8
Order Out of Disorder: Disorderly Conduct
I learned to make my mind large, as the universe is large, so that there is room or paradoxes. -Maxine Hong Kingston Tbe Woman Warrior
How are the pains and fears of human existence approached in a masculinist psychology/psychiatry? One strategy is to organize, categorize, and delimit them. In this way, they are flattened; they lose texture and variability while sounding clear, objective, and even scientific. Psychiatric diagnosis is accomplished by just such separating and flattening out of multidimensional experience, reducing many complex stories into one. The most popular and frequently used beginning texts for psychiatrists and psychologists (such as MacKinnon and Michels I97I; Basch I980) not only adopt this perspective but use the generic "he" when referring both to therapists and to most patients-with the exception of discussing the ubiquitously popular with the generic, male, heterosexual therapist) hysteric or histrionic personality as female (MacKinnon and Michels I97I).
The language of diagnosis is distant and often disapproving. Its perspective is externa!, its voice one of authority. Instead of addressing the all too frequent fear and pain of human existence, of suffering and longing, of loss and disappointment, instead of listening to the voice of the sufferer or of the psychotherapist, it speaks in the neutral, impersonal voice of professíonal objectivíty, using the formal language of disease or dísorder. From this professional perspective, disease or disorder is seen to líe wíthin the individual. A border between the individual and complex sociocultural influences is erected and carefully maintained.
The American Psychiatric Association published the original Diagnostic and Statistical Manual (DSM) in I952 as an attempt to categorize and enforce the medical perspective on what are considered abnormal psychological symptoms and syndromes. In I958, it was revised and the DSM-II was published. Both manuals were extensive inventories of mental diseases. lt was again revised in I980 and, with the most recent revision, DSM-IIIR, in I987, many medical concepts were replaced with behavioral and empiri- cal observations. Its highly fragmented cookbook approach results in a strange mélange of value-laden psychodynamic and behavioral assessments.
The current official psychological and psychiatric language of abnormality has evolved into one of "disorder," more palatable and defensible than "disease":
In DSM-IIIR each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painful symptom) or disability/impairment in one or more important areas of functioning or with a significantly increased risk of suffering, death, pain, disability, oran important loss of freedom. [American Psychiatric Associ- ation I987, p. xxiii; italics added]
It further states that this system does not classify people, but rather "disorders that people have" (p. xxiii). But it neither reflects nor impedes the prevalent use of these categories to classify people; almost all therapists refer, for example, to schizophrenics, hysterics, and borderlines as if the person becomes the disorder. Imagine how absurd it would sound to do this with physical diseases or disorders: the "canceric," "tuberculic," or "fluitic." This sense of the individual decontextualized, a faithful echo of the predominant Western concept of the self, is psychological in only the narrowest sense.
The authors of this document, from their position of self-proclaimed theoretical neutrality, go on to discuss uncritically a related system, the ICD-9 classification system, noting that it has only a single category for "frigidity and impotence despite the substantial work in the areas of psychosexual dysfunction that has identified several specific types" (p. xix; italics added). By taking no exception to this terminology, they implicitly endorse it. Can anyone doubt that the use of these terms to describe female and male sexual dysfunction is not only antiquated but unequivocally biased? As I asked in an article written some fifteen years ago (Kaschak I976), can it be that the very same orgasmic difficulty in females is coldness and in males is lack of power? From the masculinist perspective, yes, because in the sexual arena, as everywhere else, women are assigned emotions and men are assigned power.
Psychological and psychiatric language need not be as blatandy sexist as this in order to be oedipal. The first question to ask about the system of disorder is the one I have been asking throughout: Whose perspective does it reflect and whose does it render invisible? The nomenclature of disorder is derived from a particular psychological model suggesting that a properly functioning person is psychologically organized in an orderly and predictable fashion, and that a problem is a malfunction in which things are outside that order. Disorders are aberrations, normal development gone awry. They are contained within the person, who is guilty of "disorderly" conduct. Yet another dualism is invoked: you either have a disorder or you don't. Yet another boundary is delineated by those with the power todo so, and is generally accepted as natural: there are those who have disorders within them and those who are normal, who are in order or, perhaps better said, who follow society's orders well. The makers of these boundaries need not be informed about the daily reality of a woman's life. Their perspective is externa!and dualistic, overlooking the texture of the ordinary.
As Dorothy Smith has aptly noted in her insightful work:
Psychiatric agencies develop ways of working which fit situations and people which are not standardized, don't present standardized problems and are not already shaped up into the forms under which they can be recognized in the terms which make them actionable. What actually happens, what people actually do and experience, the real situations they function in, how they get to agencies-none of these things is neatly shaped up. There is a process of practical interchange between an inexhaustibly messy and different and indefinite real world and the bureaucratic and professional system which controls and acts upon it. The professional is trained to produce out of this the order which he believes he discovers in it. [I975, p. 97]
Clearly, daily life is not an orderly process. But the more prospective information is eliminated, the more life can be made to appear orderly. Taxonomies, if they accomplish little else, serve this function of reducing the complex to the orderly. Such emphasis on control and order in the psychiatric establishment translates into the popular vernacular through such expressions as "being out of control," "having a breakdown," "falling apart,"and "having one's defenses crumble."These are all euphemisms for expressing feelings, usually painful feelings, often to the point of discomfort of others, including the therapist or diagnostician. They are circumstances of disorder.
Decisions about what is and is not a disorder are vested in the voting membership of the American Psychiatric Association. For example, homosexuality, as a diagnostic category, was removed from the DSM-III by vote of the membership of the American Psychiatric Association. This is certainly a democratic way of determining disorders, but it underlines the fact that these disorders are determined by the opinion of those who have the power to vote on them. Imagine the American Medical Association voting on whether tuberculosis exists. Homosexuality is now considered a problem only if the individual who has it so defines it. Why not say the same of heterosexuality? Of tuberculosis? And what exactly does it mean if an individual in a society that considers homosexuality a problem agrees with the majority? Does someone with a paranoid disorder get a vote also? Apparently only if he or she is a member of the American Psychiatric Association.
All these efforts to reform the diagnostic system highlight its basic problem: it is culture-bound while assuming universality. For example, in many societíes homosexual behavior is not ídentified as a problem and is not even seen as being central to one's identíty. lt is just something that is done at certain ages or in certain situations, not a reification of sorne homosexual/ heterosexual dichotomy. So-called disorders are matters of opiníon and perspective.
Many feminists, induding the psychologísts Lenore Walker, Laura Brown, and Lynne Rosewater, have actively opposed the nature of recently introduced diagnostic categories, but to little avail. Testifying against the DSM-IIIR's inclusion of Self- Defeating Personality Disorder and Late Luteal Phase Dysphoric Disorder (Rosewater I987; Caplan I988), they have shown how these presumed disorders pathologize normal and ordinary reactions that are exclusively or primarily women's. Paula Caplan (I990) has proposed a parallel category-Delusional Dominating Personality Disorder- to pathologize men's ordinary gender-related problems as well, and thus make visible the process of pathologizing the ordinary for women only. The new category would include fourteen qualities, among them: the inability to identify and express a range of feelings in oneself; the inability to respond appropriately and empathically to the feelings and needs of close associates and intimates; the tendency to use power, silence, withdrawal, and/or avoidance in situations of interpersonal conflict; and an excessive need to inflate the importance and achievements of oneself and of males in general. If women have disorders within themselves, then men must have them too.
But a larger question looms: Are any of these behaviors worthy of being included in a diagnostic system, or is the profession of psychiatry calling ordinary gender-related behavior abnormal?
For women (and theoretically for men, were both groups to be treated equally), disorders all too frequently flow directly from complex physical! Psychological/societal experiences and meanings related to gender. In this sense, they are quite orderly and even ordinary. They derive from and contribute to the aspects of women's experience that I have traced in the prior chapters. They are the perimeters that define women's place, for it is time and place that create the ways in which women become disorderly, the ways in which women turn against themselves or social strictures, the conflicts that women embody.
The act of determining pathology, done from the narrowly psychological perspective that is totally externa!to the person being considered, is divisive of experience. A woman can appear to be in psychological disorder or disarray, which can seem to come from within her, as women take in and embody society's injunctions and conflicts as their own. While a more particular understanding comes from knowing how each woman has woven meaning from events in her life, the commonalities of being female in an oedipal society delineate the path on which each treads.
The incidence of psychological problems, as well as the various forms they take, has been shown to be a function of membership in particular societies, classes, and ethnic groups at particular times. For example, hysteria, a condition characterized by emotional excitability, sexual repression, and physical conversion symptoms, was prevalent in women in a society whose standard for femininity was based upon fragility. Elizabeth Veith has written of hysteria: "Throughout history the symptoms were modified by the prevailing concept of the feminine ideal. In the nineteenth century, especially young women and girls were expected to be delicate and vulnerable both physically and emotionally" (I965, p. 209). In Victorian society, there was a direct injunction that women's physicality and sexuality were not to be visible, or even to exist. Women's senses were considered weak and easily disturbed. Women were supposed to be fragile. Hysterical reactions incorporated and actualized these masculine definitions of women in a parody or an exaggerated form, such as paralysis, blindness, or other physically expressed psychological symptoms: "Perhaps because of this emotional vulnerability there was a striking rise in the prevalence of hysteria throughout Europe. Concurrent with its proliferation, which reached almost epidemic proportions, the malady exhibited a diminution in severity, and the disabling symptoms gave way to the faintings, whims, and tempers so elegantly designated as vapors" (Veith I965, p. 2I0).
Other diagnostic categories, such as schizophrenia, have also been shown to vary as a function of different groups. A large body of literature has repeatedly confirmed the greater incidence of this disorder, or at least its diagnosis, among persons of the so- called lower socioeconomic classes (Hollingshead and Redlich I958; Holzer et al.
I986; Neugebauer, Dohrenwend, and Dohrenwend I980). Members of this group are subject to more and cenain kinds of stresses. They are also more frequently assigned more severe diagnoses since they differ more from their middle-class diagnosticians and tend not to express their distress in cognitive and insightful ways.
Similarly, the patterns of physicall/psychologicall/social development of women in industrial and postindustrial Western societíes more readily dispose them to develop particular psychological problems and concerns, as I will demonstrate in the next two chapters. Several writers have suggested that there is a direct relationship between being a woman in modern society and certain disorders, including depression, hysteria, phobias, and eating disorders (Weissman and Klerman I977; Wolowitz I972; Fodor I974; Frances and Dunn I975). These problems are rooted, equivalently, in the normal development and training of women in this society, in the ways women are treated, in the meanings attributed to women and to their physical/psychological selves and to the meanings and understandings that women themselves develop, internalize, and live out. These are not internl pathologies or disorders that anyone simply has.
In Western society, women's bodies and physicality are still a masculine obsession. As the particular definition of them has changed, so has symptomatology. Hysteria has given way to eating disorders, anxieties, and depression-but all are adjustments to traumatic experience. The woman who experiences any of these disorders is well adjusted or attuned to her psychological and social environment.
A woman's identity is organized around oedipal perceptions and evaluations of her based on equating her with her physicalness and, more precisely, on its meaning according to current masculine standards, needs, and conflicts. In this way, conflicts are located in her and not in conflicting demands or meanings. The core of the Oedipus-Antigone arrangement finds women subsumed by masculine meanings and needs.
The meaning of women's physicality has changed since Victorian times and is currently focused upon appearance rather than on fragility. A woman's concern with appearance and its value, images and mirrors, dieting and food, seem so natural to most of us that we do not notice it. In this and the following chapter, I will show how these disorders actually orderly developments are stemming from the training to be a woman in this society.
What is the subjective constellation of experiences that we agree to call depression? It includes as a central component a feeling of sadness, embellished by despair or hopelessness. The feeling may differ in intensity and may be intermittent or constant, but it is always more than simple sadness or even the focused sense of grief that surrounds particular loss. The depressed person often senses that he or she is never going to feel any better, that circumstances are bleak and will undoubtedly stay that way. He or she may feel lonely and unable to love anyone or to receive love. This is accompanied by a sense of personal worthlessness and self-blame. There are often also feelings of anger, of being mistreated or misunderstood, of shame and unworthiness. Depression may seem both well deserved and unfair at the same time.
In a severe case of depression, the person may no longer experience the body or emotions as part of the self (MacKinnon and Michels I97I). Instead there is a sense of emptiness and unreality, which tends to be intermittent and accompanied by feelings of longing and especially of loss. This detachment both leads to and flows from apathy, if not anhedonia (an inability to experience pleasure). Yet there is often a vague sense that the emptiness could be, or could have been, filled by an intimate relationship or circumstance. That is, the something missing typically has todo with other people rather than with a sense of one's own self being missing.
Carolyn is a slightly built and carefully groomed woman in her mid-forties. Despite, or perhaps in keeping with, the care with which she presents herself, sheseems timid and self-effacing.Having spenteighteen years ofher life at home raising children, she has recently returned to school and is studying journalism. She was devastated to Jearn the week prior to making an appointment with me that her husband of twenty- two years,a professor ata local university, had been having an affair with a nineteen- yeac-old student. She lets me know of her sense of loss and self-blame, acknowledg- ing that she is no longer very attractive and is just a boring middle-aged woman. She obsessively ruminates about what she has not done or been. She has settled upon her looks and her lack of interest to an intellectually active man as the reason for her husband's affair. She desperately wants to win him back by showing him how much she has sacrificed for him and the childrenoverthe years andhow much heowesher. She is also shocked that his new lover is only a year older than their own daughter, but realizes that many men have these sorts of relationships in these post-sexual revolution times. Fearing that she has lost her husband lorever, she cries intermittently as she tells me her story.
Sonia arrives for her first appointment looking worried and somber. She speaks in a barely audible voice. As she puts it, ""life is a drag" and not worth continuing. She has tried to maintain several serious relationships, but they have all ended. She hates being alone, but feels hopeless about finding someone with whom to ha ve a ""committed relationship."She is not activ