Brief Intervention Strategies
As a general rule, feminist counselors have not embraced the recent trend toward brief therapies for two reasons. First, the goals of feminist counseling are not compatible with a brief approach. Deeply ingrained gender biases are not easily brought into awareness nor are they easily changed. Second, feminist counselors are cognizant that the push for brief (sometimes even single-session) therapy has been driven in large part by the managed care movement. Cost-saving measures that benefit the largely White-male-dominated health care corporations typically are not viewed by feminist counselors as an appropriate rationale for selecting therapeutic interventions. This is not to suggest that feminist counselors attempt to prolong the counseling relationship unnecessarily; clients often are encouraged to make the transition from individual counseling to a group format such as joining a support group or political action group as expeditiously as possible.
Clients With Serious Mental Health Issues
Feminist counselors are concerned about problems inherent in the prevailing Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; DSM-IV-TR) medical model diagnostic system (American Psychiatric Association, 2000). Since Phyllis Chesler, in Women and Madness (1972), articulated the view that the DSM approach pathologizes any difference from the standards established by the dominant group in society, feminists have argued that it is important to assess not just symptoms and behaviors but also the context of women's lives (Brown, 1994; Santos de Barona & Dutton, 1997). Within this broader context, many symptoms can be understood as coping strategies rather than as evidence of pathology (Worell & Remer, 1996). Thus, feminist counselors use a broad, bio-psycho-socio-cultural-structural model of assessment and diagnosis (Ballou & West, 2000). Using this broader approach to assessment, feminist counselors have obligations to familiarize themselves with the literature on gender and its relationship to clinical judgments of mental health and to examine their own gender biases and expectations. They actively inquire into the meaning of gender for the client, assess the rewards and penalties of gender role compliance or noncompliance for the client, attend to the client's responses to the counselor's gender and their own responses to the client's gender, and check their diagnoses to guard against inappropriately imposing gender-stereotyped values of mental health. Arriving at a diagnosis is a shared process in which clients are the experts on their distress and its social meaning. Clients' understanding of the meaning of their behaviors is considered equally with the counselor's interpretations, and client strengths and resiliencies are identified (Evans et al., 2005). Some of the types of distress commonly experienced by women are discussed in the remainder of this section.
According to the DSM-IV-TR, women are twice as likely as men to suffer from depression. From a feminist perspective, women have twice as many reasons as men to experience depression. Women, taught to be helpless and dependent and to please others, may feel that they are not in control of their lives or their environments. Their subordinate position – along with their experiences of domestic violence, sexual or physical abuse, poverty, or harassment or sex discrimination in the workplace – can result in a sense of powerlessness that can manifest as symptoms of depression. Feminist counselors view women's depression as revealing the "vulnerabilities of a relational sense of self within a culture that dangerously strains a woman's ability to meet basic needs for interpersonal relatedness while maintaining a strong sense of self" (Jack, 1987, p. 44). Feminist counselors work to help clients reframe their understanding of the causes of their depression so that they can move away from blaming themselves for the problem and from believing that they must "adjust" to their circumstances. They help clients become aware of external forces that limit their freedom so clients can release self-blame and focus their energies on circumstances they can influence (Enns, 2004).
As a result of conflicting societal messages and multiple pressures and demands, women may experience symptoms of anxiety disorders. Ballou and West (2000) related the example of Beth, a working-class single mother who presented with "fear, worry, and the experience of racing and jumpy energy, all symptoms of an anxiety disorder" (p. 279). Beth was struggling to juggle at least three responsibilities: parenting young children, maintaining a home, and working at a job she did not enjoy, all within a cultural context that isolated her and devalued her status. A feminist counselor, rather than recommending an antianxiety medication, might work with Beth to help her develop concrete ways of challenging her gender role expectations, establish a self-nurturing program, join a support group for women who are experiencing role strain, develop relaxation skills, and identify and mobilize resources that are available to help her meet ongoing responsibilities and demands.
One specific anxiety disorder that has received considerable attention in the feminist literature is posttraumatic stress disorder (PTSD). Feminist counselors have identified rape trauma syndrome and battered woman syndrome as women's typical responses to traumatic environmental events. They connect the personal to the political by stressing that violence influences the psychological self and that the symptoms are normal responses to abnormal events. They have proposed new diagnostic categories, such as "complex post- traumatic stress disorder" (Herman, 1992) and "abuse and oppression artifact disorders" (Brown, 1994), to describe reactions to a history of subjugation over a period of time. A feminist counselor, in working with clients who present with symptoms of PTSD, addresses the connection between abuse and sexism and behavior patterns of learned helplessness, avoidance, and rescuing. The counselor listens respectfully to the client and does not minimize the extent to which the client has been wounded (Chesler, 1990). In the therapeutic relationship, the counselor and client explore the ways in which emotions and cognitions have become constricted or distorted by fear or gender stereotyping, self-blame, or shame. The process involves naming the distress accurately, identifying the complex contextual factors that contribute to the client's problems, and transforming possibilities for oppression into opportunities for liberation and social change.
A feminist approach to working with clients with eating disorders focuses on messages conveyed by society, and by the mass media in particular, about women's bodies and androcentric standards for attractiveness. Feminist counselors use gender role analysis to help clients examine the messages about body image that are conveyed by the media and other societal forces. They help clients challenge the stereotyped ideal of a woman with large breasts and pencil-thin thighs that is held up as the standard toward which they should strive. Power analysis may help women understand how they relinquish their personal power when they diet and dress to please men, as well as how their preoccupation with weight, size, and shape contributes to a lack of power (Sharf, 2000). Group work can be effective with women who suffer from anorexia, bulimia, and other eating disorders because it provides a supportive environment for examining, challenging, and reframing body image.
Feminists have drawn attention to the high rate of sexual and physical abuse in the histories of women who have been diagnosed as having borderline personality disorder (BPD; Brown & Ballou, 1992). In the traditional diagnostic system, the link between these traumatic experiences and the symptoms that lead to a diagnosis of BPD is ignored and the problem is placed within the individual. Viewed from a feminist framework, BPD is seen as a long-term chronic effect of posttraumatic stress. Feminist counselors, rather than focusing on a client's problematic behaviors, frame the symptoms as indicators of the client's strength as a survivor. The counseling process involves strategies such as establishing a contract that defines expectations for both counselor and client and sets limits in non- punitive ways. Careful consideration is given to the client's level of readiness to explore past abuse, to help the client strengthen her fragile sense of control over her inner and external worlds. Symptoms such as dissociation and mood swings are reframed as ways of coping. The counselor helps the client understand the needs beneath behaviors that seem impulsive and self-defeating, so that the client can find new ways to meet these needs. The feminist approach, built on a collaborative relationship and the coconstruction of diagnosis and treatment planning, provides a foundation for a more empowering and liberating helping process (Eriksen & Kress, 2008; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). Feminist counselors continue to propose new conceptualizations of reactions to abuse with the goal of changing the way the mental health professions deal with disorders that affect so many women (Enns, 2004).