CHAPTER 9
FEMINIST THERAPY
Feminist therapy sprang into existence at the end of the 1960s as a form of protest against sexism in the mental health professions. In the nearly 40 years since therapists began to use the term feminist to describe themselves and their work, the theory has evolved significantly from its roots into a sophisticated integrative model of psychotherapy practice. Nonetheless, what remains true about feminist practice as much today as 30 years ago is its attention to the dynamics of power both inside and outside of the therapy office. A close and careful analysis of the meanings of gender and other social locations in our clients’ lives as well as in the distress that brings them into therapy is also important. This chapter constitutes a broad overview of feminist therapy theory, tracing its evolution from “not business as usual” to its current status.
Feminist therapy can be defined as:
The practice of therapy informed by feminist political philosophies and analysis, grounded in multicultural feminist scholarship on the psychology of women and gender, which leads both therapist and client toward strategies and solutions advancing feminist resistance, transformation and social change in daily personal life, and in relationships with the social, emotional and political environments. (Brown, 1994, pp. 21–22)
The project of feminist therapy is one of subversion (Brown, 2004, 2005), the undermining of internalized and external patriarchal realities that serve as a source of distress and as a brake on growth and personal power. Psychotherapy is itself construed as a potential component of the system of oppression, with therapy as usual practiced in ways that can uphold problematic status quos.
Patriarchies, the social systems in which attributes associated with maleness are privileged and those attributed to women are denigrated (Lerner, 1993), no matter in whom they appear, are identified as the problem in feminist therapy, rather than the actual distress or dysfunction about which the client initiates therapy. Therapy is thus considered to have political meaning in the larger social sphere because it has the potential to undermine such systems as they are represented in the intrapsychic and behavioral/interpersonal lives of humans.
Unlike many other approaches to therapy, feminist therapy’s origins lie in several political movements that are all subsumed under the rubric of feminism. It situates within critical psychology (Fox & Prilleltensky, 1997), which includes theories, such as liberation psychology (Martin-Baro, 1986, 1994), multicultural psychology (Comas-Diaz, 2000), and narrative therapy (White & Epston, 1990). All of these theories stand at the margins of mainstream psychology and critique its assumptions about health, distress, normalcy, and the nature of the therapist-client relationship. The particular strain of feminist therapy to which I refer here is most influenced by feminist psychology, although feminist therapists are also found in the fields of psychiatry, social work, and counseling.
Because of its name, feminist therapy is frequently thought to be both by and for women only. Indeed, almost every initial adherent to this model was a woman, and the early years of feminist therapy are marked by an attention to women’s special needs in psychotherapy. Today this is not the case, and feminist therapy is practiced by people of all genders, with every possible type and configuration of client (Brown, 2005; Levant & Silverstein, 2005). Feminist therapy, unlike many other theories of therapy, does not have a founding parent. It is a paradigm that developed from the grassroots of practice, and its beginnings occurred in the context of many people’s experiences and interactions, all of which have combined to create consensus models of feminist practice, as well as some distinct schools of feminist practice.
HISTORY OF FEMINIST THERAPY: INITIAL STIRRINGS
Feminist therapy can trace its conceptual origins to three founding documents, two of which were explicitly feminist, one of which was situated in psychology’s main stream: (1) Chesler’s Women and Madness (1972), (2) Weisstein’s Kinder Kuche Kirche as Scientific Law: Psychology Constructs the Female (1970), and (3) Broverman, Broverman, Clarkson, Rosenkrantz, and Vogel’s Sex Role Stereotypes and Clinical Judgment of Mental Health (1970). All of these texts are discussed in detail later. Each presaged developments to follow, and each functioned to effect the first step in any process of feminist therapy—the arousal of feminist consciousness. Feminist consciousness, as defined by historian Gerda Lerner (1993), is the development of awareness that a person’s maltreatment is not due to individual deficits, but to membership in a group that has been unfairly subordinated; and that society can and should be changed to give equal power and value to all.
For the early feminist therapists, the development of feminist consciousness arose from their own experiences as therapists and sometimes clients within the patriarchal system of psychotherapy as practiced universally prior to the early 1970s. Feminist psychologists and therapists, like many women of that era, participated in consciousness-raising groups as part of the second-wave women’s liberation movement that occurred in the United States in the late 1960s. In those groups, women met together without a leader and shared personal experiences of their lives, including experiences of discrimination. For feminist psychologists, a significant portion of those experiences of sexism had occurred in professional and educational settings (Chesler, Rothblum, & Cole, 1995), and those experiences were the genesis of two of feminist therapy’s founding documents.
Phyllis Chesler, trained as a research psychologist in the mid-1960s, authored Women and Madness (Chesler, 1972) as a protest against what she saw as unjust and sometimes inhumane conditions for women in psychotherapy. In a personal memoir (Chesler, 1995), she describes returning home from the 1969 convention of the American Psychological Association, at which a feminist protest had occurred, feeling compelled to use her skills as a researcher to document empirically how psychotherapy oppressed women. She used early tools of feminist analysis to argue that in psychotherapy, the conditions of a sexist and oppressive society were replicated for women. Most psychotherapists of the time were male and most, in the middle 1960s, were trained either in the rigid psychoanalytic orthodoxy of the day that implicitly denigrated women via its interpretation of psychoanalytic theory, or were proponents of a version of humanistic psychotherapies that, while more open and accepting of women’s experiences, were also often lacking in boundaries for sexual contact between therapist and client. Most clients were women, frequently struggling to make sense of conflicts between pursuing their goals, desires, and interests and societal demands that White, middle-class, educated women work as unpaid homemakers and full-time parents. Chesler noted that in this configuration women were defined as neurotic and disturbed simply because of desires to work in professions or not parent full-time. The client, she wrote, was a wife or daughter in therapy with the man who assumed the complementary role.
She was also the first author to document the problem of sexual boundary violations in therapy and to compare such violations to other forms of sexual assault. Although in the twenty-first century therapists take for granted the prohibitions on sexual contact with clients, Chesler’s work occurred in an era when several famous therapists and founding fathers of humanistic approaches were publicly flaunting their sexual relationships with their clients (with one of them rising in a public forum at a psychotherapy conference in 1982, in the presence of this writer, to state that it was good for women’s self-esteem to “seduce” their powerful older male therapist), and when women’s reports of any form of sexual violation were routinely dismissed as fantasy productions, or attributed to the woman’s own misconduct.
All of these arguments rendered Chesler’s work revolutionary and controversial when it was published. Her willingness to state that psychotherapy as usual could be harmful to women because of its replication of oppression was itself consciousness raising to many of her readers. Her exposure of the problem of sexual misconduct was the catalyst for changes to ethics codes so that such behaviors would be explicitly proscribed. Her insights into what needed to happen in psychotherapy to render it both nonharmful to women, and potentially contributory to feminist social change, laid the groundwork for what was to follow.
The second founding document of feminist therapy, also arising in an explicitly feminist context, and also written by a psychologist, was Naomi Weisstein’s Kinder Kuche, Kirche as Scientific Law: Psychology Constructs the Female (1970). Weisstein, trained as a comparative and physiological psychologist at Harvard in the early 1960s and thus was herself an extreme rarity. Women were actively kept out of doctoral programs in psychology prior to the mid-1970s (for a more complete description of this experience, see Chesler et al., 1995). Feminist Foremothers, in which several eminent psychologists describe the explicit discrimination they faced and active radical feminism, analyzed several taken-for-granted assumptions about women’s functioning that were ubiquitous in the psychology taught and practiced at that time. Chesler noted that women were actually rarely the subjects of study, carefully analyzing the research of several areas of psychology to demonstrate that subject samples were routinely composed only of men. Women’s behavior was explained by means of extrapolation from animal research, which itself contained interpretations of the behavior of female animals that was rife with sexism; thus, if female rats appeared to instinctively engage in certain behaviors, women ought to have a similar instinct, and women who did not behave similarly were ipso facto pathological.
Weisstein also took aim at psychoanalytic formulations of women. Although psychoanalysis had begun as a theory that liberated women by acknowledging them as sexual beings, orthodox analytic theories in the United States had become contaminated with cultural sexism and complicit in its enforcement. Thus, Deutsch’s Psychology of Women, in which women were defined as inherently passive and masochistic, had become the primary authoritative source for many practicing psychotherapists. Weisstein, perhaps echoing Karen Horney’s earlier observation that the concept of penis envy might simply reflect the egocentric musings of a male child who was himself so attached to his penis that he could not imagine how those not possessing one would not envy him, critiqued then-pervasive psychoanalytic formulations of women as less morally capable, more dependent, and less fully adult and pointed out the utter absence of empirical, research-based support for these assertions.
Weisstein’s article can be seen as the genesis of research feminist psychology, with many social, developmental, and other research psychologists arising to her challenge to develop empirical data about women’s actual functioning. Her article was also a prophetic comment about the findings of the last founding document of feminist psychology, which appeared in Journal of Consulting and Clinical Psychology in January of 1970.
“Sex Role Stereotyping and Clinical Judgments of Mental Health,” authored by Broverman et al. (1970), reported the findings of a study in which experienced practicing psychotherapists from the range of mental health disciplines were asked to describe three people on a 102-item scale of bipolar adjectives (e.g., “Functions well in a crisis versus Does not function well in a crisis”) separated by a 100-point continuum. Presented in random order, the persons to be described were the mentally healthy adult male (MHAM), the mentally healthy adult female (MHAF), and the mentally healthy adult (MHA). Participants in this study were both women and men.
The findings offered the first empirical support for what Chesler and Weisstein had written, and for what psychologists participating in consciousness-raising groups were saying. The MHAM and the MHA were essentially the same constructs, and both constructs had a high social desirability valence. The MHAF was significantly different from both the MHAM and, importantly, the MHA; this construct was also significantly less socially desirable. Women were being held to a different standard of functioning, and that standard was one less than, and less desirable than, adulthood.
Feminist therapy can thus be seen as arising in an attempt to correct the serious problems identified in these three founding documents. In just over 30 years, corrective process has taken root so deeply in the mainstream of psychotherapy practice that many well-accepted norms of good practice, such as the use of a written informed consent document (first proposed by feminist therapists Hare-Mustin, Marecek, Kaplan, and Liss-Levinson, 1979) and the explicit prohibition on sexual relationships with clients (first proposed by Chesler in 1972), are no longer known to have their origins in the work of feminist therapist. Other aspects of feminist practice remain distinctive.
DEVELOPMENT OF FEMINIST THERAPY THEORY
I have arbitrarily divided feminist therapy’s development into several distinctive periods, each described by the theme informing its practitioners. These stages, which each occupy roughly a decade, reflect both the zeitgeist of research and practice in psychology in general, and the zeitgeist of feminism as propounded primarily in the United States. I define these stages as:
- No-difference feminism (late 1960s to early 1980s)
- Difference feminism (mid-1980s to mid-1990s)
- Difference with equal values feminism (mid-1990s to present)
The initial stage of no-difference feminism, which is represented politically by a reformist feminist model (see Enns, 1992, 2004, for reviews of these different flavors of feminist political theory), asserts that there are no actual differences between women and men. Consequently, women should not be excluded from any profession or occupation simply because of sex. This stream of feminist psychology was a direct response to cultural sexism of the time that justified differential treatment of women on the grounds of inherent sex differences. The feminist psychological scholarship of this period is marked by many studies that attempted to challenge the concept of essential differences or that identified what differences did exist and then downplayed their functional meanings. The initial research on women’s psychology was done during this period, which can be seen as encompassing the years between 1969, when feminists in psychology first coalesced as a group, and the early 1980s. During this time the first journals addressing empirical research on women and gender were founded, and two professional organizations, the Association for Women in Psychology (AWP), and the American Psychological Association (APA) Division 35 (now called the Society for the Psychology of Women; SPW) were established.
Feminist therapy practice during this period focused on identifying what were seen as women’s unique and special treatment needs, as well as on the person of the woman therapist. Feminist therapy at this stage was best defined by what it was not. There was not yet a theory; at that stage, some feminist therapists rejected the notion of a theory as itself being too reflective of patriarchal norms. Defining itself against the therapy-as-usual of its day, feminist therapy was construed as a short-term process, focused on raising women’s consciousness and teaching women specific skills for better negotiating their world. Women’s distress was seen as arising solely or largely as a result of oppression, and feminist therapists of the day posited that once women became aware of that oppression and learned how to respond differently, they would no longer experience that distress. Therapy was postulated as a sort of “consciousness-raising group of two” (Kravetz, 1978) in which a relationship of near-equals would obtain. This grew into the construct of the egalitarian relationship in feminist therapy, a paradigm that is explored later in this chapter. An excellent example of the scholarship of this stage is Greenspan’s A New Approach to Women and Therapy (1983). Her work integrates and synthesizes the development of that initial stage of feminist practice.
During this time period, women therapists began coming together to develop models of practice. Some of this occurred during sessions of AWP conferences, as well as at symposia sponsored by SPW during annual APA conventions. The Women’s Institute of the Orthopsychiatric Association and the Feminist Therapy Institute (FTI) were two specifically therapy-oriented groups that coalesced in the early 1980s, producing the next set of foundational documents in feminist practice and setting the stage for the development of the second phase of feminist therapy. These were smaller, more intimate groups of practitioners who met in intense encounters, sometimes yearly, sharing experience, writings, and ideas about feminist therapy.
Feminist practice’s emphasis during its initial flowering in the 1970s can be seen in the chapter headings from an edited collection of papers presented at the first meeting of FTI, held in the spring of 1982 (Rosewater & Walker, 1985): “Feminist Assertiveness Training,” “Therapeutic Anger in Women,” “Can a Feminist Therapist Facilitate Clients’ Heterosexual Relationships,” “Feminist Interpretation of Traditional Testing,” “A Feminist Critique of Sex Therapy.” All of these titles mirror how feminist practice was organizing itself during that decade. Women—whose anger had been silenced, whose sexuality had been defined as a deficit version of men’s, whose scores on psychological tests had been interpreted in the absence of an understanding of the context of pervasive interpersonal violence—were to be empowered, informed, and liberated.
Also in this volume are the stirrings of a next focus in feminist practice—the violence in women’s lives. In the later 1970s and early 1980s, feminist therapists began to publish their findings on the ubiquity of sexual and interpersonal violence in women’s and girls’ experiences (Herman, 1981; Walker, 1979). Research and scholarship during this second phase of feminist practice focused on the issue of violence and victimization. Such violence began to be theorized by feminist scholars as a particular manifestation of patriarchy with the systemic goal of keeping women oppressed, fearful, and damaged (Dworkin, 1981; Russell, 1987). Feminist therapists, led by Walker (1979) and Herman (1981), proposed models for treating battered women and women survivors of sexual assault and childhood sexual abuse.
Additionally, during this period, a trend emerged in political feminism that adopted an essentialist view of women’s psychology. This trend valorized the previously denigrated qualities traditionally ascribed to women (e.g., nurturance, peace-making, a focus on relationships over rules) and proposed a model of women’s functioning and psychology arguing that these traits and characteristics were rooted in women’s essential biological function of mothering. This difference feminism argued that while women and men were different in essential ways, those differences simply meant different distribution of skills and talents.
The work of such scholars as Nancy Chodorow (1978, 1989), Dorothy Dinnerstein (1976), and Carol Gilligan (1981) yielded both theoretical and empirical bases for this strain of feminist psychology, frequently alluded to as the “different voice” model of women’s development, playing off of the title of Gilligan’s well-known book on gender differences in moral development. During this time, the work of Jean Baker Miller, a feminist psychiatrist who had proposed a difference voice model of women’s psychology (1976) cofounded the Stone Center group of feminist therapy theorists at Wellesley College. Stone Center theory blended feminist analysis with psychodynamic formulations to propose a relational model of women’s development and a relationally focused paradigm of feminist therapy practice that is currently known as the Relational Cultural school (Miller & Stiver, 1997).
Simultaneously, Hannah Lerman proposed the first criteria for a feminist therapy theory (1983, 1986). Lerman’s proposal was the initial assertion by a feminist therapist that theory was needed, and that feminist therapy was more than simply not therapy-as-usual, but rather a unique and distinct approach to practice. She offered the following criteria:
- The theory is clinically useful.
- The theory reflects the diversity and complexity of human experience (no normative dominant group).
- Views women (the “other”) centrally and positively, rather than as deviant.
- Arises from the experience of women (and other groups on the margins).
- Remains close to the data of experience (reflects the real world as people know it).
- Theorizes behavior as arising from an interplay of internal and external worlds (the biopsychosocial model).
- Avoids using particularistic terminology (no mystical and mystifying language).
- Supports feminist modes of practice (e.g., automatically leads toward egalitarian and empowering strategies for practice).
Feminist therapy also grew during this time frame to begin the development of its own ethical standards. Meetings of the FTI had uncovered examples of blatantly unethical practices, including sexual abuse of clients, by therapists self-describing as feminists. Frequently, these women utilized feminist therapy concepts, particularly that of the egalitarian relationship, as a rationale for their behaviors. Feminist Therapy Institute and its members decided to clarify the boundaries of feminist therapy ethics and developed its own code (FTI, 1990), which continues to stand as an aspirational model for feminist practitioners, and informed the latest iteration of APA’s own Ethical Principles and Code of Conduct. A number of books about ethics in feminist therapy practice were developed by the FTI’s Ethics and Accountability Committee (Lerman & Porter, 1990; Rave & Larsen, 1995).
Finally, this second period saw challenges arising to feminist therapy from within, as therapists of color, poor and working-class therapists, therapists with disabilities, lesbian therapists, and other feminist therapist who were not themselves members of the dominant European American heterosexual middle class challenged feminist therapy for being inattentive to issues of diversity and complexity in women’s experiences. Several heated and emotional meetings were held, resulting in several important publications in which the integration of feminist and multicultural models began to emerge. Brown & Root’s Diversity and Complexity in Feminist Therapy (1990), Adleman and Enguidanos’s Racism in the Lives of Women (1995), and Comas-Diaz and Greene’s Women of Color (1994) all marked important theoretical movement in feminist therapy, deepening the theory and practice and taking it permanently beyond seeing itself as being about some sort of generic women’s issues. Consciousness not only of sexist oppression, but also of powerlessness and privilege arising from social locations of ethnicity, culture, social class (Hill & Rothblum, 1996), and so on began to more actively inform feminist therapy theory and continues to do so.
Another within-the-field conflict regarding diversity had to do with the emphasis on feminist therapy versus therapy with and for women. Barbara Wallston, a founder of both AWP and SPW, had called in the late 1970s for the psychology of women field to abandon that name and instead adopt the title of feminist psychology that, she argued, was an epistemology that analyzed issues of gender and power within the lens of feminist theory, rather than a more atheoretical study of women. Wallston’s argument has informed the opening of feminist practice to men because the essentialist notion that only women could be feminist therapists, and/or that feminist therapies were about “women’s issues” began to fade in favor of therapies focused on analysis of power, gender, and, increasingly, other social locations informing identity. Feminist therapists who worked with men, such as Ganley (1991) who developed treatment programs for batterers or feminist family therapists such as Bograd (1991) or Nutt (1991), brought to the foreground how sexism and patriarchy were oppressive to men as well, albeit in ways different from how women are affected.
The most recent and current phase of feminist therapy, difference with equal value feminism, began in 1993 as the result of a consensus conference on education and training in feminist practice held under the auspices of SPW and the APA Education Directorate. Findings of this conference were described in Worell and Johnson (1997). More than 200 feminist psychologists, mostly but not exclusively women, and feminist psychology graduate students attended and met in working groups for several days. The groups developed initial theoretical and conceptual paradigms for a range of aspects of feminist practice, including supervision, assessment, and the integration of issues of diversity into feminist theory. Two factors marked this conference as significant: First, it represented a gathering of some of the most powerful and influential writers, thinkers, and practitioners in feminist therapy, all coming together with the single goal of creating norms for training feminist therapists. Second, the conference’s sponsorship by APA made a statement about feminist therapy’s impact on the mainstream of psychology.
Several other important theory contributions emerged in the early 1990s. Building on Lerman’s earlier work, Brown (1994), in Subversive Dialogues: Theory in Feminist Therapy, developed a paradigm for defining feminist practice that offered feminist models for assessment and diagnosis and that more deeply explored what was meant by the egalitarian relationship. Kaschak (1992), in Engendered Lives, proposed a feminist model for understanding identity development through the lens of gender. Stone Center theory also deepened during this period in response to critiques that it referred primarily to the lives of White, middle-class, heterosexual women, and renamed itself relational-cultural theory (Jordan, 1997). All of these authors and groups of feminist therapists brought feminist therapy to a juncture where it could now be clearly defined and distinguished from other approaches to therapy, not simply by what it was not, but by how it was a specific theory of psychological practice.
CURRENT STATUS
Feminist therapy today is growing to meet the challenges of the twenty-first century. Brown (2005) discussed how feminist therapy situates in the discourse on evidence-based practice. She notes that although there continues to be a dearth of outcome research on feminist therapy that has been done indicates that its documented effectiveness likely represents the application of relationship skills that have been empirically demonstrated to constitute large parts of the outcome variance in other psychotherapies (Norcross, 2002). As we see later in this chapter, feminist therapy’s emphasis on an egalitarian, collaborative, and empowering relationship as the foundation for practice strengthens and deepens empathy and energizes the therapeutic alliance, both factors important to good outcomes.
Feminist therapy is also moving toward a more specific set of models for understanding personality and “psychopathology” (in quotes here because in feminist therapy, the pathology is located externally, not in the individual, and distress is not seen as pathology; Ballou & Brown, 2002). Models of identity development such as Root’s (2000) paradigm for multiple and intersecting identities are being proposed. Feminist-informed assessment tools are being developed (Zimberoff, 2006). Men’s engagement with and integration into feminist practice is decreasingly controversial (Brown, 2005). International feminist therapy practice, which integrates and synthesizes local experiences of gender and power with feminist constructions of psychotherapy, is emerging (Enns, 2004; Norsworthy & Khuankaew, in press). Feminist family therapies (Silverstein & Goodrich, 2003) are proliferating. Several distinct strains of thought in feminist therapy can be identified, including Worell and Remer’s (2002) empowerment therapy (which continue to reflect the early feminist therapy emphasis on treatment of women and girls), the Stone Center relational-cultural model (Jordan, 1997), and extensions of Brown’s (1994, 2005) model of multicultural subversive feminist practice. The Guidelines for Psychotherapy with Girls and Women were adopted by APA in February 2007, thus placing 3 decades of feminist work squarely in the norms of psychological practice. Plans are afoot for a second national conference on education and training in feminist practice that will likely take place sometime before the year 2010. It can be confidently stated that feminist therapy has entered a phase of increasing activity in which specifically feminist models of practice can now be developed. The remainder of this chapter describes current feminist therapy paradigms for understanding distress and dysfunction, and the processes by which healing is seen to take place.
THEORY OF PERSONALITY AND PSYCHOPATHOLOGY: DISTRESS, NOT PATHOLOGY, AND USUAL, NOT NORMAL
Feminist therapy takes an explicitly biopsychosocial approach to understanding human development and distress, frequently adding the realm of spirituality or meaning-making to the biological, intrapsychic, and social/contextual. All four realms are construed as being in constant exchange and interaction. Thus, humans are born into bodies that are sexed, and that, in Western cultures, are forced into two sexes despite the frequency (1 per 2,000 live births) of intersexed infants. Gender, a set of socially constructed roles and ways of relating, is conveyed to infants based on the sex to which they are assigned. Gender is commonly the first identity that people experience, coming before other identity markers such as culture, ethnicity, or social class because gender, as a sex-derived social construct, is frequently the variable of greatest importance to the human world into which a child is born. In twenty-first-century America, the first question asked at the 4-month sonogram, when sex is determinable, is not whether the fetus is a healthy one, but what its sex is so that the family can begin assigning gender to the child in ways that previously occurred only postbirth. Thus, for feminist therapy, understanding constructions of gender as they have existed in the life of an individual takes a central place in theorizing both usual trajectories of development and those in which distress emerges.
Gender is ascribed differential meanings in all cultures, and almost every culture in the world today, whether individualist or collectivist, patrilineal or matrilineal, is a patriarchal one. In patriarchy, as noted earlier in this chapter, those characteristics constructed into masculinity are valued, and those associated with femininity devalued, even when the person exhibiting feminine characteristics is of the male sex. Depending on the narrowness and/or rigidity with which gender is constructed, the experience of enacting gender can become a source of distress by and of itself (Ballou & Brown, 2002; Kaschak, 1992; Lerman, 1996).
Gender is a social construct, but it also becomes quickly represented internally as an intrapsychic one. “Who I am” often has deep roots in “how I am female or male.” One branch of feminist theory posits that children develop gender schemata (Bem, 1993) that are not simply internalizations of external gender roles, but rather that represent dynamic interactions between the person, the social environment, the age, and the developmental stage of the individual (and thus her or his capacity for more or less abstract thinking). Chodorow (1978, 1989), arguing from an object relations perspective, has suggested that internal representations of gender arise in the intrapsychic space evolving from interactions between mothers, who are the primary caregivers of children, and very young children who either become like mother (girls) or unlike her (boys). Root (2000) has proposed an ecological model of identity development, founded in the experiences of racially mixed people, that situates gender among other factors influencing identity, and posits an interactive process by which gender and other social constructions are internalized in a continuously transforming process. What is similar throughout these feminist models, all of which initially derive from quite different schools of identity development, is their assertion that identity’s usual trajectory is an interactive one. Body invites interpersonal interactions that are gendered, leading to a self that is gendered, leading to behaviors and relationship to body and self that are gendered, leading to a relationship with spiritual and meaning-making systems that is gendered, and leading back again into one another in a continuous, fluid, and interactive process.
Both Root (2000, 2004) and Hays (2001, 2007) have proposed multicultural feminist identity models that add in other components of social location. As feminist therapy theory grew in the late 1980s to attend more specifically to human diversity and complexity, so feminist therapy has come to rely more on paradigms for the trajectory of identity development that are themselves inherently diverse and that perceive identity as an ever-changing gestalt in which different components combine in different amounts to become foreground in the context of different social demands and intrapsychic pulls. Root, for example, has demonstrated that within a given family of racially mixed siblings, each sibling, even those of the same sex, is likely to define ethnicity in a unique manner and also to report having defined ethnicity differently depending on age, stage of development, and a variety of social/contextual variables (1998).
As is true in usual developmental trajectories, those that lead to distress are also conceived by feminist therapy theory as biopsychosocial plus meaning-making/spiritual in origin. Distress and behavioral dysfunction are terms used in preference to the word psychopathology. As Brown and Ballou (2002) note in the Forward to their most recent text:
… we see that the decision to call nonconforming thoughts, values, and actions psychopathology does two things. First, it discounts she or he who is described as such. Second, it blocks our ability to look outside the individual to see forces, dynamics, and structure that influence the development of such thinking, values and actions. (p. xviii)
As a consequence, feminist therapy theories refer to distress (the subjective experience of ill-being) and dysfunction (behaviors and ways of being that create difficulties in life) rather than psychopathology. The larger cultural context of patriarchy and oppression is perceived as pathological; thus, an important origin of the problem is always located outside of the individual. Distress is postulated to arise from internalized oppression (Brown, 1992) that can include exposures to micro-aggressions or insidious trauma (Root, 1992), experiences of interpersonal betrayal (Freyd, 1996), or other experiences of powerlessness.
Specific symptoms are defined as evidence of resistance by the individual to these experiences of oppression and attempts to solve the problem of powerlessness via whatever means are available biologically, developmentally, intrapsychically, contextually, and/or spiritually (Brown, 1994). Feminist therapy posits that all persons make attempts to solve the problems of their existence, but that not all strategies work as well as others. Effectiveness of a strategy (Brown, 2004) reflects variables such as (a) the ages and developmental stages at which it was invented by the person, with those strategies from younger ages usually leading to more problematic outcomes; (b) whether the individual was required to invent the strategy alone, or had assistance and/or modeling, with individual efforts frequently leading to more difficulties for the person; and (c) whether the strategy is one common to or dystonic with the culture and context in which the person lives, with culturally acceptable strategies usually giving better short-term outcomes (Brown, 1994). A person’s resistance strategies may be culturally coded as socially desirable and not immediately lead to distress or be seen as dysfunctional.
For example, the young girl sexually abused for 4 years beginning at age 9 may use overwork as a dissociative coping strategy that deflects her awareness from the events happening at the hands of her perpetrator. Working hard at school and becoming involved in extracurricular activities, which transforms into workaholism in adult life, are developmentally available strategies for coping. The overwork may be construed by others as her being organized, dedicated, or hard-working, and she is likely to be rewarded for it while in school and in the workplace. However, overwork interferes with intimate relationships; this same girl, grown into a young woman, may approach therapy in distress because a partner is unhappy with her inability to take time for intimacy, at which point the resis tance strategy has become a problematic symptom.
Feminist therapy acknowledges that some experiences of distress have strong biological components and origins. However, it argues that how distress is culturally received has as much if not more impact on the lived experience of distress and any dysfunction arising from it as the biological phenomenon. Various forms of psychosis are, for example, thought today to be most likely due in large part to as yet unidentified biological variables. However, feminist commentators have noted that the reception given today to a woman who reports speaking with the Archangel Michael (she is likely to be hospitalized and placed on an antipsychotic medication that will cause her to gain weight, develop type II diabetes, dull her thinking, and make her sleepy) is very different than that given to one particular young woman named Jeanne who reported this communication in northern France in the 1300s (we know that second woman as St. Joan of Arc). A close reading of the lives of many saints and Biblical prophets suggests that all or most experienced what would today be called some form of psychosis or delusional thinking. Similarly, different cultural systems of understanding distress constructs what our clients tell us in various ways. A cluster of symptoms that would be identified as somatic delusions in Western psychiatry are symptoms of a specific and well-known diagnosis in the Chinese system of energy medicine that informs acupuncture (Kristin Allott, personal communication, July 2006). Feminist therapy theory argues, consequently, that even those sources of distress that are primarily biological are still given social/contextual meaning, which in turn informs the meta-distress (how upset is the woman that she is hearing an angel speaking to her) experienced by the individual, as well as the ways in which the culture around her responds both to her experience and to her meta-distress. The meta-distress may be where the resistance can be identified, and it reflects the client’s experiences of oppression and powerlessness, as well as resilience and personal power. The response of the cultural context also informs the meaning that an individual makes of her or his experience, which in turn colors the meta-distress.
Diagnostic thinking in feminist therapy does not, as a consequence of this model for distress, focus on assigning a DSM diagnosis. In common with humanistic and narrative therapy models, feminist therapy eschews the use of the DSM except where necessary to obtain access to care for a client, and then only in consultation with the client about the necessity for the use of the DSM label. As Brown (2000) noted, “Feminist psychology has a long and ambivalent relationship with the construction of psychological distress as disorder or pathology” (p. 287). This ambivalence is most commonly enacted at those junctures where the practicing feminist therapist must decide whether and how to use formal diagnostic labels; feminist therapists have discussed how to use formal diagnostic codes without nonconsciously participating in the reification of distress as pathology inherent in the medical model (Ballou & Brown, 2002; Brown, 2000).
What a feminist therapist does practice is the diagnosis of the client’s various resis tance strategies. Inquiry, direct or subtle, is made by the therapist into how a person dealt with the vicissitudes as well as the triumphs of life, focusing attention on questions identified earlier as to variable informing resistance strategies. In common with therapists informed by solution-focused models, feminist therapists invite their clients to appraise their symptoms as problem solutions that may have outlived their usefulness or that have always suffered from insufficient information or resources during development. This discussion becomes a component of the core construct of feminist therapy practice—the development of an egalitarian and empowering relationship between therapist and client.
Formal assessment thus also rarely has a place in feminist practice. A striking exception to that has been the field of feminist forensic practice, which is an offshoot of feminist therapy (Dutton, 1992; Rosewater, 1985a, 1985b; Walker, 1985). Feminist forensic practice was initially developed to offer expert testimony in cases of battered women claiming self-defense after killing their batterers. Rosewater (1985a) developed an empirically defined Minnesota Multiphasic Personality Inventory (MMPI) profile of battered women that then began to be used in such courtroom testimony; Dutton’s research expanded on that. Other feminist forensic psychologists, such as Brown (1999) and Fitzgerald and her colleagues (Fitzgerald, Swann, & Magley, 1997), have explored applications of standard objective assessment tools to sexually abused and sexually harassed populations in a feminist lens. Currently, some original research is being conducted to develop a tool that would assess feminist constructs such as resistance and empowerment in individuals (Zimberoff, 2006). However, the role of formal psychometrics used with the goal of delineating the nature and intensity of distress is minimal in feminist psychotherapy practice. Feminist therapists may utilize formal assessment, but must be careful to do so in a contextualized manner, eschewing any use of computerized interpretations of test findings that are likely to be demeaning to clients and fail to take the larger social context into account (Brown, 1999).
THEORY OF PSYCHOTHERAPY: COLLABORATION OF EXPERTS—FEMINIST THERAPY, EMPOWERMENT, AND THE EGALITARIAN RELATIONSHIP
At the heart of feminist therapy lies the egalitarian relationship, the cauldron in which empowerment is brewed. Not a consciousness-raising group of two, and not a relationship of equals, it is nonetheless a relationship founded in the notion that equal value should be accorded all participants in therapy; that each participant is an expert, bringing particular sets of skills and knowledge to the collaboration, with no one set more highly valued than another; and that every act of the therapist has one aim—the empowerment of the client.
The egalitarian relationship ideal has suffered much from the fact that it and the term equal have the same Latin root. In some of the earlier phases of feminist therapy, particularly during the first phase in which there was no clear theory or ethics of feminist practice, some therapists used feminism as a rationale for having no boundaries, including few or no sexual boundaries with clients. These individuals rationalized their actions by pointing to the egalitarian relationship ideal and arguing that this meant a relationship of pure equals; thus, a therapist could not exploit a client or abuse power if the powers of both parties were equal. Few feminist therapists or thinkers agreed with this construction of egalitarianism, however, leading to the development of the FTI Ethics Code in which the reality—that the therapist, by virtue of role, has unequal power in the relationship and holds responsibility for delineation and maintenance of boundaries—is affirmed as consensus in the community of feminist therapists (FTI, 1990).
An egalitarian relationship makes certain assumptions about client characteristics that allow for a greater equality of power in the relationship. To the degree that any client moves away from these, the feminist therapist is challenged to find new and different strategies for egalitarianism that meet the client where she or he is located, rather than ever abandoning the egalitarian ideal no matter how much a particular client pulls for the therapist to assume a more authoritarian stance, even if a benign-appearing one. A client is assumed to be in therapy of her or his own free choice, identifying some aspect of life in need of change.
This can be true even when therapy is occurring in a coercive environment. An example of this aspect of feminist therapy practice can be seen in Cole’s (2006) description of working with women in prison. She describes her initial encounters with her clients, where she stresses that she will not make attendance at therapy a component of the corrections process. She tells her clients that they must decide whether they will attend a scheduled session, and that if they chose not to attend, this is a decision made with no negative consequences. She also informs her inmate clients that within each session they have the choice about what the session focus will be. Finding every possible manner in which to invite clients to a more powerful stance is the theme running through what feminist therapists do in practice; in this instance, by removing any coercive elements from treatment in a highly coercive situation, the client is invited to begin to know ways that she has choice and, consequently, personal power.
Most clients have some sense of personal power, no matter how small; one of the greatest challenges for feminist therapy is the client who perceives her- or himself as powerless and/or her or his fears becoming powerful and effective. Related to this is the client’s sense of capacity to be responsible for a change process; although the location of the problem is outside of the client, the location of the solution in feminist therapy is always at least partially in the client. A client in feminist therapy is likely to have values reflecting some aspect of feminist norms of respect for diversity and nonoppression of others; another very difficult and interesting conundrum for feminist therapists has been how to develop strategies for working with and empowering people who abuse power, such as domestically violent men (Ganley, 1991) or clients who are overtly racist (Adleman, 1990).
Thus, in work with a client who batters his partner, a feminist therapist would ask that client to consider how his behavior is ultimately disempowering to him. He would invite his client to look at both short-term feelings of power and control as well as longer-term consequences of the choice to use violence to solve problems in a relationship. The battering man’s abusive behaviors would be reframed as examples of extreme helplessness and powerlessness, given the medium- and long-term consequences, and the client would be invited to experience the powerless feelings associated with the choice to use violence. A powerful person does not routinely choose actions that could lead to incarceration, mandated treatment, payment of fines, and estrangement from partner, children, and others who learn of his actions. In feminist practice, the therapist utilizes this larger picture of power to invite the power-abusing client to become more genuinely powerful.
In egalitarian relationships, clients are also seen as worthy of the therapist’s trust; therapists, conversely, are not construed as trustworthy per se. Instead, in the egalitarian model, therapists are charged with acting in such a manner as to earn clients’ trust, thus offering clients the power to decide about the therapist’s trustworthiness, rather than having the therapist declared trustworthy simply by virtue of occupying that role in the exchange.
The emphasis in the egalitarian relationship is on empowerment of the client. Empowerment is construed in a variety of forms, some of them overt, many of them subtle, and all of them reflecting a sophisticated set of definitions of what constitutes power. As begins to become visible in the previous examples, power is defined in feminist therapy not only in the usual manner—control over human and material resources and the ability to force others to do things. It is also defined as intra- and interpersonally. A powerful person knows what he or she thinks and is able to think critically about her/his own thoughts and those of others. Powerful people know what they feel as they are feeling it and can use their feelings as a useful source of information; they are not numb, their current feelings are about current not past or possible future experience, and they are able to soothe themselves and contain their feelings in ways that are not harmful to themselves or others. Powerful people are able to have an effective impact on others, being able to be flexible and influential without regular negative consequences; they are capable of forming relationships that work with other individuals, groups, and systems. Powerful people are able to create and sustain intimacy, to be close without loss of self or engulfment of other. Powerful people are in contact with their bodies and are able to accept those bodies as they are rather than be focused on making the body or some part of it larger or smaller, nor do powerful people intentionally engage in behaviors that hurt the body; powerful people are able to know their sexual desires and act on them in ways that lead more often than not to pleasurable outcomes consistent with their values. Powerful people enter roles in life—parent, partner, worker—from a place of choice, intention, and desire, not through accident. Powerful people have systems of meaning-making that assist them in responding to the usual existential challenges of life and that give them a sense of comfort and well-being in the midst of the chaos of the universe. Powerful people have a sense of their heritage and can integrate it into their identity in ways that allow them to better understand themselves. Powerful people are aware of the social context and can engage with it rather than being controlled by it or being unaware of its impact.
Within this broad aspirational construct of what constitutes inter- and intrapersonal power, feminist therapists invite clients to find ways to become more powerful by offering ways in which they can access all of these sources of power. Frequently, the power experienced by our clients prior to their encounters with feminist therapy has been invisible to them or felt as negative and dangerous rather than self-affirming. Many clients perceive their resistance strategies—in which creativity, talent, and desperate attempts to ward off disempowerment can be discerned as the feminist therapist diagnoses the resistance—as evidence of their powerlessness and failure. Often people have experienced extreme violations of body, mind, spirit, culture, or some combination of all of these and have protected themselves by developing strategies of passivity (as one client told me, “No one can blame me for screwing up if I do nothing at all”); dissociation from body, affect, or memory (another client reported, “When I didn’t remember being sexually abused, I wasn’t someone who’d been sexually abused. I was just someone who never had sex, which I told myself was no big deal.”); or self-inflicted violence (“Hurting myself means that I’m in control of the violence for once,” quoting another client).
In her work with a feminist therapist, Harjit, a woman of Sikh ancestry raised by her immigrant parents in the United States, found herself angry with herself because she had coped with painful abuse by those parents via a creative dissociative strategy. She had a collection of inner voices: one was cruel and critical and sounded like her father, but another spoke in the voice of her beloved great-aunt, who lived with the family, cared for Harjit until she was age 7 and had been kind and caring. She felt deeply ambivalent about her faith and the community that was built around it because her father had often quoted religious sayings to her to underscore her utter lack of worth. Her feminist therapist invited her to admire her creative solution of making the critic not a part of herself, and invited her, as well, to consider how to make the loving “auntie-ji” voice blend more completely into her own adult one. She became able to see how, as a suffering child, she could develop one all-purpose solution that both protected her somewhat from internalizing self-hate, in that she dissociated her father’s verbal abuse, but also made it difficult for her to internalize her self-care and compassion because her auntie’s voice was equally dissociated. Her therapist offered her reading materials about children and dissociation because one of Harjit’s talents was being an autodidact; in this manner, the therapist spread out the power associated with being an authority on dissociation and development, supporting Harjit in making an autonomous acquisition of the information. She used that information to assist herself in having an understanding of her inability to “do it right” as a child, and to increase her self-appreciation as she moved through the process of integrating self-love.
The previous use of the word invite is used intentionally to imply an offering that can be accepted or rejected with no negative consequences and that acts from a position of respect for the client’s current strategies. It also makes a statement about who is on the receiving end of our invitations; the people with whom feminist therapists work are, to some degree, the guests in the house of therapy, honored for their willingness to step through this difficult and often frightening door to transformation. Feminist therapists take seriously that our clients, no matter how much they are suffering, have devised means by which to arrive alive, albeit in deep psychic pain, in our offices. Offering respect for that reality, which includes communicating it directly to our clients, can make it possible to consider other means of surviving, or even thriving, that do not require the disempowering process of disowning the client’s previous attempts to do so. This author might, for instance, note a client’s talent for dissociation as a way of having been able to shift himself out of painful childhood experiences and frame current problems related to dissociation as the evidence that this strategy may have outlived its usefulness for the client’s current life, rather than evidence that it was a disordered strategy to begin with.
Within this construct of invitation, there is a range of behaviors a therapist may obtain; a therapist may sit quietly with one client and be very active and coaching with another. Feminist therapy is a purposefully technically integrative model (Brown, 2005) that fits the work to the client and draws on the therapist’s expertise regarding the range of possible ways for a person to become more powerful in her or his life. As a result, there are not specific strategies or interventions that all feminist therapists would utilize; rather, the overarching strategy, which will be implemented in a range of ways, is that of client empowerment.
For example, a client may be struggling with intrusive voices that tell her to hurt herself and she express to her therapist a desire to be less frightened or controlled by those voices without taking medication. A feminist therapist might invite the client to have a more powerful relationship with this aspect of herself, and to keep safe, by offering instruction in mindfulness-based methods such as acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2003), which unlike antipsychotic medications does not make voices go away. However, it does change the individual’s relationship with such voices so that the individual has more choice in relationship to them. Acceptance and commitment therapy involves a fair amount of direct instruction and activity by the therapist and may on the surface appear not to be egalitarian or empowering. But as Brown (2002) notes in a discussion of another fairly active technique, eye movement desensitization and reprocessing (EMDR; Shapiro, 2002), a therapy may be feminist so long as it meets the criteria of supporting feminist practice—the creation of feminist consciousness, the development of egalitarian relationship, and the empowerment of the client. Thus, ACT may be utilized as a feminist empowerment strategy if the client identifies feeling disempowered by the voices in her head because it offers a powerful tool for increasing the client’s choices. However, if the therapist were to impose the use of ACT to treat voices when that was not the client’s agenda, then egalitarianism would have been violated and the practice would no longer be feminist.
Gender as a risk factor for depression has long been discussed (Strickland, Russo, & Keita, 1990), and feminist therapists frequently work with people who are depressed. Although a feminist therapist might employ cognitive therapies for depression given their known effectiveness, that therapist might augment the usual treatment strategies with feedback focused on questions of power and powerlessness. Sean, a blue-collar fifth-generation Irish American man, came into therapy with the symptoms of a depressive episode. The symptoms that bothered him the most were his irritability and his lethargy because both interfered with his self-concept as an energetic, social, and gregarious person. He had begun to drink to excess to manage the first symptom, and to use methamphetamines to deal with the second, which worsened the first in a destructive synergy. In consequence, his stated reasons for being in therapy were “I drink a bit too much and I tweak (use methamphetamines) a lot too much, but I’m not a drunk or an addict. I just want my old self back.”
His feminist therapist, who he had found because her web site mentioned her use of nonabstinence-based, harm-reduction strategies for working with substance dependence, worked with Sean to explore how his attempts to solve his problems were being less than empowering to him. She invited him to engage in an identity exercise in which he drew a picture of the different components of his identity and then placed them in relationship one to the other to get a visual representation of his multiple identities. She chose this strategy to offer to him because he was a skilled woodworker who made fine jewelry in his free time. This diagnostic exercise was focused on giving Sean a chance to use his artistic and visual strengths, which in turn began the process of empowerment. She also offered to him the concepts of relapse prevention, which are core to harm-reduction models for working with substance abuse, and asked him how he could best track his risk-for-relapse behavior chains. Sean found himself delightedly coming up with the plan to create a relapse prevention “Advent calendar,” reminiscent of the intricate calendars that his grandparents had had in their home; his visual system, which engaged him in his strengths as a craftsperson, also connected him to his culture and his family, from whom he had become estranged as his substance abuse worsened. The therapist, by not prescribing the record-keeping strategy (e.g., a diary card), invited Sean to be powerful in his own recovery process.
Feminist therapists also utilize a number of structural and ecological strategies to increase systemically power similarities in therapy, although none of these is prescribed or required. Consistent with the research on positive effects of self-disclosure, feminist therapy has long supported therapist self-disclosure in the client’s interest (Brown, 1991a, FTI, 1990). Therapists practicing from the relational-cultural model of feminist therapy place a particular emphasis on emotional mutuality in the therapy process, and on the therapist’s willingness to be emotionally transparent and available to a client (Banks, 2006; Miller & Stiver, 1997). Feminist therapists are thus required to consider how they and their clients have power and privilege differences not only in the office, where a therapist is powerful by virtue of role, but outside in the larger social milieu, where clients may possess more kinds of social powers than therapists. Feminist therapists have long ascribed to the notion that there are nonharmful nonsexual dual roles, called overlapping roles (Berman, 1985) in the feminist therapy literature; as a consequence, boundary maintenance, although ultimately the responsibility of the therapist, may be a co-constructed project, particularly if therapist and client are both residents of similar small communities (Brown, 1991a).
Feminist therapists also consider how the details of their business practices, including where their office is situated, how they are addressed, and how they set the fee, are consistent with a message to clients about equality of value and empowerment (Brown, 1991a; Luepnitz, 1988). Therapists must consider what message of welcome their office conveys; is it in a setting that shouts of social class privilege, located in a setting where people of color might feel uncomfortable, far from bus lines? If so, even if this sort of office is a norm among other local therapists, the ecology of the office setting will have begun to set a nonegalitarian tone that will potentially permeate the therapy and undermine feminist goals. “Setting the fee as a feminist,” in Luepnitz’s words, is a component of creating a relatively seamless web of empowerment and egalitarianism in all aspects of the therapy process.
Alexander (1977), in his book on the psychology of spaces, A Pattern Language, noted that how space is organized conveys to people whether a space is welcoming, safe, or intimate; feminist therapists attend to those questions not necessarily in terms of spatial patterns but rather in terms of how a space speaks a message of equality of value. As noted earlier in the discussion of diagnosis, feminist therapists discuss the use of DSM diagnoses with clients when the giving of such is necessary for payment purposes and collaborate with clients on arriving at a diagnosis.
Feminist therapists also pay attention to the larger social context because it influences both the distress that a client brings into therapy and the process of therapy itself. Feminist therapists invite clients to attend to ways in which the external environment has been a source of misinformation about themselves, their value, and their capacities. They also invite clients and themselves to notice how changing external worlds affect internal and relational worlds.
An excellent and painful example of this occurred during the week in which the initial draft of this chapter was written; in that time, a gay marriage lawsuit in Washington State was defeated and a Jewish organization in Seattle was the subject of a fatal shooting attack. The author, a Jewish lesbian living in Seattle, was affected by these events and was left feeling less safe, less powerful, and more vulnerable. As a therapist preparing to enter my workweek with my clients, some of who are lesbian, some of whom are Jews, some of whom are aware of my identities and others who are not, I needed to consider how these two powerful public events would affect power dynamics in my relationships with my clients, how some might attempt to give away time and attention to me, how others might unknowingly make remarks that hurt my feelings, and how still others might simply ignore the realities of the past week and go on addressing the more pressing problem of how their life does not work. But the external social world would be a third party in the room, no matter what role it played; feminist therapy offers its practitioners a framework for thinking about how that world is present in the office.
Ironically, what emerged was that the person most affected by that week was neither a Jew nor a lesbian, but a heterosexual woman raised in no particular faith tradition who had known one of the dead woman’s children well in college and who came to her appointment directly from the funeral service. The social context was in the office for her in a way it had never previously been.
Feminist therapists collaborate with client on goals of therapy, both macro and micro. Such collaboration requires careful attention to client’s levels of readiness and willingness to approach any topic or problem and places the definition of the problem into the collaborative space. A feminist therapist cannot have a favored, one-size-fits-all strategy because this would implicitly disempower clients. Even with clients who are actively suicidal, feminist practice does not eschew client empowerment. The feminist therapist in that situation must instead be creative in finding ways to both protect client safety and also continue to respect the client’s autonomy. This author has noted (Brown, 2006) that many therapists, fearing liability, turn coercive and disempowering of clients when this most frightening topic emerges in the therapy. This can in turn lead to clients’ asserting their autonomy from a stance of “I’ll show you who’s the boss of me” by experiencing increasing suicidality or even engaging in self-destructive gestures as a means of conveying to the therapist a message about who is really in control.
Feminist therapy theory suggests that a therapist at this juncture must instead find ways to empower the client that do not require demonstrating power and autonomy in self-destructive manners, something common in the lives of individuals who struggle with the urge to commit violence against themselves. A feminist therapeutic assessment of potential lethality (Brown, 2006) empowers both therapist and client by identifying how or if the therapy relationship itself, and other contextual factors in the client’s life, might be modified so as to be protective against the client’s urge to permanently disempower her- or himself.
An example of this can be seen in the case of Karen. She struggled with very high levels of anxiety and depression even before a car accident in which she developed paralysis of her lower body. The accident had not been her fault—her small subcompact had been driven into by a large SUV driven by a man distracted by answering his cell phone. Her prior strategies for protecting herself—which included anticipatory worry, avoidance, and running several hours every day—had, in her opinion, failed her badly. Now running, which had had a useful emotion regulation function for her, would never again be available. Her sense of having failed to keep herself safe, and as a result of that failure having lost the one activity that left her feeling less dysphoric, deepened her depression. She became suicidal and made an overdose attempt serious enough that she was on a ventilator for several days.
When she became well enough to be moved from the ICU to the psychiatric unit, her feminist therapist offered her an option. Agree to stay alive until their next therapy session and he would argue against her being an involuntary patient. “This is a place where you have choice,” he told her. “It’s a lousy set of choices, but if you don’t renounce being dead for at least the next few weeks, you’ll have no choice at all. You can always choose death later. If you want some control over what happens next, you have some choices to make.” Her therapist accurately identified Karen’s suicide attempt as her struggle to experience control over her life given the loss of other means of control, and he immediately moved to construct her current situation in terms of control and choices. In their sessions over the next several months, he emphasized the issue of control in her life; at each session, he invited her to commit to staying alive until the next, reminding her that it was a choice that he would assist her with through between-session coaching. Making empowerment primary rather than focusing on how Karen’s suicide attempt had stripped her of yet other choices in her life allowed her to be respected for her attempts to regain control via lethal means, even while her therapist continued to invite her to find other, nonlethal avenues for experiencing power in her life.
Because of its biopsychosocial-spiritual emphasis, feminist therapy does value somatic interventions as one integrated component of treatment. Many feminist therapists invite clients to consider learning about strengthening or increasing flexibility of body, to discover how to feed themselves in a loving way, and to explore the usefulness of formal medications. Feminist psychopharmacology (Jensvold, Halbreich, & Hamilton, 1996) has studied how sex differences in hormones and responses to drugs, while often little is known by those prescribing them, need to be taken into account if prescribing is to happen in a nonoppressive and empowering manner. Modern psychotropic medications carry risks of side effects that dull sexuality, increase risk of weight gain and diabetes, and have unknown consequences for children who are in utero when pregnant women use them. Feminist psychopharmacology supports clients in exercising judgment and autonomy regarding these and other somatic interventions.
FEMINIST THERAPY AND MULTICULTURAL PRACTICE
Feminist therapy is also an intentionally multicultural approach to therapy. Although initially feminist therapists focused entirely on issues of gender when attending to identity, the past 2 decades of feminist therapy theory and practice have been marked by an increasing attention to issues of other social locations such as ethnicity, culture, social class, sexual orientation, disability and ability, and the meanings of indigenous status, histories of colonization, and experiences of emigration and dislocation. Hays (2001, 2007) has proposed a feminist-informed model of understanding multiple social locations as they inform experience and identity, arguing that for each person every one of these varieties of social location must be attended to if a therapist is to deliver culturally sensitive and competent treatment.
Feminist therapists thus argue that attention must be paid to issues of privilege (McIntosh, 1998); that is, certain social locations confer on those situated in them experiences of power and access to resources, as well as protection from harm, that are unearned and that may function to oppress others, intentionally or unintentionally. Thus, persons of European American ancestry whose skin is called White in Western cultures have phenotype privilege; by virtue of being born with certain pigmentation and shapes of eyes, nose, and mouth, these people benefit from the fact that they live in a culture that is informed by White racism. Even a person who is not intentionally or actively racist or discriminatory benefits from phenotype privilege. McIntosh’s article, which focused on this “white skin” privilege, listed a host of things that people of European ancestry can easily take for granted, from the banal (e.g., makeup and hair products that work) to the serious and endangering (a European American person is unlikely to be stopped by the police if he is driving a luxury car because there is no assumption that a White person driving that car will have stolen it or have drugs in it). Similar privileges attend on other dominant social locations in Western cultures such as heterosexuality (the many legal benefits of being able to marry the person you wish to partner with), adherence to a Christian faith (imagine never having your primary religious holidays be the official days off work), middle-class and higher social status (access to resources such as checking accounts, good credit ratings, high quality schools, safer neighborhoods), and so on.
Feminist therapy theory thus argues that a component of the egalitarian relationship emerges from the therapist’s exploration and analysis of issues of privilege as they emerge in the therapeutic encounter. Privilege unexamined increases power, and privilege unspoken of operates in an oppressive manner. Feminist therapists take on an ethical obligation to introduce discussions of privilege into the therapeutic environment, owning theirs when it is present, and exploring for themselves the meanings of it when they have less privilege than clients (FTI, 1990). An Asian American feminist therapist working with an African American client might, for example, ask her client what is means to him that she is a member of another ethnic group of color, but one that has been used in unfavorable comparison for the client’s own group. By doing so, she invites her client to know that she will honor and make explicit any symbolic meanings of their differences in power and privilege as they emerge in their work together, rather than treating those differences as immaterial.
In exploring issues of privilege, feminist therapy also increases cultural competence by encouraging its practitioners to pay attention to the multiple, intersecting, and overlapping aspects of identity that are present in each person. Because every person has multiple social locations, awareness of those locations and their centrality to a client’s identity are crucial aspects of client empowerment.
Comas-Diaz (2006) illustrates the integration of feminist and multicultural principles in her work with Latino clients, providing an excellent example of how feminist therapy points its practitioners toward cultural competence. She notes that in working with clients from a particular heritage (in her example, those from Central and South America and the Spanish-speaking Caribbean), a therapist must pay attention to the worldviews held by clients from that heritage and culture. Such worldviews may be expressed through spiritual traditions, use of language, social arrangements, rituals and celebrations, food, art, and important sayings or proverbs. She argues that to effectively empower clients, therapists must actively embrace these aspects of our clients’ phenomenologies. She also notes the importance, for cultural competence, of knowing and understanding how histories of oppression and exclusion have shaped worldview and give meaning to current experiences.
This perspective is similar to that expressed by Greene (2000) in her work on feminist therapy with African American women. Greene discusses the importance of attending to the meaning of womanhood in African American communities in the context of the history of slavery and racism. She notes that for these women, sources of resilience can also be sources of distress due to the extreme and conflicting demands placed on them by the intersection of racism and sexism, and the particularly gendered forms of racism, and raced forms of sexism, encountered by women of color.
The message from feminist therapy is that all of these social locations matter and that people cannot be arbitrarily divided into and responded to from discrete components of their identities. What is necessary is attention to clients’ experience of identities and the meaning of those identities to the distress that brings them to therapy, as well as the symbolic meanings that therapist and client develop with one another.
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