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The Politics of Diagnosis: Feminist Critiques


The whole intellectual thrust of feminist analysis has brilliantly illuminated the political power of naming: those who name some phenomenon thereby claim it in the sense that they determine how it shall be known. Patriarchal social arrangements rest upon male-defined understandings of the nature of the sexes and their proper social spheres. Social constructivist thought (e.g., Berger & Luckman, 1967; Watzlawick, 1984) has demonstrated how the meaning of all consensual social reality is constructed through people's purposeful activities. The basic constructivist insight is that all, or any part, of consensual social reality could be defined and understood differently, depending on the ideas and actions of people in a particular social context. The social processes through which naming takes place are essentially political ones, and this is certainly true in the domain of mental health.

Together, feminist and constructivist approaches to social reality challenge institutionalized belief systems which claim to possess scientific truths, such as the proclaimed truths about women's psychology and so-called mental health. We have seen the development of extensive feminist critiques of the dominant mental health paradigms and their institutional structure (for example, Caplan, 1985; Chesler, 1972; Miller, 1976).

The early feminist critiques of Freud's thought revealed the relativistic, culture-bound and sexist character of his posited truths about the nature of women (for example, Friedan, 1963; Homey, 1967; Millett, 1969). Moreover, the Freudian view of human nature was highly deterministic: men and women alike were viewed as driven mechanistically by unconscious forces, the most basic of which was the sex drive. Within this model, even as it was enlarged by later followers of Freud in the psychoanalytic tradition, human beings were portrayed as quite unfree; women in particular were destined by their biology and lack of a penis to be inferior to and envious of men.

The cultural dominance of the traditional Freudian paradigm has declined in recent times as one outcome of the intellectual and political challenges posed by newer, ascendant models such as be­haviorism and humanistic psychology. Moreover, much important re-visioning of psychoanalytic theory has gone on through the work of feminists seeking to enlarge the model rather than abandon it, on the grounds that the theory and the method had much to offer women (see for example, Chodorow, 1978; Luepnitz, 1988). 

The relative decline of Freudian hegemony over naming has been good for women, freeing us to some extent from the grips of a `science' which in effect purported to prove our essential inferiority to men. Alternative models of psychological development with different epistemologies and methods of treatment have led to the popularization of less explicitly sexist explanatory concepts than those of Freud and at least some of his intellectual descendants.

Nonetheless, we are still faced with a deterministic and hegemonic mental health system which names and medicalizes psychological distress. The most widely used classification scheme for mental disorders in North America is the Diagnostic and Statistical Manual of Mental Disorders (DSM) devised by the American Psychiatric Association. The DSM is a taxonomy of the various forms of psychic distress which have been defined at a particular time. Its diagnostic labels presume that each so-called mental disorder is a discrete entity which can be distinguished from all other mental disorders. Following the medical model, mental illness is something that people either have or do not have, just like physical illness.(1)

This medicalized approach to naming distress is particularly problematic for feminist theorists and therapists who view women's psychological problems as always in some way related to the politics of gender inequality. Patriarchal assumptions, reflected in the attitudes and structures of mainstream psychotherapy, result in the pathologizing and privatizing of women's psychic pain and of our resistance to oppressive practices. A diagnostic system which locates the source of distress solely within the individual would seem to contradict a political analysis which wants to understand the person in their social context.

Moreover, the process by which diseases or disorders get named can be viewed as essentially political. Canadian psychologist Paula Caplan has written extensively about her investigation of efforts within the American Psychiatric Association to get a newly-in­vented disorder called Self-Defeating Personality Disorder (SDPD) included in the revised DSM. The criteria for diagnosing SDPD coincided with traditional socialized feminine behavior. Recognizing that its inclusion in the DSM would be anti-feminist and pathologizing for women, Caplan and other feminist clinicians engaged in sustained professional and political activities to denounce this enterprise in naming (Caplan, 1991). SDPD was listed in the Appendix of the DSM III-R, but ultimately failed to gain inclusion in the DSM-IV, presumably less because of the vigorous feminist objections to its reification, and more because, according to one feminist critic, "even research from a mainstream perspective did not support its existence and inclusion" (Brown, 1994, p. 135)

What this particular publicized process succeeded in revealing, however, was the subjective and ultimately arbitrary fashion by which mental disorders are created. With this in mind, in 1990, Paula Caplan and Margrit Eichler proposed a new disorder for inclusion in the DSM-IV: the Delusional Dominating Personality Disorder (DDPD). Despite rather compelling argumentation and references to abundant empirical evidence, the DDPD was rejected on the basis of lacking empirical support for general recognition. In an article describing these processes, Caplan asks: "[have they] ever talked to frontline workers at battered wives' shelters, to feminist therapists . . . Precisely who constitutes `the general'?" (1991, p. 168)