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Psychological and Social Aspects of Psychiatric Disability


The major thrust of psychiatric rehabilitation is to provide skill development and supports enabling individuals to function in their roles of choice. The model thus contains an underlying assumption that meaningful life roles are “chosen” roles. It therefore may tend to overlook the impact on persons’ lives of the roles that they are given. These given or ascribed roles include those based on gender, ethnicity, and socioeconomic class. Self-definitions, behaviors, beliefs, attitudes, and values are all likely to be structured within such social roles, which can also serve as important social identities (Oyserman & Markus, 1993). In spite of increased awareness of gender as an issue, in current Western culture, gendered roles are those for which there are, perhaps, the least latitude. Yet, as we shall show, the field of psychiatric rehabilitation has paid little attention to the subject of gender differences. We reviewed the 1992-93 volumes of the Psychosocial Rehabilitation Journal and found that only 15 out of a total of 21 studies, which reported information on individuals who were recipients of psychiatric rehabilitation services, presented the gender composition 171 of the study sample at all. Furthermore, of these articles, less than half (N = 6) tested for gender differences (40%). Thus, only 28% of the articles could inform their readers about whether men and women differed on the study results.

It seems likely that when differences between women and men are not even examined, the result is likely to be a service model that is theoretically androgenous, but in actuality male-biased. Again, the psychiatric rehabilitation literature on service approaches bears this out. The primary domain considered in services is vocational. There has been some consideration of the generic topic of rehabilitation in housing choices. However, those domains where women are considered to occupy primary roles, e.g., the family, parenting, and interpersonal relationships (Miller & Stiver, 1993), have received scant attention (Oyserman, Mowbray & Zemencuk, 1996).

This lack of concern for possible gender differences in psychiatric rehabilitation overall and especially to those issues of primary concern to women, is not unique to this field, but may be seen to reflect the perspective of the entire psychiatric/mental health establishment. For decades, feminist scholars and advocates have decried sex bias in the treatment system. Early research by Braverman et al. (1970) established the negative perceptions of women held by clinicians and the double bind in which women were placed, in that the expected characteristics of a “healthy” adult varied markedly from those for an adult female. Similarly, Chesler (1972) contended that because gendered roles were so proscriptive of mental health, women were in double jeopardy; those who overconformed to female sex roles were likely to be viewed as mentally ill as well as those who violated “appropriate” gendered role expectations. Additionally, clinical and practice research has found gender biases in diagnosis (Loring & Powell, 1988) and in treatment, which serve to demean women (as dependent, passive, seductive, hysterical, etc.), foster traditional and limited sex roles, and respond to women patients as sex objects (Hankin, 1990).

An awareness of how such biases might affect services to women with long-term psychiatric disabilities is of more recent origin. Test and Berlin (1981) were apparently the first to point out that the “chronically mentally ill are regarded as almost genderless ...” (p. 136). Although the research literature was limited, their review was able to identify the existence of significant gender differences in numerous domains of life functioning: instrumental roles, social and sexual roles, marital and family roles, and physical health. Several authors have elaborated on the problems raised in Test and Berlin’s pivotal article (e.g., Bachrach, 1984; Bachrach, 1985, Bachrach & Nadelson, 1988). However, systematic attention to gender differences is still clearly lacking. For example, a 20-year metaevaluation of published treatment effectiveness studies involving aftercare services (Feis, cited in Mowbray & Benedek, 1988) found that 22% of studies did not indicate the gender composition of their sample and another 15% contained all male subjects. Over all the studies which did report gender ratios, there was a predominance of male participants (54.8%). A more recent review of 1992 issues of the American Journal of Psychiatry found that while a large proportion ( 84%) reported on the gender composition of their samples, less than half (46/99) tested for gender differences. Considering the significance of the topic of gender differences and the state of our practice ignoring women’s special needs, more writing, discussion, and training are clearly mandated concerning psychiatric rehabilitation for women. In this article, we will review the most recent literature concerning women with long-term, severe mental illness. The review has been organized to cover the major topics earlier identified by Test and Berlin (1981) regarding role functioning. We will begin with a summary of gender differences in the target population on demographics and clinical characteristics. We end our review with a discussion of ways to improve both the treatment and knowledge bases.

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Center for Pyschiatric Rehabilitation, Boston University