Research on Feminist Treatment Protocol for Female Depression
Disproportionately affecting women within all Western societies, depression is a critical health problem negatively impacting women's functioning and participation within the social, economic, and political spheres. Emerging research suggests that common protocols for treating female depression are insufficient for a wide spectrum of reasons, not the least of which is their orchestration by male professionals who inadvertently reinforce culturally incompetent conceptualizations of women's experiences with the disease. From a feminist perspective, the continued inadequacy of existing treatments for female depression serves to further marginalize women within the global community; this, in turn, perpetuates their social immobility and continues to preclude gender equality. Depression in women is widespread and detrimental to women's health and wellness, lowering life quality and creating nearly insurmountable barriers to female empowerment. The following inquiry asserts that feminist therapy, specifically feminist cognitive-behavioral therapy (CBT), represents a culturally competent treatment protocol for female depression which values the woman's empowerment and unique narrative as a key aspect of healing.
The issue of gender is grossly ignored within the bulk of empirical literature focusing on depression treatment; and yet, research concurrently suggests that women experience depression at a 2:1 ratio over their male counterparts. Feminist scholars have highlighted that the gender disparity within depression research is often dismissed as a methodological problem or interpreted as a product of research subjectivity. Stoppard describes the problem of insufficient depression treatments for women as follows: "The continued dominance within psychology of positivist methodologies in research on depression, along with uncritical acceptance of the realist assumptions of mainstream medicine, have also been questioned from a feminist perspective. Findings of research conducted within mainstream paradigms have provided few helpful directions for women in understanding and explaining their depressive experiences" (p. 4). Women, according to the same author, are charged to choose between depression's biological roots, specifically neurotransmitters and hormones, or the disease's sociocultural roots; while the latter source is far more feasible and meaningful from a feminist perspective, Stoppard suggests that the dominant therapeutic approaches which afford attention to the social and cultural sources of female depression do so from a largely patriarchal perspective. Consequently, common depression treatment protocols for women are markedly limited and largely counterproductive.
The empirical literature focusing on feminist treatment approaches highlights two, central forces which undergird healing; these are relinquishing the status-quo within the woman's life in order to seek out greater self-advocacy and self-efficacy (1) and empowerment of the woman within her own life in order to improve well-being (2). These key issues do not diminish or reject the very real biological influences on women's depression experiences, but, rather, they embed the role of biology within a gender-sensitive sociocultural context (Stoppard, 1999). Common treatment protocols which do not adopt a feminist approach seek to maintain the status quo within women's lives, returning the woman experiencing depression to a preconceived ideal which reinforces patriarchal social structures.
Theoretical Framework: Feminism and Social Constructivism
Undergirding feminist treatment protocols for women are two relevant and complementary theoretical frameworks; these are feminism and social constructivism. Feminism asserts that the large majority of existing social structures are grounded in gender inequality, with male domination consistently reinforced through existing and longstanding institutions. In order for greater gender equity to be achieved, by extension, these institutionalized mechanisms for female disempowerment must be acknowledged and weakened, replaced by structures more supportive of female participation within the social, economic, and political spheres (Kimball, 2002). Social constructivism, alternatively, highlights that human values, influenced weightedly by various sociocultural forces such as discourse, religion, and philosophy, both prestructure and consequently shape knowledge within the global community. At the crux of social constructivism is that knowledge is socially constructed and, by extension, not value-neutral. Stoppard criticizes depression treatments for women according to both feminist and social constructivist frameworks:
As a method, inquiry conducted from a feminist standpoint position involves beginning research from the perspective of those whose lives are shaped and constrained (or "marginalized") by the dominant (patriarchal and androcentric) social order or "ruling relations...". From a feminist standpoint perspective, an important strategy for addressing the research goal of understanding and explaining depression in women -- to conduct inquiries that are grounded in the experiences of women -- to proceed from the standpoint of women. Research based in women's experiences is required to understand depression in women, because women are marginalized within patriarchal societal and androcentric cultural contexts." (p. 4).
Moreover, the medicalization of female depression has reduced treatment effectiveness and created deeply embedded treatment protocols which encourage pharmaceutical treatment over psychotherapy; this results in a gross ignorance of women's unique experiences, sociocultural backgrounds, and personal value systems.
Mechanisms which shape common, insufficient treatment protocols for women experiencing depression are two-fold; these are victim-blaming (1) and pathologization (2). Both of these mechanisms yield a shared outcome, however, as they diminish the importance of the sociocultural dimension in diagnosing and treating the illness. Western, mainstream models of depression do not ignore the role of the social dimension entirely, but narrowly frame it in terms of negative life events, stressors, and a lack of social support networks. Stripped of the influence of larger social structures, and patriarchal forces in particular, the social context is inaccurately defined by avoiding political and economic conditions which counter female empowerment and create conditions which may well reinforce depression among women.
Rationale for Feminist Treatment Protocol
In grounding a feminist treatment protocol in a social constructivist framework, a critical assertion is that mainstream treatment approaches do not acknowledge the negative impact had by inequality on women's lives. Inequality in the political and economic spheres manifests as employment inequality, lack of child support, challenges relative to family-work roles, and other issues which exacerbate the life events afforded significant attention during depression treatment. Kimball (2002) and Stoppard and Gammell (1999) contend that while women's life events such as divorce and childbirth undoubtedly inform the onset of depression, they do so within a unique social context which cannot be ignored. Social inequalities compound the impact of stressful life events and create conditions for depression which must be addressed during treatment.
Additionally and very saliently, women's mental health must be framed according to unique sociocultural backgrounds. Eansor (2008) highlights that conventional depression treatments fail to acknowledge women of non-heterosexual orientation and ethnic minorities: "A balanced, diverse and culturally sensitive and nuanced approach that considers all available mental health care options and treatments is needed for every woman who presents with mental health issues" (p. 4). The same author argues that current depression treatments are so inadequate for women that a sense of urgency must be embraced in developing and asserting feminist treatment approaches which are concurrently culturally competent.
Female depression is associated with feelings of extreme sadness which, when severe and enduring, can lower quality of life. Eansor highlights that comorbidity represents a significant challenge with respect to women's depression, with nearly half of all individuals afflicted with depression concurrently afflicted by at least one additional mental health disorder; the most common disorders coinciding with depression are anxiety, panic disorder, and post-traumatic stress. The prevalence of depression among women and the strong comorbidity rates render the disease a severe, global health problem caused by the interactivity of individual vulnerability and environmental stressors. From a social constructivist perspective, the environmental stressors must be afforded at least equal attention as the individual vulnerabilities, but common treatment protocols inclusive of pharmacological solutions and psychotherapy focus disproportionately on the individual dimension.
Recommended Treatment Protocol: Feminist CBT
Despite the dearth of empirical evidence supporting the notable success of feminist therapy for women, the practice emerged during the 1970s. Evans et al. (2005) cites that "since its inception, feminist therapy has evolved in terms of theory, therapeutic techniques, and scope of application.... Feminist philosophers, therapists, and clients have had a profound effect on the fields of counseling and psychology, especially regarding gender bias and gender role stereotyping" (p. 273). In tracing the history of the recommended treatment protocol, it is critical to afford attention to how the treatment evolved within the context of, and largely in response to, shifting social structures; this, in turn, reinforces the social constructivist framework.
History of Feminist Therapy
During the 1960s, the Civil Rights Movement coincided with second-wave feminism, acknowledging women as an oppressed group. Consciousness-raising groups emerged as advocates for women, engaged in catalyzing social change in order to bolster gender equality. Evans et al. cites that the original assertions of feminist therapy targeted traditional psychotherapy's presumption of women's distress as solely personal (1) and only relievable via professional intervention (2). Major social problems which perpetuated gender equity were acknowledged increasingly during the 1970s as informative of women's mental health, with emerging feminist treatment highlighting environmental factors as highly influential of women's experiences.
The majority of theoretical frameworks in psychology are easily traceable to a single individual, but feminist therapy has no obvious founder (Evans et al., 2005). Feminist therapy can be framed as a sort of grassroots movement through which collaboration between various groups created a sound theoretical framework over time. Feminist psychology authors published during the 1990s included Laura Brown, Carol Zerbe Enns, and Judith Worell, with the assertions of these professionals streamlining existing theory and extending many assertions to multicultural backgrounds and social minorities. Evans et al. (2005) cites that "the challenge of the 1990s was for feminist therapy to move beyond the issues of women who were representative of the majority culture and to consider issues involving race, ethnicity, and class. Over the past 10 to 15 years, feminist practice has considered the interaction of gender with these factors" (p. 275).
Feminist CBT and Depression
The amalgamation of feminist therapy with alternative therapeutic approaches is a relatively recent phenomenon, with the earliest empirical research occurring during the 1990s. Hurst and Genest highlight that CBT, as the dominant treatment approach to depression in general, must be embedded within a feminist and social constructivist theoretical framework in order to meaningfully address the unique experiences of depression by women in the global community. CBT does not, in theory, address gender issues and differences; it does, however, allow considerable room for the practitioner to tailor treatment approaches to the individual.
CBT focuses on the dual dimensions of the individual and the environment, with feminist approaches seeking to equalize these two dimensions rather that frame the former as a dominant consideration. The individual dimension is assessed in terms of a primary vulnerability with respect to negative self-schemas, or negative beliefs regarding the self. Hurst and Genest (1995) explain that depressive self-schemas can be latent but activated by negative life events which, in turn, support distorted thoughts which will create conditions influential of behavior. The therapist, by extension, focuses on aiding the individual in acknowledging how various cognitive conditions can influence behavior. From a CBT perspective, it is not the environmental events themselves which catalyze depression, but, rather, the ways in which the individual interprets those events.
Feminist CBT contextualizes both the individual vulnerabilities as well as the external conditions within the broader context of patriarchal society. Two, key considerations for feminist CBT are powerlessness within society (1) and the unique female sex-role (2). The individual's vulnerability is framed as socially derived, in part, with her depressive symptoms and self-denigration rooted in widespread inequalities. The therapist aids the woman in acknowledging powerlessness as a possible cause of depression throughout the therapeutic process. Hurst and Genest describe the relationship between CBT and powerlessness as follows:
Cognitive-behavioural theories could effectively attend to women's experiences of powerlessness and how these influence their beliefs about themselves and their coping options when stressed. Ignoring the social context in which depressive self-schemas and powerlessness originate runs the risk of overlooking the specific ways that women experience a different societal reality, which increases the likelihood of seeing depressed women as personally responsible for believing they are powerless and ineffectual (p. 4).
The relational ways in which the woman frames herself with respect to her family may be an additional consideration, with her depression influenced significantly by the female sex-role within the family.
Additionally, the role of the therapist is unique within a feminist CBT perspective, with professional reflection on various biases and values systems warranted on a consistent basis. Deeply embedded patriarchal values systems influence therapist perceptions, charging the professional to remain aware of being affected by the very values s/he seeks to counter during feminist therapy (Davis-Gage, Kettman, and Mole, 2010). Throughout the treatment process, the therapist must engage in active professional reflection in order to seek out existing prejudices which may inadvertently affect therapeutic outcomes.
Davis-Gage, Kettman, and Mole examined the application of feminist CBT among populations of minority women affected by postpartum depression (PPD). The authors highlighted that minority women with depression are uniquely experienced to benefit from feminist CBT because of the higher levels of attention afforded to oppressive sociocultural structures. The authors describe a case-study depression treatment protocol for a Latina woman (Christina) afflicted with PPD. Following diagnosis, Davis-Gage, Kettman, and Mole conducted an in-depth assessment of how the woman's values and culture impacted her depression via the completion of a developmental lifeline, a social and gender role analysis, and a genogram. The CBT sessions then focused on bolstering the woman's well-being by allowing her to self-identify treatment goals and, by extension, feel empowered to heal herself. Davis-Gage, Kettman, and Mole cite that "feminist counseling was described as a collaborative process in which Christina's unique life experience would be valued and appreciated. The counselor explained how her personal values might influence her therapeutic approach. She carefully checked with Christina to make sure she understood how they would approach treatment" (p. 119). Throughout the treatment process, the therapist aimed to empower and encourage Christina in order to acknowledge her depression as a result of both internal and external circumstances. In particular, PPD was largely resultant from conflicting roles with respect to her familial relationship as wife, mother, and other relational role definitions. Christina was empowered to reconcile her new mother role with her other roles, with the therapist highlighting the ways in which society has influenced her self-perceptions.
Ethical and Legal Implications
The literature clearly suggests that feminist CBT is markedly conducive to women and minority populations. Evans et al. suggests that feminist therapy is emerging as pertinent to diverse populations due to its emphasis on social constructivism and embedded mechanisms of oppression which influence mental health. Legally, the same protocols exist for feminist CBT as do for traditional psychotherapy, with the counselor necessarily abiding by state and federal licensing restrictions. The woman's informed consent and confidentiality need be protected fervently, with ethical issues potentially surrounding the feminist framework that traditionally excludes men. Evans et al. (2005) cites that feminist therapies are now less exclusionary toward male populations but remain highly focused on the unique experiences of women. Utilization of this protocol does not, however, significantly impact risk reduction and other issues within psychologists' code of conduct.
Davis-Gage, Kettman, and Mole posit that in addition to being very conducive to minority populations, feminist CBT is also positioned to promote financial accessibility to psychotherapy. The authors recommend that providers acknowledge the potential for depressed women's social immobility issues to impede the ability to pay, garner insurance, and afford childcare or other accessibility-related resources. Consequently, providers are charged to be mindful of the ways in which patriarchy affects treatment access in addition to the ways in which it affects depression, empirical research, and other aspects of their professional world.
Depression affects twice as many women as men within Western societies, warranting effective treatment solutions which acknowledge the deeply embedded social structures reinforcing patriarchal oppression of women. This inquiry asserts feminist CBT as an ideal treatment protocol for depression in women due to the attention afforded to social structures' influence on the disease in addition to individual vulnerabilities. Traditional treatments focus too narrowly on individual vulnerabilities without acknowledging the environmental forces at work which influence female depression. Feminist CBT represents a viable channel for supporting women's recovery from depression in a culturally competent and accessible manner.
Davis-Gage, D., Kettmann, J. J., & Mole, J. (2010). Developmental Transition of Motherhood: Treating Postpartum Depression Using a Feminist Approach. Adultspan Journal, 9(2), 117-139.
Eansor, D. M. (2008). Positioning Women, Mental Health and Depression on Canadian Health Care Agendas. Forum on Public Policy: A Journal of the Oxford Round Table. 1-14.Evans, K. M., Kincade, E. A., Marbley, A. F., & Seem, S. R. (2005). Feminism and Feminist Therapy: Lessons from the Past and Hopes for the Future. Journal of Counseling and Development : JCD, 83(3), 269-279.
Hurst, S. A., & Genest, M. (1995). Cognitive-Behavioural Therapy with a Feminist Orientation: A Perspective for Therapy with Depressed Women. Canadian Psychology, 36(3). 4-11.
Kimball, M. (2002). Understanding Depression: Feminist Social Constructionist Approaches. Canadian Psychology, 43(2), 124-130.
Stoppard, J. M., & Gammell, D. J. (1999). Women's Experiences of Treatment of Depression: Medicalization or Empowerment? Canadian Psychology, 40(2). 1.
Stoppard, J. M. (1999). Why New Perspectives Are Needed for Understanding Depression in Women. Canadian Psychology, 40(2). 1-12.