“Women in Psychiatry: A Need for Reform?”

In acknowledgement of Mental Health Awareness Month (USA) and Mental Health Week (UK), the following piece will address both the historical and contemporary abuse of women in psychiatry and mental health care systems around the world, in hope that practices can improve.

Psychiatry is a field marked by well-intentioned individuals aiming to fulfill the discipline's core goal: to properly medicalize mental suffering as illness, and effectively treat it to reduce that suffering. Unfortunately, the discipline has had a long history of abuse, sexism, racism, and the trespassing of individual rights. Much of this is known by the public, for example unregulated asylums, electro-shock therapy, and the forced institutionalization of the disabled throughout the 20th century. As a field and profession, psychiatry presents itself as largely above these past abuses - a constant move towards progress.

Without debating the philosophy of psychiatry or its scientific basis, we can nonetheless identify a slew of human rights abuses in both the developed and developing world that fail both the discipline and the people it serves. In other words, the abuses of the 'past' seem to continue throughout the world and must be stopped. This piece will focus predominately on gendered issues and the rights of women within the remit of psychiatric care, particularly involuntary treatment.

Involuntary care often involves an emergency call that individuals are a potential danger to themselves or others, or more often than not, a loved one is unsure how to deal with a psychological crisis of the person they are calling for. Speaking from an American context, there are a number of rights that are revoked upon a 911 call for an emergency of this nature, which ends in involuntary hospitalization in every circumstance assuming the person making the 911 call confirms their concern.

  1. There is no warrant or probable cause, nor investigation. An individual is hospitalized based on the phone call, and time spent in hospital is based on professional opinion. 
  2. There is no right against self-incrimination or a Miranda warning (the reading of your rights). Everything you say can  - and often will - be used against you. 
  3. There is no opportunity for bail.
  4. You have no right to cross-examine the people who reported you as a danger to yourself or others.
  5. Your freedom. You are not allowed to leave psychiatric care until a medical professional deems you are able to do so.
  6. You have no right to a speedy trial. In most U.S. states, you will expect a minimum of 72 hours in an institution before they are considered for a trial, whereby you may be subject to an additional 14-day review period. All statements and behaviour while in the institution will be recorded and used in your trial as evidence for or against release. 

"If there are no completely solid and scientific, objective standards for mental illnesses, it is inevitable that ideas of a more socially constructed nature will fill this vacuum"

Eric Frasco Junior Associate, Global Thinkers Forum

Patients are also very frequently subject to forced medication, and indeed, even electro-shock convulsion therapy (ECT). While most states in the U.S. do not allow for forced medication, in all of these situations the autonomy of the individual is nulled - a representative of the state is in command of your body and mind. Despite that medication is ‘voluntary’ it is still coerced. This is shown particularly during court hearings, as a reluctance or refusal to take medication is viewed as insubordinate or an inability to accept the ‘severity of your condition'. In this regard, the ideal patient fit for release is an obedient one, a person who willingly submits themselves to the institution’s choices. Later upon your release, you have no entitlement to compensation if you feel the government has wronged you, nor are you entitled to the payment of your hospital bills (despite your involuntary commission). Given the nature of the U.S. healthcare system, it is not unheard of to see former patience in bankruptcy or thousands of dollars in debt upon release. 

Women’s ward of Thane Mental Hospital in the suburbs of Mumbai. Photo Credit: Shantha Rau Barriga/Human Rights Watch

In the UK, the laws are not much different. Recent statistics show a near 20% rise in the number of people 'sectioned', i.e. involuntary hospitalized under the Mental Health Act (MHA), making nearly 40% of patients in NHS psychiatric units are there under legal obligation. This has skyrocketed along with the growing use of community treatment orders (CTOs), where patients are released from detention, but can be forcibly returned to hospital if they fail to take their medication or engage in other forms of treatment. Given the drastic negative side effects of most psychotropic drugs - and the very minimal evidence of positive effects - this coercive method of treatment is often physically and mentally damaging, along with the psychological damage that accompanies the experience of losing bodily autonomy. Also, "forced medication appears to be unique in its significant impact on patient disapproval of treatment," and "all coercive measures are associated with patients staying longer in hospital, and seclusion significantly so, and this association is not fully explained by coerced patients being more unwell at admission." Among these patients, the number of women is close to 40% more than men, and they report significantly worse results than men.

Why this disproportionate number of women? There is potential in pointing out the historic racial and gender biases of psychoanalytic theory, such as Freud's theory that women unconsciously see themselves as mutilated males and are jealous of men (‘penis envy’), or Jung's belief that a woman's social and psychological well-being is determined by motherhood. While these theories are largely not shared with the majority of the psychiatric community in this age, a different type of bias remains: the locus of Western psychiatry is the individual, or more accurately the brain of the individual, with psychopathology largely divorced from the social context. If they are not careful, practitioners run the risk of medicalizing gendered stereotypes/biases. In other words, socially constituted perceptions of gender and what it 'means' to be male/female may penetrate the practice of psychiatry, including in diagnosis. For example, a number of psychologists have pointed to gender bias in personality disorder diagnosis and the argument that "stereotypical female characteristics are pathological," although this is disputed. However, bias can take hold not only in diagnostic criteria and psychiatric theory, but through practitioners, whether intentional or not. The World Health Organization (WHO) also states that gender bias occurs in the treatment of psychological disorders, as doctors are more likely to diagnose depression in women compared with men, even when they have similar scores on standardized measures of depression or present identical symptoms. Female gender is also a significant predictor of being prescribed mood-altering psychotropic drugs. This coincides with the current lack of scientific evidence in psychiatry, where even the American Psychiatric Association admitted that there is no laboratory test that reveals a brain defect or other biological factor in the onset of mental illness, but that the diagnostic manuals such as the DSM-V are rather checklists of behavior used to apply a label and subsequent treatment. If there are no completely solid and scientific, objective standards for these illnesses, it is inevitable that ideas of a more socially constructed nature will fill this vacuum. 

Photo taken in India. Photo Credit: Mint

Coinciding with the globalization of psychiatric categories and diagnostic criteria through the WHO initiative for Global Mental Health, the Western criteria for mental health/illness is being adopted by a number of developing countries. While the effectiveness of this approach is a debate onto itself, there are important implications for this case study. For example, modern India is marked by gender inequality at multiple levels and it is reflected in their current mental health system, as evidenced by the over 100 page report from the Human Rights Watch: 'Treated Worse than Animals’: Abuses against Women and Girls with Psychosocial or Intellectual Disabilities in Institutions in India, where "overcrowding and lack of hygiene, inadequate access to general healthcare, forced treatment – including electroconvulsive therapy – as well as physical, verbal, and sexual violence" is commonplace.

If psychiatry’s goal continues to be the ‘nurturing a healthy mind’, it must be more conscious of the way it operates in a social context influenced by politics, culture and social stratification. Only then will it have the potential to truly put the past behind and move towards a better future.   

References

Cbc.ca. (2018). A 'psychiatric refugee:' why one woman fled B.C.'s mental health laws. [online] Available at: http://www.cbc.ca/radio/the180/facts-vs-values-in-canadian-health-care-forced-psychiatric-care-and-urban-indigenous-people-need-a-voice-1.3764173/a-psychiatric-refugee-why-one-woman-fled-b-c-s-mental-health-laws-1.3764440

Hodges, Katherine. "The Invisible Crisis: Women and Psychiatric Oppression." Off Our Backs 33, no. 7/8 (2003): 12-15. http://www.jstor.org/stable/20837868.

Human Rights Watch. (2018). India: Women With Disabilities Locked Away and Abused. [online] Available at: https://www.hrw.org/news/2014/12/03/india-women-disabilities-locked-away-and-abused

Jane, J., Oltmanns, T., South, S. and Turkheimer, E. (2018). Gender bias in diagnostic criteria for personality disorders: An item response theory analysis

Knutson, S. (2018). 72 Hour Hold for Inalienable Personhood - Mad In America. [online] Mad In America. Available at: https://www.madinamerica.com/2017/09/72-hour-hold-for-inalienable-personhood/

McLaughlin, P., Giacco, D. and Priebe, S. (2016). Use of Coercive Measures during Involuntary Psychiatric Admission and Treatment Outcomes: Data from a Prospective Study across 10 European Countries. PLOS ONE, 11(12), p.e0168720.

Olfson M.E. (2018). Is gender a factor in psychiatrists' evaluation and treatment of patients with major depression? - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11246091

Psychology Today. (2010). Demystifying Psychiatry: can the mentally ill be hospitalized against their will?. [online] Available at: https://www.psychologytoday.com/us/blog/demystifying-psychiatry/201010/can-the-mentally-ill-be-hospitalized-against-their-will

Psychology Today. (2018). Sexism in Mental Health Practice. [online] Available at: https://www.psychologytoday.com/us/blog/science-isnt-golden/201503/sexism-in-mental-health-practice [Accessed 3 May 2018].

Public Radio International. (2018). One woman in India battles the label, and stigma, of mental illness. [online] Available at: https://www.pri.org/stories/2015-01-02/one-woman-india-battles-label-and-stigma-mental-illness

Szasz Thomas. The psychiatric protection order for the “battered mental patient” BMJ 2003; 327: 1449

Theguardian.com. (2018).Mental health patients complain of ‘zombification’. [online] Available at: https://www.theguardian.com/society/2011/mar/15/mental-health-patients-forced-detention [Accessed 3 May 2018].

Published: 21/05/2018