BRIEF

Am

COMMUNICATIONS

lems,

and

little

emotional

attention

was

disorders

by

paid

most

to

of the

management

physi-

I . American Psychiatric the Primary Physician. APA, 1970

cians.

In one of the centers, the liaison-consultation approach was abandoned temporarily (for reasons beyond our control). During that time and for many months after, integration of services and a collaborative This

approach to patient was true despite

care were the center

concurrence in our approach of it in caring for his patients. Finally,

role

the

psychiatric

is significant.

jointly,

with

and

to achieve. director’s

his own

skillful

consultants’

Decisions

primary

difficult medical

care

social

are

worker,

and

consultant each contributing his own expertise. Referral to a mental health professional is seldom made without the consultant’s concurrence, and responsibility for ongoing care is always shared, regardless of who provides the psychotherapy. Because of the consultant’s continuing cian more readily therapeutic role.

Success

involvement, accepts

the

the primary principal

physipsycho-

Task

Psychiatric

Force

Report

1978

Education

and

2. Washington,

DC,

4.

Coleman

and General

5.

Am J Pub Health 68:451-457, 1978 Engel GL: The need for a new medical biomedicine. Science 1%: 129- 136, 1977

JV, Patrick

DL:

8.

Lazerson AM: The psychiatrist ing: a solution to the mind-body 133:964-966, 1976

The

his

patient Press,

New

for

physian over-

Health

Care.

a challenge

for

education in a fam101:629-631, 1974

the

illness.

in primary dichotomy?

New

York,

medical care trainAm 1 Psychiatry

to primary

care.

Am J

1977

FP: Psychiatry

lem solving. Kahana RI,

and 1957

of psychiatry

134:126-129,

10. McKegney

Psychotherapeutic

doctor, Universities

P1: The relationship

Psychiatry

11.

model:

LF, Mackintosh A: Psychiatric residency. Virginia Med Month

Balint M: International

9. Fink

in psychiatry

Psychiatry

7.

ment.

or Failure:

Association:

in the seventies: 1977

6. Rittelmeyer ily practice

made

September

Rittelmeyer LF: Continuing education cians. JAMA 220:710-714, 1972 Lipowski Zi: Psychosomatic medicine view. Am i Psychiatry 134:233-244,

3.

administrative

on patient

physician,

2.

use

135:9,

REFERENCES

of

primary

J Psychiatry

and primary

Psychiatric

Opinion

care -a

14:38-43,

Bibring GL: Personality types York, International Universities

Considerations

for

need for prob-

1977

in medical managePress, 1964

Women

in Conflict BY

CAROL

C. NADELSON,

M.D.,

MALKAH

T. NOTMAN,

M.D.,

seen The authors describe conflicts experienced by women who request therapeutic intervention because of symptoms ofdepression anxiety marital discord, difficulty in asserting themselves, or inability to complete work that would lead to advancement. They discuss the developmentally based difficulties experienced by women in making career choices, advancing their careers, andfacing midlife issues. The therapist who deals with such patients must be aware ofreality-basedfactors and ofhis or her own values and attitudes as they influence choice of therapeutic approach. ,

by

Women

AND

MONA

our

society

are

often

asaggressive

approval norms.

,

B. BENNETF,

as

consistent

conflicted

rejection

with

about

or competitive

and

M.D.

because

if

Until recently, women chose a life pattern that set their peers. The capacity to has important psychological therapists see women who areas but who are conflicted

they

“femininity.”

activities they

violate

AMONG

THE

MANY

CHANGES

in the number Establishing

of the past decade

Hospital, 330 Brookline also Associate Professor

is a more complex and difficult problem for women than for men (1) because self-actualization, the pursuit of independent goals, and risk-taking have not been 1092

0002-953X/78/0009-1092$0.50

Dr. Nadelson is Director, man is Liaison Psychiatrist

has

of women entering proa professional identity

Medical

loss

of

established

entering careers thereby them apart from most of tolerate being “deviant” implications. Psychoare successful in many about the discrepancy be-

Presented at the 130th annual meeting of the American Association, Toronto, Ont. , Canada, May 2-6, 1977.

been an increase fessional careers.

regarded fear

Student

Education,

to Obstetrics-Gynecology, Ave. , Boston, of Psychiatry,

Mass. Dr.

Psychiatric and Dr. NotBeth

Israel

02215. Dr. Nadelson Notman

is also

is

Associ-

ate Clinical Professor of Psychiatry, and Dr. Bennett is Instructor in Psychiatry, Harvard Medical School, Boston, Mass. Dr. Bennett is also Director of Outpatient Services at the Massachusetts Mental Health Center in Boston.

© 1978

American

Psychiatric

Association

Am

J Psychiatry

tween familial

135:9,

their and

aspirations developmental

are influenced psychic

find

September

and

as are

it difficult

BRIEF

activities experiences.

by the same

factors

1978

cultural,

their

and

their early Therapists

familial,

and intna-

patients.

to objectively

Thus,

they

may

the

nature

and

examine

CAREER

the

rapidity

of change

in values

years. Concepts of what is healthy pniate, rational, or acceptable dividuals; objective criteria

Brovenman

and

associates

and

mores

in recent

that

these

woman’s by their

factors

identity, biological

women

women’s timetables

are concerned

reality from the men are concerned

nize

their

clearly lives than

in one way

beginning about

life plans

do

not

around

about

CAREER

this

Although not orga-

issues

same way women do. Thus, considerations and values as well as of the developmental and reproductive issues provide a framework derstanding the problems currently presented en in therapy.

in the

of goals life cycle for Unby wom-

CHOICE

Early in life one often makes choices on the basis of idealism, romanticism, faddism, or family pressure without adequate appreciation of the complexities and realities inherent in any choice. The rapid increase in the acceptability of and even insistence on women’s achievement has found many women unprepared for making these decisions or for following through on decisions already made. This is particularly true for young women whose early developmental experiences

were

in families

identifications

for

of such

future

young would

meet

expectations.

women either

with

She may competitive

with

attempts exceed

disapproval, be concerned feelings.

a traditional women

orientation. may

Anxiety a life course hen mother’s

particularly

The

not

provide

may

occur

past

from

hen mother. or have

avoided including

the entire dilemma, but current expectations, hen mother’s, often make that option less

feasible

today.

estab-

from less

male colleagues, interesting and

the option

they may rewarding

of assuming

nesponsi-

seek

therapy

because

lead

of the

symptoms

discord, difficulty in asto complete work that

to advancement.

Women

may

become

depressed

after

recognizing

anger or discontent with a situation they had previously accepted. This occurs because the woman feels that by experiencing on expressing anger she has violated hen internalized ego ideal as a nonaggressive person. She may continue to see herself as helpless and powerless’ or may retreat out of fear of losing the relationship if she expresses angry feelings. Even “successful” women may maintain this self-image.

The

need

their

lives

fulfilled.

to avoid so

externalized bosses,

conflict certain

e.g. an unplanned to return to work. ,

and

projected

peers,

the

to

reality

leads wishes

a life event

ofdiscrimination.

a therapist

enable

that

Sometimes

frontation; less possible

ence a

that she believes achievements or

about expressing aggressive In the past a woman might

to actively

Conflict avoidance and regression diminish anxiety by preventing the open expression of ambition or selfassertion. Because acknowledging aggression, even when it is conceptualized in terms ofmastery and creativity, is more threatening to women than to men’ the therapist must be ready to confront resistances to achievement when achievement is perceived as aggression. Because women often view competitive activity as injurious to others, they may feel guilty about competing (3).

ily,

models

when

aid are

with

women

would a

on another do

and that

confronted

Many

influenced lives. All

reproductive

life

ofdepnession, anxiety, marital serting themselves, or inability

are more are men’s

of adolescence. fertility, they

student

long-range career plans and unconsciously sabotaging the efforts of others to help them. They may regress and become more dependent, helpless, or childlike to

when

views

constitute

from

bility, or they may deprecate their achievements to avoid jeopardizing relationships with men. Although these behaviors might have been successful for women in some areas, they are generally counterproductive from the perspective of attaining professional goals.

of mental health are affected by sex role stereotypes. Although some changes have occurred since their study, the personal and cultural values that enter into therapeutic decisions continue to be particularly salient in the treatment of women. Biological and reproductive factors are also inevitably important in any discussion of therapy of women.

Although

transition

lishing a careen requires a confrontation with pressures that may be quite different from those which were fantasied earlier in life. Women are often poorly prepared to face the demands of a career, perhaps because they have not conceptualized themselves as functioning in this role. They may find themselves unable to make

gain approval choose jobs

as well as what is approclearly differ among inare not available. In 1970

(2) demonstrated

DEVELOPMENT

The

intensity of the conflicts presented. For every therapist the ability to differentiate what is actually mentally healthy from the idea of what is healthy according to subjective personal values becomes critical. This diffenentiation is more complicated than is often acknowledged, and the problem is made more acute by

COMMUNICATIONS

This

unravel

because

in the

woman’s

to structure

never

serves

tested

to avoid

pregnancy At times,

and/or

demands

women are

may make it conflicts are

displaced of work,

is particularly there

on

a con-

onto

fam-

on the

pnes-

complex may

perception

be

for

consid-

of the

ex-

ternal difficulties. The therapist must ally himself or herself with the patient in hen exploration of her conflict about self-assertion and help her to examine the ways in which she may mask hen competent self. It is

1

Miller I, Nadelson C, gression and self-esteem

Notman M, in women

et al: Reconsiderations (unpublished paper,

of 1977).

ag-

1093

BRIEF

Am

COMMUNICATIONS

important not to simply share hen externalizations. Many women approaching the age of 30 come for treatment when they begin to face the possibility that they may not marry on when they decide not to marry. Even if they have been ambivalent about marriage, the reality of not marrying on of not having children may foster a sense of deviance on defectiveness and lower self-esteem. On the other hand, the peer pressure currently applied toward not having children may make it difficult for some women to face their ambivalence on their sadness about giving up the possibility of having a child. Some women have difficulty taking major professional steps on even making such personal decisions as moving to a better apartment on buying a can at this time. They may fear that these changes would seem to represent a commitment to being unmarried. They may blame their careen for their social isolation. Some women find a masochistic solution-they might make choices

that

avoid

careen

commitments

tions”

open.

serious

and

in order

They

may

then

potentially

rewarding

to keep

relationship

become

angry

“op-

and

disap-

pointed when rewards do not materialize. Some women handle these conflicts by adopting a life pattern in which they function as “one of the boys.” This may be adaptive because it permits them to be strong and competent peers; it also avoids sexualization of relationships. The cost, however, may be an inability to accept sexual on dependent feelings. These countendependent mechanisms are often accompanied by rigidity and can interfere with empathy in interpersonal relationships. Women who attempt to retain their emphasis on relationships without sacrificing the development of competence and assertiveness have a difficult time, particularly

in such

“masculine”

fields

as engineering,

architecture, and management. They need support and reality testing, and they must also maintain sufficient self-esteem to prevent failure. Women who combine marriage and a career often experience role strain (4). This may occur early in their careers or at a point when they begin to increase their involvement in activities that do not involve their families.

Their

husbands

may

develop

a sense

of loss

and

abandonment and may become competitive, demanding, or regressed. Children also often experience such changes as losses. Guilt oven these reactions can lead women to give up their outside interests or may stimulate them to overcompensate and become too self-sacnificing.

Some

women

respond

by

displacing

or

pro-

jecting their anxiety and are thus seen as overcritical, intolerant, or unresponsive. Some women externalize in this situation and see their family as the major source of their problems rather than understanding their own

with children and anxiety

conflicted

are

responses

especially

to pressure.

likely

Problems

to precipitate

guilt

(5). At times marital or sexual problems occur. There has been considerable speculation about the possible increase in male impotence as a result of the increase

in women’s 1094

aggressive

behavior

and

sexual

demands.

J Psychiatry

135:9,

September

1978

Although there is no good evidence to support this idea, the concern evoked reflects men’s anxiety about their masculinity when traditional roles are changed, when they receive more demands for sexual performance and for assuming traditionally feminine tasks and roles. Psychological withdrawal, including loss of sexual interest on potency, sometimes rigid conpensatory assertions

of masculinity,

cur as attempts

on other

to restore

symptoms

self-confidence

may

and

oc-

diminish

anxiety.

The specific rarely considered (6). Generally,

problems of the dual-career family are before a couple embarks on this path each partner makes plans and sets mdi-

vidual goals; these might not be consistent with family demands. Problems often appear in dual-career families when children are born. Conflicting demands force confrontations because alteration of schedules and plans are required. In this situation, as with other conflicts, the wife usually is the accommodating person, limiting hen goals and expectations (7). She may then

seek treatment handle anger,

because of marital friction,

depression, or problems

inability with

to chil-

dren.

A woman

returning

stressful;

it is

also

mitment

if she

has

to a careen difficult

been

to

may

find

increase

working

reentry

a time

part-time.

com-

Positions

may not be available, the demands of a particular field may have changed, she may not have the credentials to enter at the level she seeks, or she may find herself working with younger and less experienced colleagues. Women are often unable to confront their passivity and their internal restrictions on aggression and its expression when a more active commitment is necessary in the new role they seek. Depression and anxiety may result when they challenge their internalized self-image, or aggression may be mobilized, resulting

in guilt feelings. Some women own “space” by leaving their the challenge by backing down of authority and responsibility,

act out and seek their families. Others avoid and refusing positions although they often

state that they want these positions. At times a woman views her husband on family as critical or unaccepting as a way ofdealing with hen own ambivalent feelings.

MIDLIFE

As choices

ISSUES

people they

approach have made.

midlife Women

they who

reflect have

on the not mar-

ried or who have not had children may feel they have paid too heavy a price for the choices they made. When underlying anger is mobilized, they may find it difficult to handle it appropriately or productively and may seek treatment. On the other hand, women who have placed family commitments before their careers may face losing their primary source of identity with the onset of menopause. Divorce, the death of a spouse, the fact that children precipitate anxiety, depression, toms. Women with important

are or career

leaving home may regressive sympinvestments seem

Am

J Psychiatry

135:9,

September

1978

BRIEF

therapist

to be less vulnerable to depression in the midlife years. Those who have not had children have generally come to terms with this before they reach menopause. Women who are heavily invested in family roles respond more strongly to the menopausal changes (8).

Although

many

Therapy

of the

issues

considered

here

are

we

will

to

men as well as women, as they relate to women.

Specific

requests

may

be made

for

male

or female Women of women difficult “mater-

The

reasons

for

choosing

be based on stereotyped on traditional regard for the characteristics of the

views individual

apeutic

regardless

to this likely

area.

successful

involving

This

to occur

in-

with

an

woman

work

than

or academic

exclusive

see

Therapists

career

and

or too

re-

may

also

family

involvement

goals falls.

may

lished

she

be imon emthen-

and

possibilities

as

complex.

find

it difficult

to

women who decide to have children older or who are ambivalent about These therapists may not realistically on potential

understand

when they are having children. explore career problems

and

pit-

The woman house officer who wants to have a but who has undertaken a very demanding promay need the opportunity to explore why she to become so committed at the particular time did,

just

as the

careen

give

who

may have

40-year-old

woman

suddenly

up hen career

women or may

must

decides understand

be acting important

with

an

to have this

estab-

a baby

decision.

and Both

out in a self-destructive fashion positive reasons for their deci-

sions.

alliance.

Reality-Based

they

mutually

without thera-

pist (9). Nevertheless, these preferences may portant. The patient’s feeling ofgreater comfort pathy can facilitate the development of a positive

Demands

because

baby gram chose

a therapist

is more

interpersonal

issues,

assigns

occupationally

a man.

her

quinements are often treated as resistances in women. Some therapists still regard success for women in traditional terms; such therapists may not take self-actualization related to nonfamily areas of life seriously or may see it as postponable for women. Therapists and patients may limit their exploration of alternatives

nal” qualities, and/or to provide role models. Women who choose a woman therapist often feel that she would be more responsive to their wishes for self-actualization.

but

with

career-related

emphasis

isolated

Referral

therapists by patients or by other therapists. therapists are most often chosen for referral patients to avoid a sexualized on a potentially authoritarian transference, for the therapist’s

her

the patient

terpersonal

IMPLICATIONS

clearly applicable emphasize them

concerned

than

of the priority

with THERAPEUTIC

is more

relationships

COMMUNICATIONS

Another

Factors

area

what constitutes therapist who

The realities of the patient’s specific life situation are important factors that influence the choice of thenapeutic modality or approach. A method of problem-

of concern

is the

psychopathology finds it difficult

assertive

behavior

in women

passive,

masochistic

stance

therapist’s in

to accept

may

view

women. aggressive

accept

rather

than

of The or

a woman’s help

her

mas-

solving or conflict resolution that is optimal under certam conditions may not be realistic in others. It is ob-

ten hen anxiety or depression by taking a more active self-directed position. On the other hand, the therapist

vious that or aborting

may pressure activity and

a woman who must decide about continuing a pregnancy requires a short, focused thentherapy.

A 40-

therapist

year-old woman with conflicts about becoming nant cannot spend several years in psychoanalysis

pregbe-

as a defensive terologically

apeutic

approach

rather

than

fore ous

deciding whether or not but important variables

and

emotional

resources

tion

that

be

may

woman

medical

ships with psychotherapy

medical

school

tic experience strain on her Values

,

The values ence clinical ty, and even cause social more critical ous problems successful in

with

problems candidate but

she may

more

and

benefit

less demanding performance. Countertransference

For

ive

situa-

example,

a

in her relationfor intensive while she is in

from and

a thenapeuputs

feels

less

and attitudes of the therapist can influformulation, choice of treatment modalithe focus of therapy. For example, berelatedness is generally considered to be for women than men, a woman with seriin interpersonal relationships but who is other areas of her life may find that her

into unwanted commitment

competitive because

Regressive

the

behavior

style may be seen in a woman as characprimitive when it is a style of presentation

than

of low self-esteem not defects in ego functioning. explonative

therapeutic

necessarily A support-

approach

may

then be recommended. Countentransference feelings may lead therapists to overidentify with patients and to project their own experience onto them. They may be in awe of women who are effective professionally and not attend to the concerns they present. The patient herself may support

Issues

rather

patient career

this is appropriate.

or a manifestation related to major

Less obvipriorities,

to a particular

stressful.

might be a good on psychoanalysis, that is academic

A ttitudes,

to have a child. are the needs,

relating

externally

student

men

long-term

the major

this

perception

because

of hen need

for

control,

a

quality that is important in her professional success. Thus, both patient and therapist may collude to accept a view that leaves out important areas for therapeutic work. In such instances therapists may foster a more egalitarian or intimate relationship or a more distant one than is helpful to the patient. The impact of feminist views has led many patients to mistrust guage (10)

formulations because of the

that use implications

psychoanalytic of such

terms

lanas

1095

BRIEF

penis this

Am

COMMUNICATIONS

envy. as

The

resistance

concerns will necessary to cally reinforce than ideologies. provocative, it difficult or

therapist without

or analyst understanding

who the

interprets patient’s

come to a therapeutic impasse. It may be explain, to avoid jargon, and to specifithe alliance between individuals rather A stance perceived by the patient as paternalistic, or authoritarian may make impossible for hen to develop a trusting

J Psychiatry

number

of

disciplines

and

R: Some effects 134:1-6, 1977 2. Broverman I, Broverman

identity,

reexamined

in the

light

of recent

supports

the

view

that

it differs

from

male

develop-

ment because of the impact of the reproductive timetable. Both childhood and adult developmental phases must be incorporated into concepts of femininity as a changing process with different expressions at different life stages. For the professional woman this integration is particularly important. The therapist must be sensitive to problems

arising

from

conflicts

between

the

demands

of professional adaptation and internalized contradictory expectations deriving from developmental

1096

in

the

context

of

social

REFERENCES of the new feminism.

.

Feminine

1978

change.

I Moulton

evidence and in the context of social changes, includes the integration of self-esteem, self-assertion, and independence as well as nurturance. A developmentally oriented view of feminine development and conflict

September

experience. The therapist must be aware of the impact of real life events as well as intrapsychic conflict in symptom formation. Formulations and therapeutic approaches must be modified in the light of data from a

relationship.

COMMENT

135:9,

D, Clarkson

types and clinical judgments Psychol 34:1-7, 1970 3. Gilligan C: In a different and ofmorality. Harvard 4. Johnson F, Johnson C:

women.

Journal

4(l):l3-36,

health.

I Consult

Clin

voice: women’s conceptions of the self Education Review 47(4):481-5I8, 1977 Role strain in high commitment career

of the American

M,

Nadelson

C,

psychotherapeutic

ternational

Congress

6. Rapoport Penguin

Academy

of Psychoanalysis

M:

Achievement

of Psychotherapy,

R, Rapoport Books, 1971

R: Dual

Bailyn L: Family constraints Sci 208:82-90, 1973

8.

Bart P. Grossman 10, 1976

9.

Nadelson C, Notman M: lem of conflicting values. J: Toward 1976

Bennett

considerations.

7.

Miller Press,

F, et al: Sex role stereo-

mental

1976

5. Notman women:

10.

of

Am J Psychiatry

M:

a New

Paris,

Career

on women’s

Menopause.

Psychology

work. and

July

New Ann

Boston,

1976

York,

NY

Acad

Health

supervision: 3 1:275-283,

of Women.

in

at the In-

France,

Families.

Women

Psychotherapy Am J Psychother

conflict

Presented

l(3):3the

prob1977

Beacon

Success or failure: psychotherapeutic considerations for women in conflict.

BRIEF Am COMMUNICATIONS lems, and little emotional attention was disorders by paid most to of the management physi- I . American Psyc...
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