.certain. are .less.. so once this ...is un-| derstood. jj ^ s paper has examined the dominant causal theories of depression I'and women. All of these causal theories have some evidence which sup-ports their explanation but none rests on conclusive evidence, '^ac^tho-.[ oryjnighlights different aspect depression and rests_on_different as-:' sumptions. For the psychoanalyst, depression is caused hy anger turned . inward. For the organic theorist, it is caused by. a chemical imbalance . j Cognit^eJ^rists view it as a thought disorder, andJbel^iorists con-clude that it is caused by insufficient reinforcement. Femini.st.sounder-i stand it as a response to oppressive societal conditions and a narrow and restricted sex role. Each causal explanation provides certain insights •into the problem; however, given the present state of our knowledge about depression, we must conclude that all theories represent an incomplete understanding of the problem. None of the theories is predictive. They -101-all rely on a retrospective analysis to support their hypothesis. As it Is clear that we will he unable_ tQ,..find, a„c.Qnip.lete _and satis-factory explanation .fox-, the nature ..andcauses of depression in women, we will have to draw conclusions based on our limited knowledge, recog-nizing that oux understanding will be incomplete. Our task is to decide • which approach (.ox-.combination, of approaches) will provide the most as-sistance In understanding and helping the depressed woman. In order to help reach these conclusions, we return to the case : example of Ester Greenwood. This time we will look at the Insights .which Plath gives us in understanding Ester's difficulty. How does Ester : make sense of her problem? How do we, as readers, feel about Ester's situation? In reviewing Plath's account of Ester's situation, we find that the central chapter does not offer us a consistent and logical struc-ture with which to make sense of her depression. Ester's sad and hope-less feelings are not abstracted our of her daily living, they are an integral part of that life experience. She experience depression in the ) context of other things. As readers, we require the background of her life to help us make sense of it. Plath's account provides that back-ground, and Ester never emerges as crazy or non-sensible. However, 'Plath does not provide us with a logical orderly process of becoming depressed. If we want such a structure, we will have to bring it to the Neither is it likely that the 'typical' depressed woman will be able to give us a rational, orderly explanation for why she feels the material -102-way that she does. Instead, she may tell us that she is not sure how to make sense of her feelings and that she feels confused and uncertain. As we read Plath's'account, it is clear that Ester feels that her life is hopeless and without meaning and that Ester herself feels unable to give it meaning. Her inability to make sense out of her depression is a central concern. It frightens her, leads her to doubt herself and ques tion her own sanity. Ester concludes that there is something wrong with her, that she is abnormal, that she is incompetent, that she is not like other women and that she is not 'Supposed to feel the way that she does. As Ester is unable to explain her depression, she feels completely power less to cope with it or change. In approaching her first interview with a psychiatrist, we under-stand that Ester experiences a mixture of emotions - sadness, fear, des-paration, powrerlessness and hope that the clinician will offer her rea-sons and relief. She brings to the clinician not only her depressed feelings but her own acknowledged 'fail UX6 ~L o cope with those feelings. This attitude makes Ester exceedingly vulnerable to the suggestions and interpretations of the clinician, who she hopes and believes is more knowing than she is and who may have the ability to make sense of all the Inexplicable parts of her total experience, and offer some relief. Plath's account of Ester's first clinical interview speaks to both the vulnerability and hope which she invests in the clinician. "I had imagined a kind, ugly, intuitive man looking up and saying "Ah! " in an encouraging way, as if he could see something I couldn't and then I would find the words to tell him how scared I was, as if I were being stuffed farther and farther into a black, airless sack with no way out. "Then he would Dean hack in his chair and match the tips of his fingers together in a little steeple and tell me why I couldn't sleep and why I couldn't read and why I couldn't eat and why everything people did seemed so silly because they only died in the end. And-then, I thought, he would help me, step by step to be myself again." ^ ^ ^ ^ ^ -All theories and t h e r a p i e s which deal with depression acknowledge ^^vulnerability of the depressed woman and her lack of confidence in her own^bility to. hand ...her problem, psjrcho^^rsts^peak of the de-pendent personality of the depressed individual. Co^ve^psZchqlogists point out that she lacks self esteem and construes herself in a negative way; B^^orists^ speak of learned helplessness, and organic re searchers point out that the effectiveness of placebos in treating depressed pa-tients .indicates their extreme suggestibility and hence vulnerability. Feminist therapists also recognize this difficulty, and they too speak of the woman's learned helplessness and inability to speak with authority. However, feminists therapists differ from the others in •that they examine the consequences which this vulnerability and lack of self esteem has in the depressed woman's interaction with the clinician. in the treatment process, . Feminist therapists point out that the depressed woman-enters, the treatment situation already convinced of her failure, her incompetence, and her inability to help herself. She not only acknowledges these pro-blems but blames herself for them. She sees herself as the problem, and . is fully prepared to assume and accept the one down position vis a vis the therapist. The feminist view suggests that the woman's acceptance of self blame and failure is a central part of the prpblem and point out that the therapist can act in many ways to confirm that view. If the ther-• apist agrees that the prohi em is within the woman,assumes that his under-standing of the woman Is more adequate than her own, and offers his assis-tance in locating all the ways in which she and her personal history cause her trouble, then he confirms this negative view and increases her feelings of dependency and self doubt. As we have seen in our review of the 4 dominant approaches to under-standing and treating depressed women, the organic, psychoanalytic, and cognitive approaches, all assume that the problem is within the woman. Only the behaviorists reject this assumption and consider her environment, and behaviorists often conclude that she Is maladapted to that environment. r^All of the k dominant theories place the clinician in a central and power-ful role as definer of the problem, and psychoanalytic and cognitive theories offer her assistance in location the way she and her personal history cause the problem.' 6nly the feminist orientation focusses attention on the inter-action of the depressed woman and the therapist and offers an explanation and treatment approach which does not confirm the depressed woman's nega-tive and self blaming view but instead actively seeks to counter It In wor-king with her. I believe that this represents a major strength in the feminist orientaaion. Pf%t ap — w o u l d like to suggest that the feminist approach to understanding v / — • • - " ' - - - - - j and helping the depressed woman offers the most assistance to social wor- 1 • kers engaged in this work and should be adopted as the professions basic theoretical and treatment framework in working with this problem. I take this position because I believe that the feminist orientation speaks most directly to the core concerns of the depressed woman, recognizes and en-gages a central problem in working with her and provides a viable alternative to understanding and helping her. 1 also believe that the feminist orien-tation is the most compatible with social work's theoretical ori en ta cion to the world and with the value stance on which the profession rests. ) As a profession, social work has adopted a theoretical orientation to the world which focuses on the individual within her. social environ-!:meni_. "This orientation has stressed the importance of social, factors I in human development and sought to understand how individual's interact : within their social environment." This concern for the person-in-situation has differentiated the social work approach from the other helping pro-fessions. We have understood that a person's behavior requires its con-• text in _>rder to be meaningful and have recognized that an individual's self concept is developed.in interaction with self and others^' Given our ' social orientation, we have long accepted the Idea that social discrimi • nation and stereotyping will have inpact on an individual's view of self. 'lf^seem_s_then compatible with—QirnJ^kgjromid orientation to the world., that we_ should accept .^_jBac4a3r--aM--4Rteractio«al-'understanding of-depres-sion and women, and I think that the feminist theo3^ y speaks to that o-< rientation most clearly. 11 offers us..a .wav..Qf..'underatandiii£...deprfission ; in women not as an individual psychologic^,!.-problem but as a problem in the woman's relation to her situation and her position in the larger so-i ciety. It accepts the Importance of social factors in the development j of self concept and understand the woman's problem as a product of both her socialization and her ongoing interaction in society. Finally, its i, analysis helps to establish important links between social discrimination \ • f and stereotyping and the problem of depression. It does not represent a i -106-complete understanding of the problem for none of the theories can do that. However, itjBOS^cleariy_addresses the problem of the depressed woman in her situation andjspeaks most directly.to .social work's orienta-tion and the work which we d o . ^ • Just as the feminist orientation is compatible with social work's theoretical orientation, the feminist approach to treatment is compatible • with the value position on which the profession rests. In offering help to the depressed woman, a feminist therapist seeks to interact with her ' in ways which will confirm: her basic sanity and health; her ability to ' define her own problem; and her right to participate in the helping pro-cess as an equal partner. In taking this approach in her Interaction with the depressed woman, the therapist strikes at the core of the de-; pressed woman's negative self concept and gives her the right to speak . with the authority of her own experience. As we examine the values I which the feminist therapist tries to operationally in the relationship, \ we find an affirmation of strength and health, a right to be treated with [ dignity and a right to self determination - the core values of the social r work profession. [ feminist therag^s approach,to the problem of depression rests on one other crucial understanding. It tells the depressed woman tha^she is not .alone - that otoe^^en, feeler., have, felt the v,ny that she docs. C o f f e r s her a broader context^in which to understand herproblem and emphasizes the depr_ess^r. wman .'.s . commqnality J^xth_other_itwom^n_not .her •' differences. . It operationalizes this understanding by /enco^ing_the ' woman to be invol^t^d^-mutual -107-others and "be helped by thorn. In taking this approach, feminist thera-py strikes at the feelings of isolation and self blame which are central to depression. ' Again, the belief in mutual self help is central to social work and. the_medial.i,ng„iaod.el„.in group. .work. shares many similarities wlth the feminist..approach... ^Tt seemsjglear that .feminist-...therapy arid, social work share siialla£_Jga.lues and |i»HRfs. As feminist therapy makes a con-certed attempt to implement those values in the helping relationship, it has much to offer social work. The basic position which feminist therapy takes in interaction with the depressed woman directly addresses and deals with the concerns of the depressed woman, and offers the most sympathetic view of the woman and her situation. It is particularly important for social work, which has tra-ditionally been a woman's profession, to accept an approach to depression which recognizes the woman's concerns, emphasizes the commona.lities among women and offers the woman sympathy and support. I believe that all of the above supports the basic premise that social work should accept the feminist orientation in understand and helping depressed women. However,1" an acceptance of a feminist framework does not mean that w:e.-.cannot...dxaw. on... .other .appraaches..tp...depres_siorL,_n.O-t recognize the contributions which thev make-in understanding and treating the problem. seems clear that both the__T2.gfo.g.Yiorist and cognitive approaches offer important insights into working with depressed .women and that these insights can be, .integrated- into,.a. feminist-interactionist orientation. Vie have already seen that the feminist orientation shares much in -108-comraon with the behavioral approach, and that many behavioral techni-ques ^e..jtB.porpprated wj.tbjji.-f.,therapy. ^Behaviorism more than any other theory recognizes that individuals do not change by insight alone, and has demonstrated the importance of helping depressed women restore their self confidence by setting reachable goals and slowly buil-ding from one small success to the next. Behaviorism has introduced the concept of learned helplessness and offers assertiveness training to help change this behavior, This technique is widely used, by feminist thera-pists. Behaviorists have also contributed to our understanding of the effects of lack of reinforcement and. social isolation on_depre_ssion_and offer help in this area. All of these techniques are compatible with the feminist orientation and add much to the approach. The cognitive appioech to depression and woaen__makes an important contribution to (••••••• understanding of how depressed women participate in producing a negative view of self. In evaluating the cognitive approach, we have seen that it stresses the ways in which the depressed woman pro-duces her own difficulties by construing herself, her experience and her future as negative. As a total understanding of depression, the cogni-tive approach is not compatible with a feminist orientation for it does not address the "woman and her situation. The feminist orientation does, however, acknowledge that women participate in prodiucing a negative view of self and link this to their spcialization as females and the devalued female role. Cognitive theorists provide a more complete understanding of how women participate in creating and maintaining a negative self Image s than Is available within feminism and offers ways of helping the women Ito change this negative self concept. I suggest thata cognitive.ap-proach coupled with a feminist ...analysis, .and orientation will enhance our effectiveness In helping women in this area. To sum up, it is the basic position of this paper that social work as a profession should accept a feminist analysis of depression and a "feminist orientation to helping depressed women. This requires that we , accept the basic feminist position that women are handicapped by both their socialization and social discrimination, and are therefore less ,.' prepared to cope with life stress in an active assertive way. This I position also asserts that depression represents depressed women's pro-; test against conditions which they feel they can neither accept nor change, 1 This position is based on a belief ahat the feminist orientation is most compatible with social work's theoretical orientation and with the basic | value stance upon which the profession rests. The feminist approach I also speaks most directly to her concerns and offers the most sympathetic f and supportive approach to the problem. This supportive approach is seen } as a major strength because self blame and self' doubt are central aspects j; I of the problem of depression. [ Within this basic orientation, itjias. been., suggested that.social work should.integrate.J,b^fiflnJ^utions which_l»th behavioral and.cogni-[' tive approaches make in understanding...and treating depression in women, ji Such an approach would lead to a more integrated understanding of the [j problem and would increase our effectiveness In helping depressed women. This paper has addressed, the implications which the feminist orien-tation has for understanding and working directly with depressed women. -no-i m m m t - * * j {/,< \f' ! However, in our roles as social workers, we are often in positions where |,we offer indirect help. He are sometimes involved in program planning land, development or in the management of social. searvxces.JatiA'-g^  effect I sr**"" 1 ^depressed women. We are often expected, to wo.rk.with the mental health ;system in preparing a woman for treatment, in providing practical support •during treatment and in dealing with the social ramifications of her de-i pression on her children and family. What implications does a feminist ;• orientation have for these situations? In concluding this paper, I will not attempt a complete discussion :' of the implications for social work in all these situations hut rather i offer some brief suggestions which may he of some help. I would hope that •• if social workers seriously consider bringing a feminist orientation to .1 their work in this aresi. that these and other implications would be dis-cu ;sed in more detail and with more elaboration. feminist orientation to depression would Imply that when we | as social workers interact with the mental health system, we wpuldjreject I the illness assumptions and instead seek to affirm the depressed woman's j basic normalcy and. strength. It would also mean that we would Insist J that the depressed, woman's situation be considered.in.understanding her | problem. It\ould imply that we would try to make her actions and feelings sensible rather than crazy and would not accept the mental health system's interpretation of her problem over the woman's own interpretation. This ' orientation would require that we affirm the woman's right to be treated ; as a responsible adult and speak with authority. It would also require i that we support her right to participate In the planning., of her treatment, - I l l -ana to he aware of the benefits and hazards which that treatment might involve. A feminist orientation would mean that we would lend our support to a l t e r n a t i v e , , , n o . , o f helping., depressed women. It would lead us t o s u p p o r t and encourage self help groups for women. These groups might include separation and divorce groups, single parent groups, assertiveness training groups conciousness.raisingJ^rou]^ etc. It"4uld also mean that we would support the development of .resourc.es which would offer practical support to women and seek to .midigata.-the ne-gative effects which social isolation can have on wmen. Reliable, af-fordable day care is only one example of s u c h - services. A feminist orientation would imjly a concern for current societal conditions which discriminate against women and increase..the .pressure and stress in their everyday lives. Thut unequal employment opportunities inadequate government support to women on public, assistance etc ...would be of concern and social workers would...ba...exp-ected- to- activ ely^ -support changes in these areas. Finally, a feminist orientation to women;and depression would imply ( that social workers recognize the real life difficulties which depressed | women encounter and the sometimes insurmountable obstacles which they face., This*orientation^would insist that we recognize that depressed w o m ^ a v e j n a n y . . . g o . o d s a l a ^ M e l f i s s f e e l w g s > I t I would director attention,toJ:heJdfe^ j her role as a woman and would ...lead usto recognize., that t h o s e stresses not solvable t h r o u g h .....therapy ..or .counselling but through social and are -112-polltlcal a c t i o n . I t w o u l d i n s t r u c t b o t h s o c i a l w o r k e r a n d c l i e n t t o seek p o l i t i c a l s o l u t i o n s . T h e a i m o f f e m i n i s t t h e r a p y w i t h d e p r e s s e d women i s c h a n g e n o t a d j u s t m e n t . I f w e a d o p t t h i s o r i e n t a t i o n , w e m u s t r e c o g n i z e t h a t o u r a i m w o u l d b e t o e n a b l e t h e w o m a n t o a c t i n t h e w o r l d a n d t o a d d r e s s h e r a n d o t h e r w o m e n ' s r e a l c o n c e r n s i n a m o r e a c t i v e a n d a s s e r t i v e w a y . I i BIBLIOGRAPHY Abramowitz, E. I. Ayd, Frank Bart, Pauline Beck Aaron Bernard, J. Broverrnan, I. et.al. Burke, L. et.al Burlin,F. & Guz: "The politics of Clinical Judgement. What Non-liberated Examiners Infer About Women Who Do Wot Stifle Themselves", Journal of Consulting and Clinical Psychology, 1973, 41, 385-391 Recognising the Depressed Patient, New York: Grune and Stratton, 1961 "Depression in Middle Aged Women" in Women in Sexist Society, Gornick and Moran (EdT) New York: "Basic Books, I97I. Depression, New York: Harper & Row, 1967 The Diagnosis and Management of Depression, Philadelphia: University of Philadelphia Press, I96? "Cognitive Therapy with Depressed Women" in Women and Therapy, Franks and Burtle (Ed.) New York; Brunner/Mazel, 1974. "The Paradox of the Happy Marriage" in Women in Sexist Society, Gornick and Moran (Ed.) New York: Basic Books, 19?1 . "Sex Role Si raotypes and Clinical Judgements of Mental Health", Journal of Consulting and Clinical Psychology, 1970", 34, 1-7." "The Depressed Woman Returns", Archives of General Psychiatry' Vol 16, May: ,.1967. :a "Existentialism: Psychotherapy for Women" Psychotherapy Theorv, Research and Practice, 14, 3, 1977, p262—266. Cammer,L & Marshall,M "A Clinieial Analysis of the Effects of Disimpramine in Outpatients with Depression", in Depression in the 70's. R. Fieve (Ed.) New York: Excepta Medica, 1971-Chesler, P. 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Depression in the ?0's, New York: Excepta kiedica, 1971 • Women in Therapy, New York: Brunner/kiazel, i9?^ ' * "The Tyranny of Structurelessness", Ms, 1973-The Feminine Mystique, New York: Dell Publishing, I963. "Hostility Factors and Clinical Improvement" Archives of General Psychiatry, Vol 23, Dec., 1970. "Some Psychical Consequences of the Anatomical Distinctions Between the Sexes (1925) in ifomen and Analysis, J, St/rouse (o&.-) New York: Grossman Publishers, 1974. "Female Sexuality" in Women and Analysis, J. Strouse (Ed.) New York: Grossman Pub., 1974. Collected Papers, Vol II, london: Hogarth Press, I953. Collected Papers, Vol IV, London: Hogarth Press, 1953-Women In a Sexist Society, New York: Basic Books, 1971. "Adult Sex Roles and Mental Illness" In Changing Women in a Changing Society,,J. Huber (Ed,) University of Chicago Press, Chicago, 1973-The Female Eunuch, london: Paladin, 1970. "Feminist Counselling, A Valid Protest" in Women look at Psychiatry, Smith and David (Eds.) 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"Depression as a Specific Response to Stress" in Stress and Anxiety Vol III, LondonV John Wiley, 1976. "On Freud's View of Female Psychology" in Women and Analysis, J. Strouse (ed.) New York: Grossman Pub., 1974. Psychoanalytic Concents of Depression New YorkTjSpectrum Pub., 1974. Psychoanalysis and Women , New York: Penguin Books, 1973. Cognitive Psychology, New York: Appleton-Centuxy-Crofts, 1966. Plath, Sylvia Rawling, E. and Carter, D. (eds.) Rosenhan, D. J., Schefi, Thomas Silverman, C. Shepard, M. Smith, D. and David, S. Sprei-Ott, J. Stoller, Robert Strouse, Jean (ed.) Szasz, Thomas Tennov, Dorothy Thompson, C. Weissman, M. and Klerman, G. The 3elI Jar, New York; Bantam Books, I 9 7 I . Psychotherapy for Women, Springfield: Charles C .""Thomas, 19??. "Or; Being Sane in Insane Places". Science, 1973, 179 (Jan) p. 1-9. Being Mentally III: A Soc101 ogi.cal Theory Chicago: Aldine Pub. Co., 19*66. Labelling Madness, Englewood Cliffs, N.J.: Prentice Hall, Inc., 1975 The Epidemiology of Depression, Baltimore: The John Hopkins Press, 1963. "A Critical Review of Drug Trials", In Depression in the r/0 ks, R . Fieve (ed.) New York": Except a Medica, 1971 Women Look at Psychiatr£, Vancouver: Press Gang Pub.,* 1975-"Feminist Therapy: A Review of the Issues", University of Maryland, 1976 (mimeographed). "Facts and Fanciesj An Examination of Freud's Concept of Bisexuality" in Women and Analysis, . J. Strouse (eel.), New York: Grossman Pub., 1974. Women and Analysis, New York: Grossman Pub., 1974. The Myth of Mental Illness, New York: Delta Books, I 9 6 I . Psychotherapy - The Hazardous Cure, New York, Anchor Press, 1976. "The Role of Women in This Culture" in Women and Analysis, J. Strouse (ed.) New York: Grossman.Pub., 197^• "Sex Differences and the Epidemiology of Depression' Archives of General Psychiatry, Vol 34, Jan, 1977. p.98-109. ! Weissman, M. and Paykel, E. Weissman, M. et. al. Williams, E. Winokur, G. Zubin, J. and Fleiss, J. The Depressed Woman, Chicago; University of Chicago Press, 197^-"Follow Up of Depressed Women After Maintenance Treatment", American Journal of Psychiatry , Vol 133, No. 7, July, 1976. Notes of a Feminist Therapist, New"York: Dell Pub. Co., 1977• "The Genetics of Manic-Depressive Illness", in Depression in the 7°'s, R • Fieve (ed.) New York: Excepta Medica, 1971• "Current Biometric Approaches to Depression" in Depression in the 70's, R. Fleve (ed.) New York: Excepta Medica, 1971• ScXoiOF SOCIAL WORK VST 1W5 


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