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psychiatry due to historical accident and the successful entrepreneur- ship of the psychiatric profession (Cove, 1976) and do not fit a pre- cise definition of mental ...

Mental Illness and Psychiatric Treatment Among Women Walter R. Gove Vanderbilt University

When mental illness is precisely defined as a functional disorder involving acute distress or disorganization (or both), women are consistently found to have higher rates of mental illness than men. This sex difference appears to be real and not an artifact of response bias, patient behavior, or clinician bias. The higher rates of mental illness among women can be linked to aspects of their societal role and particularly to aspects of the marital role. Therapists who treat women whose mental illness is in part a response to the characteristics of conventional sex roles have no treatment alternatives that are not in some way problematic. The treatment alternative chosen has, in the broadest sense, political implications for the society at large.

In the feminist (e.g., Bernard, 1971a, 1971 b; Cheder, 1971 a, 1971b, 1972) as well as the more academic literature (e.g., Bagley, 1977; Gove, 1978, 1979a; Gove & Tudor, 1973, 1977; Pearlin, 1975), it is commonly asserted that women have higher rates of mental illness than men. This is a controversial position that can be challenged on many grounds. The first part of this paper examines issues that lead to the conclusion that women have higher rates of mental illness. How mental illness should be defined and possible biases that may be involved in determining its incidence are discussed. The second part of the paper looks at two possible explanations of the sex differential in rates of mental illness: (a) sex and marital roles of men and women; and (b) learned helplessness among women. The third part of the paper briefly explores some societal implications of the The research for this paper was supported by NSF Grants # S O C 7 3 4 5 4 5 5 4 0 c and SOC76-15103. 1 would like to thank Antonina Gove for reading an earlier draft of this paper. Psychology of Women Quarterly, Vol. 4(3) Spring 1980 0361 -6843/80/1300-0345800.95 @ 1980 Human Sciences Press

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psychiatric treatment of women. Particular attention is paid to the therapist’s role as an agent of social control or change.

DO W O M E N H A V E H I G H E R RATES OF M E N T A L ILLNESS? To a substantial extent, Chesler (1971 a, 1972) drew her conclusion that women have higher rates of mental illness than men from NlMH reports concerning psychiatric treatment in mental hospitals, general hospitals, and outpatient psychiatric clinics. Earlier studies, most of which were based exclusively on data from mental hospitals, had consistently indicated that from at least 1910 to the early sixties men had higher rates of psychiatric treatment (Bohn, Gardner, Alltop, Knatterval, & Solomon, 1966; Dorn, 1938; Dunham, 1959; Kramer, Pollack, & Redick, 1961). Furthermore, if one were to limit oneself to data from mental hospitals, one would necessarily conclude that in recent years men were increasingly more likely than women to receive psychiatric treatment. For example, for state and county mental hospitals the ratio of male to female patients was 1.1 4 in 1946, 1.32 in 1955, and 2.27 in 1972 (Kramer, 1977). Chesler (1972) contends that both absolute and relative increases in rates of psychiatric treatment for women began around 1964. This period was a time of expansion in the scope and availability of psychiatric services, and there was a substantial increase in the number of persons who received these services. For example, the number of persons seen in mental health facilities excluding private outpatient care was 1,673,352 in 1955, 2,636,525 in 1965, and 6,409,477 in 1975 (Taube & Redick, 1977). The increase in the rate of persons receiving inpatient psychiatric care was comparatively slight, however, and occurred solely in general hospitals, federally assisted community mental health centers, and VA hospitals. At the same time there was a very sharp decline in the rate of inpatient treatment in state and county mental hospitals and no change in private psychiatric hospitals (Taube & Redick, 1977). The vast increase in psychiatric treatment occurred in nonprivate outpatient psychiatric services (233 patients per 100,000 population in 1955, 2,185 per 100,000 in 1975; Taube & Redick, 1977). Following Chesler (1972), this would imply that in recent years women had much higher rates of treatment in settings other than mental hospitals and particularly in outpatient facilities. The most recent data for all treatment settings to provide a breakdown by gender of the patient are for 1971 (Kramer, 1977). They show that Downloaded from at PENNSYLVANIA STATE UNIV on March 5, 2016


women have slightly higher rates of inpatient treatment in private mental hospitals and general hospitals and slightly higher rates of outpatient psychiatric treatment. Men, in contrast, have much higher rates of treatment in state and mental hospitals and particularly in VA hospitals. Overall, men have higher rates of psychiatric treatment when all facilities are combined (2049.2 per 100,000 for men versus 1863.5 per 100,000 for women). In short, the data on psychiatric treatment, excluding private outpatient care, show that men have higher rates of psychiatric treatment. Thus if we equate psychiatric treatment with mental illness, these data indicate that women do not have higher rates of mental illness than men. Very serious questions can be raised about the appropriateness of equating being in psychiatric treatment with being mentally ill. Elsewhere I (Clancy & Gove, 1974; Gove 1978, 1979a; Gove & Tudor, 1973, 1977) have strongly argued that many persons in psychiatric treatment are not mentally ill, at least when mental illness is narrowly and precisely defined. Many disorders, such as alcoholism and drug abuse, appear to have fallen into the domain of psychiatry due to historical accident and the successful entrepreneurship of the psychiatric profession (Cove, 1976) and do not fit a precise definition of mental illness.

A Precise Definition of Mental Illness The position taken in this paper is that mental illness i s most appropriately treated as a specific phenomenon involving personal discomfort (as indicated by distress, anxiety, depression, etc.), or mental disorganization (as indicated by confusion, thought blockage, motor retardation, and, in the more extreme cases, hallucinations and delusions), or a combination of both conditions, that is not caused by an organic or toxic condition. The two major categories of psychiatric dysfunction that fit this definition are the neurotic disorders and the functional psychoses. The chief characteristic of the neurotic disorders is either anxiety or depression, or both, in the absence of psychotic disorganization . The functional psychoses are psychotic disorders with n o established organic cause (APA, 1968). The two other categories that fit this definition are not often used. Transient situational disorders are acute symptomatic responses to overwhelming situations in which there i s no underlying personal disturbance. When the situational stress diminishes, so do the symptoms. This diagnosis is assigned mainly to children and adolescents and only occasionally to adults. The other category is comprised of Downloaded from at PENNSYLVANIA STATE UNIV on March 5, 2016



the psychophysiological disorders. These are characterized by somatic symptoms that appear to be the consequence of emotional tension, although the person may sometimes be unaware of the tension. The psychophysiologic disorders do not fit within the definition of mental illness being used here as clearly as the other disorders. They are included, however, because they are functional disorders and they reflect a fair amount of distress, albeit in a somewhat masked form. There are a number of reasons for treating these disorders as a distinct set which corresponds to a relatively narrow definition of mental illness. First, there i s a simliarity in symptomatology-persons in all these diagnostic categories are typically severely distressed. Second, these disorders respond to the same general forms of therapy, namely, drug therapy and psychotherapy (Gove, 1978; Gove & Tudor, 1973; Kazdin & Wilson, 1978; Kellner, 1975; Klein & Davis, 1969; Malan, 1973; Smith & Glass, 1977). Third, cross-cultural and historical evidence suggests that the concept of mental illness does not typically include the types of disorders we are excluding (Gove, 1978; Gove & Tudor, 1977; Murphy, 1976). Two frequently used diagnostic categories do not fit this precise definition of mental illness-the acute and chronic brain syndromes and the personality disorders. The brain syndromes are caused by a physical condition, either brain damage or toxins, and are not functional disorders (APA, 1968). Most investigators clearly believe it is important to distinguish between the brain syndromes and the disorders we are classifying as mental illness. The fact that the brain syndromes make up approximately 25% of the first admissions to public mental hospitals emphasizes the need to distinguish between the incidence of psychiatric treatment and the incidence of mental illness as defined in this paper. Persons with a personality disorder do not experience personal discomfort, being neither anxious nor distressed, nor do they suffer from any form of psychotic disorganization. They are viewed as mentally ill because they do not conform to social norms and are usually forced into treatment because their behavior i s disruptive to others. These persons are characterized by aggressive, impulsive, goaldirected behavior which is either antisocial or asocial in nature and creates serious problems with and for others (APA, 1968; Dohrenwend, 1975; Klein & Davis, 1969; Kolb, 1973). Not only are the symptoms associated with the personality disorders different from those associated with mental illness as we have defined it, but the forms of therapy effective in the treatment of mental illness are not

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effective in the treatment of the personality disorders (Gove, 1978: Gove & Tudor, 1977; Klein & Davis, 1969; Malan, 1973). Moreover, data from nonwestern societies are consistent with the distinction between the personality disorder and what we are labeling mental illness. Persons in these societies who manifest the behavior that would lead to a diagnosis of a personality disorder in our society are viewed as deviants, but not as ill, and shamans and healers do not believe that such behavior can be cured or changed (Murphy, 1976). In fact, the personality disorders have only recently come to be considered within the domain of psychiatry (e.g., Robbins, 1966). It i s worth noting that labeling theory, which provides the most comprehensive alternative theoretical explanation of mental illness to the one provided by the psychiatric perspective, would also exclude these disorders from the definition of mental illness. For example, Scheff (1966), who presents by far the clearest and most elaborate labeling explanation of mental illness, treats mental illness as residual deviance-namely, deviance for which we have no name and for which there is no societal role. As alcoholism, drug addiction, mental retardation, and senility are socially recognized categories with relatively clearly defined expectations for behavior, Scheff does not see them as residual rule breaking (i.e., mental illness). Thus I, a proponent of the psychiatric perspective (Scheff, 1975), and Scheff, one of its leading critics, are in agreement that these four forms of behavior should not be treated as mental illness.

Sex DifferencesUsing a Precise Definition of Mental illness


Applying this precise definition of mental illness to national data for 1966, Gove and Tudor (1973) found that women uniformly had higher rates of psychiatric treatment in mental hospitals, inpatient psychiatric treatment in general hospitals, and outpatient care in psychiatric clinics. Similarly, comprehensive reviews of studies conducted in Western industrial nations after World War I I of the practices of private psychiatrists, the psychiatric care provided by general physicians, and the results of the community surveys of mental illness showed, without exception, that women had higher rates of mental illness (Gove & Tudor, 1973). The studies themselves did not use a consistent definition of mental illness, although the vast majority of the cases considered would fit under the definition of mental illness used in this paper. An updating of these reviews (Gove, 1979a) showed that in all the studies of practices of general physicians and private psychiatrists,

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women had higher rates of psychiatric treatment. Of the 35 community studies covered in the second review, 34 showed women to have higher rates of mental illness. The one exception, a small study ( n = 683) by Brunetti (1973), indicated that the rates of mental illness between the sexes are so similar that if one more woman had been mentally ill, women would have had higher rates. In short, the work using a precise definition of mental illness consistently shows women to have higher rates than men. Data on patients in institutional settings have not been updated. As noted above, the most recent complete statistics on treatment in institutional settings are those for 1971 presented in Kramer (1 977). Kramer uses diagnostic categories consistent with recent NlMH practices. Previously, persons with alcohol and drug abuse problems were categorized under the brain syndrome diagnoses if they entered treatment in a toxic state and usually categorized as having a personality disorder if they entered in a nontoxic state. Kramer, however, treats alcoholic and drug disorders as two separate diagnostic caiegories. This means that persons diagnosed in his study as having an organic brain syndrome almost all had some form of senile disorder. He also combined the neurotic and psychotic depressive disorders. Kramer’s data show men to have higher rates of psychiatric treatment than women. If, however, consistent with our precise definition of mental illness, we eliminate from consideration alcoholics, drug addicts, persons with an organic brain syndrome, and the mentally retarded, then women emerge as having higher rates of treatment for mental illness in state and county mental hospitals, general hospitals, community mental health centers (inpatient and outpatient), and other outpatient psychiatric services, as well as for all settings combined. Thus the most recent data on treatment in institutional settings are consistent with the earlier data presented in Gove and Tudor (1 973). In summary, if one uses a precise and narrow definition of mental illness, then the data uniformly indicate that women have higher rates of mental illness. In contrast, if one uses an eclectic definition, which includes a much wider range of deviant behavior, then the evidence i s mixed. With an eclectic definition, women have higher rates in community surveys, private practices of psychiatrists, and among persons receiving psychiatric treatment from general physicians, whereas men have slightly higher rates in institutionalized settings as a combined category, although this is not true of some specific institutional settings. It is critical to recognize that the eclectic definition of mental illness encompasses a variety of very different phenomena. Regardless of the reader’s preference for the precise or Downloaded from at PENNSYLVANIA STATE UNIV on March 5, 2016


eclectic definition, he or she should keep in mind that in the remainder of this paper the term “mental illness” will be used to refer to a functional disorder involving the overt manifestation of distress, or mental disorganization, or a combination of both. Are the Higher Rates for Women an Artifact of Response Bias? Phillips and Segal (1969) have argued that in our society women are expected to be more emotional than men and as a consequence it is less stigmatizing for women to verbalize emotional problems. Women are presumed to be aware of this fact and are thus more willing than men to discuss their emotional difficulties. Thus it is the position of Phillips and Segal that the apparent higher rates of mental illness among women that are found in community surveys are an artifact of societal norms which make women more willing than men to articulate their emotional problems. Unfortunately, they present no evidence bearing directly on their argument. Phillips and Segal limit their discussion to respondent behavior in community surveys. Their argument, however, has frequently been expanded by others who see the processes they describe as reflecting a generalized response set that would lead women to seek psychiatric treatment. In a series of three studies (Clancy & Gove, 1974; Gove & Geerken, 1977a; Gove, McCorkel, Fain, & Hughes, 1976), my associates and I examined the possibility that the reports of more psychiatric symptoms by women in community surveys are an artifact of response bias. We employed the same general techniques as Phillips (Phillips & Clancy, 1970, 1972) and measured three types of response bias: perceived desirability or undesirability of psychiatric symptoms, need for approval, and tendency to yeasay or naysay. In all, we have used seven mental health scales, slightly varied our indices of response bias, and used different interviewing techniques (telephone interviews once, direct interviews twice). Perception that psychiatric symptoms were not particularly undesirable, a tendency to yeasay, and a lack of need for approval were all fairly consistently related to the reporting of high rates of psychiatric symptoms. In all of the studies, however, there were no sex differences in the perceived desirability of psychiatric symptoms or in the respondents’ need for approval and in two studies there were no sex differences in the tendency to yeasay or naysay. In Clancy and Gove (1974), however, women were more likely than men to naysay. As a consequence, in all but one case we found that controlling for response bias had no effect on the reports of either men or women,

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and in the one exception (Clancy & Gove, 1974) the controls resulted in an increase in the rates of women. As this is the only evidence bearing on Phillips and Segal’s position, and it is all negative, it i s reasonable to conclude that the higher rates of reports of psychiatric symptoms among women are not an artifact of sex differences in response bias. These studies, of course, bear most directly on community surveys which consistently find women more likely to report that they experience psychiatric symptoms. Are the Higher Mental (flness Rates for Women an Artifact of Clinician or Patient Behavior? A frequently cited study of Broverman, Broverman, Clarkson, Rosenkrantz, and Vogel (1970) indicates that clinicians tend to see the average man as more emotionally healthy than the average woman. This finding, which i s consistent with data on sex-role stereotypes among the general population (McKee & Sherriffs 1957, 1959; Sherriffs & McKee, 1957), has often been interpreted as suggesting that clinicians are more likely to perceive women as mentally ill, regardless of actual level of disorder. This presumed bias on the part of clinicians might account for the higher rates of treated mental illness among women (e.g., Abernathy, 1976; Abramowitz & Dokecki, 1977; Cheder, 1971 b, 1972). By now there i s a fairly extensive body of clinical judgment analogue studies in which the evidence of such sex bias has been examined. This literature clearly suggests that for comparable levels of psychiatric disorder clinicians are not more likely to perceive mental illness i n women than in men. For example, Abramowitz, Roback, Schwartz, Yasuna, Abramowitz, and Gomes (1976) found that “{he impact [on clinical judgments] of varying the patient’s gender was surprisingly slight. The patient received a better prognosis ( p

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