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
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.
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
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Psychology
work. and
July
New Ann
Boston,
1976
York,
NY
Acad
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of Women.
in
at the In-
France,
Families.
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