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Engendering the Diagnostic Boundary:
Psychology 107 (E. Kaschak)
San Jose State University
Spring Semester 2003
Engendering the diagnostic boundary: civil dialogue
How is it that women who should be 'sisters' come to fractious differences when issues of madness raise their head? Judi Chamberlin (1994:284), one of the founders of the 'mental patients' movement, describes her anger with the seminal text Women and madness:
I remembered how angry the book had made me when I first read it. I haven't looked at it since; rereading it has only reminded me why it made me angry - in fact, I think I am angrier now. I remember meeting with Phyllis Chesler shortly after the book was published, trying to explain to her how the very new (at that time) mental patients' liberation movement - and not 'feminist therapy' any more than any other kind of therapy - claimed the right to define and explain 'madness' and what to do about it. She listened politely, but it was clear then she just didn't get it.
In the following, I rely on a paper by Cindy Veldhuis ("The trouble with power," 2001) to represent the views and insight of 'third wave' feminist therapy in regards the problematic that Judi raises.
Thus, Veldhuis notes that feminist therapists may deny this effect of power. It "may cause us to create a dynamic in which our client feels she must comply, and we, without even knowing it, are in a position of dominance." (2001:46) The existence of such effects amounts to a challenge to 'third wave' feminist therapy, which must attend therefore to the need to engage this power imbalance authentically. "If we deny this power, we risk causing our clients to deny their own voices." (Veldhuis, 2001:49)
Formerly this power differential was represented in terms of Labeling Theory (Scheff, 1966), which posits the derogatory social definition ('label') as a 'blame' barrier to normal dialogue. More recently the Antidiagnosis formulation (Gergen, n.d.) reframes the tension as deriving from the (problematical) social construction of "mental disease." The Female Sexual Dysfunction movement (Kaschak & Tiefer, 2002) has identified a corporative support structure for that "mental disease" paradigm. The Bias in Psychodiagnostics perspective (Caplan & Cosgrove, 2003) offers us, finally, a dialogical basis for regaining authentic dialogue.
Finally, this paper shows how dialogical developments in the 'clients' ('mental patients') movement can render such dialogue more and more functional and productive. Hopefully this will help networking and help put the 'social change' commitment of feminist therapy (Feminist Therapy Institute, 1999) on a more solid relational ground.
Lack of recognition of power may be damaging
"Early feminist therapy sought to level the power playing field." (Veldhuis, 2001:39) But that "power playing field" is not always clearly demarcated, nor .. demarcated correctly. Thus there were situations where lack of recognition of power (a) obtained and (b) produced systematic dilatory effects due to power being misapplied. While such phenomena are more widespread and are involved in many parts of life, I try to focus on the effect on the diagnostic boundary between therapist and client. First, that is, I focus on the therapeutic context, but also on its impact on broader social boundary issues.
Example: The 'schizophrenogenic' mother.
A prevailing social causation theory of the etiology of schizophrenia is that "mother induced it." The notion of 'schizophrenogenic' mother is of a "cold, dominant, conflict-inducing mother believed to cause schizophrenia in her child." The theory implies that women are liable to find themselves in that damaging way of being. How can woman in her role as mother prevent the dilatory outcome of driving her child crazy? Cowdry (2001) writes:
Since schizophrenia was thought to be the result of schizophrenogenic mothers or the double bind or some other defect in parenting, it stood to reason that psychosocial interventions treating the family as the patient or the parents as the real patients would be effective in either "primary" or "secondary" prevention. The very term identified patient spoke to the belief that a psychotic relative was merely expressing the psychopathology of the family unit. Of course, this perspective is laughable today-but here, too, the prevention movement staked out one end of a now-discredited set of beliefs. And these beliefs caused a world of hurt, guilt, and anger.
The putative existence of such mothers can be regarded as presenting a chilling indictment of the integrity of motherhood. People interested in family advocacy found that the charge of 'schizophrenogenic' mother would be used to put their advocacy in disrespect. A perspective arose promoting the view that the 'schizophrenogic' mother is a 'myth'. Nevertheless, the diagnostics having indicated that there was such an issue, a contrary advocacy was then found that said "mental illnesses are biologically based." Thus the behavior of the mother is excused as 'incidental' to the condition of the child's mentality.
The biological attribution shifts the pendulum from vilification to exoneration. It does not speak to the meaningful impact of the mother's behavior, "cold, dominant, conflict-inducing" or the like. That is what I'm calling here the "lack of recognition of power." The mother need not take responsibility, because the effect is biologically based. Yet the child, especially, the adult child will bear the scars of such behavior, as it were unaccountably, according to the attribution.
This exemplifies what amounts to a diagnostic boundary breakdown, where nobody directly involved has the empowerment needed. Still, that "guilt-free" motherhood does a poor job of replacing a responsible motherhood. Historically, this diagnostic rearrangement has left alienated and 'helpless' family advocates in conflict with alienated and 'enraged' mental health clients.
This diagnostic breakdown example evinces powerlessness on the part of the client and a different, related powerlessness on the part of the family member. It also reflects de facto powerlessness on the part of the therapist, whose role includes sanctioning the diagnostic process. And it raises the question of how the missing power that is needed is to be engendered.
Veldhuis discusses how women feel powerless when in fact they have power. "Women in American society have less structural, social, and interpersonal power than do men. This may have an impact on women's perceptions of their own power, and cause them to be unaware in certain situations." (2001:41) It follows that an accurate understanding of power is likely to help and that systematic confusion is likely to hinder. The alternative condition seems to be a "wounding," a situation where neither party, client nor provider, is facing a kind of diminished capacity to use power and act productively.
Labeling, anger, and gendering
Here I'm going to speak to two psychological aspects that seem to derive from the empowerment paradox described above. The first aspect derives from Labeling Theory and implies a kind of contentiousness, or 'bitterness' dynamic. The second is how such a dynamic would lead to disempowerment. I apply the logic of 'situated knowledges' (Haraway, 1991:191) to explain how the embodiment of the labeling problematizes relationships.
Labeling Theory and Anger
Another main dynamic of disempowerment is reflected in the recent history of Labeling Theory. Sarbin & Mancuso (1980) posed the concern that Labeling Theory was about to be overtaken by the 'biopsychiatry revolution', and that is in fact what happened at that period. Dr. Loren Mosher, former Chief of NIMH's Center for Studies of Schizophrenia, - and an advocate of Labeling Theory (Mosher & Burti, 1994) - lost his job there in 1980 and the politics of biopsychiatry has "never looked back." So Labeling Theory, which is a social psychological way of comparing the attribution of 'schizophrenic' to 'similar' negative social attributions (e.g., 'juvenile delinquent'), did not prove effective in delineating the disempowerment issues. We need to look at (a) its effect and (b) why the effect was insufficient.
Tavris (1982:292) "Good humored laughter at oneself may really be the best antidote to anger," she says, quoting Scheff. But how does that deal with the bitterness of the disempowerment, if it is larger than a 'personal' issue? She points out, under Biological Politics, that "we are in the middle of an excuse epidemic, in which more and more physiological 'conditions' are considered legitimate pardons for behavior that is immoral, illegal, or fattening." By now, indeed, we are into the Treatment Advocacy Center "'mental patient' atrocity stories" as the basis for public policy. (Treatment Advocacy Center, n.d.) We see the 'iron hand' under the 'velvet glove' that renders the labeling dysphoria so pathetic. To recall Veldhuis (2001:49) , the consequence of power denial is that "We risk causing our clients to deny their own voices." And when it reaches to challenging the integrity of women's bodies, the challenge runs in direct conflict with the values of feminism.
Example: Female Sexual Dysfunction
Therapy involves structural power (Veldhuis, 2001:42) and "has the potential to create a safe space where the client knows what the rules are, and what the limits are." Labeling a person 'mentally ill' is a use of power that (abstractly) might either help or harm. The pejorative character of the label produces a power problem. 'Mutuality' (Veldhuis, 2001:43) is impeded by the negative allegation, which is yet reinforced if there is a lack of truth in it. Dialogue, it would seem, depends pretty much on dealing with the confusing situation related to the labeling.
Paula Caplan describes the inside process by which PMS became a diagnosable disorder in DSM IV. "My main conclusion: The sheer mass of evidence that the major players in the DSM continually ignore both the research and the harm suffered by patients due to the handbook's categories is incompatible with their being driven by only the most altruistic and balanced of motives." (Caplan 1994:227) This puts the worst possible light on the labeling process, for not only are the labels socially damaging, but they are of dubious validity as analytics of 'mental illness'. In the case of PMS, it is women's bodies that get diagnosed, a direct transgression of wholesome embodiment.
Another confounding level is that there is a concerted move, led by the pharmaceutical companies, to redefine women's sexuality. Kaschak and Tiefer (2002) detail aspects of this effort to influence and take over the politics of DSM for proprietary reasons related to drug sales. The diagnosis of PMS is seen in the frame of a broad commercial program to define and medicalize sexuality: "Blood flow to the genital organ" is to replace "relationship satisfaction" as the criterial category for sexuality. (Byers, 2002) What we see is that there are levels and again levels where the social experience of labeling becomes more and more internalized in women's bodies.
Haraway (1991) describes a kind of feminist empiricism, leading to "a no-nonsense commitment to faithful accounts of a 'real' world, one that can be partially shared and friendly to earth-wide projects of finite freedom, adequate material abundance, modest meaning in suffering, and limited happiness." The particular "scientific knowledge," here the DSM category, is situated by 'embodiment'. When it is situated as an expression of derogation, as with labeling, it is difficult for being. "Splitting, not being, is the privileged image for feminist epistemologies of scientific knowledge." (Haraway, 1991) Clearly the integrity and truthfulness of the splitting is vital to the wholesomeness of the process. When women's bodies, their very sexuality becomes the "privileged image," we go from potential wholesomeness to the realm of toxicity. The breakdown in "faithful accounts of a 'real' world," the dialogue breakdown engendered, leads to an unwholesome disembodiment in therapist, in client.
Rhetoric of psychodiagnostics is discriminatory
Rhetoric, or the expression of social being in tropes (as, metaphors) is the ground of the way we create social meaning. (Grassi, 2001). The objectification of madness via psychodiagnostics (currently the DSM IV) thus leaves two questions. One, of course, is whether that analysis of the processes of madness is veridical; the other, is what is the effect of the resulting tropes being expressed, in the ways that are customary, upon social relations. Practically speaking, the immediate effect of rhetorical mis-application amounts to confusion and distorted understanding of power dynamics.
In the frame of Veldhuis, we have a paradox of powerlessness. "When we think about our power in [such] terms, it is humbling, to say the least." (2001:44) And, "I am perhaps then at risk for seeing my clients as having increased power over me, and myself as powerless." (2001:45) A common impetus for this concern in feminist therapy is the (intentional) social leveling of client and professional; however the concern extends to social relations in a broader sense. Peterson (1992), cited by Veldhuis, "outlines four characteristics of boundary violations: reversal of roles, secrecy, double binds, and the indulgence of personal privilege." "Powerlessness," says Veldhuis, "runs amok." (2001:47)
It follows that we need to consider both the veridicality of the diagnostics and the social impact of how it is presented, with an eye to amelioration. From the above, especially Caplan (1994) the veridicality of the diagnostics is not accessible to being fixed, if it is possible at all to fix it. Gergen (n.d.) argues that instead of sticking with the social construction of madness as 'brain disease', we should approach the problematic of madness by "democratic dialogue." Caplan and Cosgrove (2003) have promoted a perspective meant to engender this critique, which they call "Bias in Psychodiagnostics." Lisa Cosgrove (in press) has developed that perspective in the practicum of clinical pedagogy.
Example: Discrimination Case Study
Cosgrove's pedagogy manuscript emphasizes that "diagnostic language confers power" (in press:7) and "DSM categories are constructs, not tangible entities." (in press:11). Regarding case studies as "texts in discrimination" enables her to import a power analysis into the teaching of psychodiagnostics. That is, students are trained to look at the social impact on the client of the diagnosis; then, they are asked to consider how to take responsibility.
In a case study from the DSM-IV Casebook (1994:123) called "The Wealthy Widow," for instance, a wealthy widow is diagnosed "Bipolar I (Provisional)" at age 72, where the presenting evidence includes the possible alternative explanation (which is rejected in the study) that "this poor lady simply has avaricious children rather than a mental disorder." Over the woman's judgment, her plans are to be blocked based on psychiatric intervention based on this diagnosis. Where is the study of boundary violations, where is the process whereby legitimacy is conferred on medical control of the woman's life? According to the paradigm of Veldhuis, the therapist coming to such a possible diagnosis should be problematized by the power dynamics. Cosgrove teaches students to take that problematization seriously, and to recognize and engage discriminatory circumstances. (Caplan & Cosgrove: 2003).
Choice and Respect
If "democratic dialogue" is an alternative to the "brain disease" version of social relations, what kind of rhetorical approach should we look towards? The words of Cindy Veldhuis (2001:49) match the received opinion of mental health client activists, that choice is essential for them:
This becomes an issue of informed consent. We need to make clients a part of these difficult discussions, but we must also make certain that they are informed enough to either consent or not, and we must be aware that because of the inherent power differentials, they may not feel completely free to consent or dissent.
I would argue that while choice is a necessary component for wholesome dialogue, it is not sufficient. For the rhetorical position of the client to make sense, it requires ontological grounding. The rhetorical topics need to have the ground in reality necessary to provide social meaning, in Grassi's sense. People need adequate boundaries, in Peterson's sense. Haraway (1991) speaks to the construction of 'objectivity' thus:
Siting (sighting) boundaries is a risky practice.
Objectivity is not about dis-engagement, but about mutual and usually unequal structuring, about taking risks ..
Perhaps our hopes for accountability, for politics, for ecofeminism, turn on revisioning the world as coding trickster with whom we must learn to converse.
Finally, we must "learn to converse." Shotter discusses the matter of "being with an addressee 'without rank'. " The final issue is "to exhibit a respect for the otherness of the other in one's speech." (2003) If we are to exhibit such respect, then the social conditions of client, specifically, the topic of damage experienced in their encounter with treatment, with society's (discriminatory) attitudes towards madness issues must be authenticated. The 'coding' of the 'trickster' does not admit of disregard.
Power and ethics
"Stay aware, listen carefully, and yell for help if you need it." (Judy Blume, from Veldhuis, 2001:51) Beyond such an existential response to the problematic of power dynamics, we had ought to consider a strategy. A direct approach might call for "training in 'trickster coding'." The 'second wave' FTI Code of Ethics represents a working effort to guide the handling of power dynamics. Identification and implementation of the ethical constraints related to the concerns raised by the psychodiagnostics critique is what's called for here. How do we extend those in a way that coordinates with the Code's "support for social change" prescription? (Feminist Therapy Institute, 1999)
This is a creative problem. Taking it on directly looks a daunting task. Practically speaking, we need to reduce the stress on the conversation. The dominant stressor of our times is the national war agenda. Why not render the public aspect of this conversation in the frame of seeking peace? Moreover, it's worth noting that the logic of engendering the peace agenda calls for resolving the dialogue glitch described in this paper. For the shape of peace is not the recovery of the status quo ante, rather it's in the engendering and construction of a social order that matches the social dynamics of the peace arrangement. Doesn't this raise the question of the madness of the present war dynamic and the need for resolving its current (and dilatory) engendering?
Example: Gender and Peace
In Women & peacebuilding, Mazurana and McKay argue:
At the grassroots and NGO levels, networking was found to be a powerful means to widen one's community, make local global connections and analyses, increase solidarity, learn from others, and expand information and delivery channels. (1999:95)
That essential networking here in the U.S. is impeded by the dialogical breakdown represented by labeling and, ultimately, psychodiagnostics. An opening has been provided by the Female Sexual Dysfunction movement (Kaschak & Tiefer, 2002). A full breakthrough of this social resistance will have to come in a new dialogical paradigm between professionals and clients. "Grassroots women's peacemaking and peacebuilding is personal, interpersonal, creative and political," and it calls for "peace inventions." (Mazurana & McKay, 1999:25). Here we need a "peace invention!"
Lips describes the gender problem thus, that "the equation of real with biological implies the acceptance of two mistaken assumptions: that biologically based differences are necessarily set and immutable (i.e. essential), and that it is possible to discern the separate effects of biology and environment." (2003:68) What we have done here is deconstructed the existing monological arrangement and we have shown a way to connect with the "two mistaken assumptions" as evinced in current practice.
Enforcing the Boundary
Paragraph 1D of the Feminist Therapy Code of Ethics states, "A feminist therapist evaluates her ongoing interactions with her clientele for any evidence of her biases or discriminatory attitudes and practices." (Feminist Therapy Institute, 1999) This is precisely the boundary problem at issue in psychodiagnostics; however, the concern is to render it sensitive to the intensity of feeling present here. Specifically, it involves emphasizing the logic and truth issues, whether by what Cosgrove calls the "postmodern toolkit" (Cosgrove, 2003) or again by what Shotter addresses as "social accountability" within the frame of the "philosophy of involvement." (Shotter, 1994)
The work of Norma Haan (1985) on interpersonal morality has a potential here for guiding us through ethical complexity at the boundary. Carol Gilligan's development (1982) of certain themes of Norma's is more familiar, but it is embedded in Norma's core thinking on moral development that we find strong tools for working on the boundary carefully and effectively.
The Code of Ethics also states, "The well being of clients is the guiding principle underlying this code." The importance of client voicing indicates that the formulation of the client activists on how they should promote dialogue is also an imperative for "enforcing the boundary." The Accountability Caucus, a client organization dedicated to nurturing a maturation of the clients movement, states that it advocates:
.. a micro-empowerment program, which strengthens client involvement through:
(Accountability Caucus, n.d.)
"Recognizing triggering behavior," here, is the parallel responsibility to the direction indicated in paragraph 1D above. The clients are not expected to be trained to make psychological evaluations at the level of the therapist. They can be expected to care if what they do goes awry and take responsibility to mitigate untoward effects.
We do not know how the peace will come about, nor how much the resolution of society's way with madness issues will obtain in the social conditions leading to and involved in that peace. The resolution of the formidable barrier related to labeling/psychodiagnostics appears to have the potential of being a part of that peace dynamic. It seems generating such a "peace invention" could have a strong positive impact. And it seems that a focus on achieving civility by 'boundary ethics' has the prospect of guiding such a peace project.
The obstacles are large. It is not just the war but the modernist proclivity to sustain the social construction we know as 'objective social science' which acts as impediment. The feminist logic which challenges the essential dominance of Descartes' cogito is a powerful tool. It is more powerful yet when it is grounded in the social meaning of people wanting peace and, especially, when it is engendered by way of linkage to originary dialogue about madness issues.
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1. Special thanks to Paula Caplan and Lisa Cosgrove for their support, encouragement, and insight.
2. Carol Gilligan stayed at Norma's home in Berkeley during the "Social Science as Moral Inquiry" conference in Berkeley, 1980. Norma reported to a staff meeting that privately Carol admitted to agreeing with her on moral development, public posture notwithstanding. Carol had been Lawrence Kohlberg's chief assistant during the period that Norma did her breakthrough study (1975) of cognitive moral levels and behavioral correlates based on the 1964 Berkeley Free Speech Movement.