Psychiatric Annals

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Developing a Course on Women in the Residency Curriculm

Sidney H Fleming, MD

Abstract

Since 1972, a seminar series focusing on psychologic issues pertinent to women has been under development in the Emory University Department of Psychiatry. This series of four one-and-a-half-hour seminars is now a part of the curriculum for third-year residents.

The course arose as a natural concomitant of the women's movement. It did not evolve out of either confrontation or conflict in the Department of Psychiatry. It arose from persistent questions and informal discussions in numerous situations between many people. These discussions were undoubtedly a response to everyone's increasing awareness of women and their individuality.

The national climate undoubtedly contributed to the rising interest about appropriate roles for women. The debates about Equal Rights Amendment are a pertinent example of national interest in the legal basis for a woman's role. After 50 years of dormancy, the ERA was voted out of Congress and sent to the states for ratification. Substantive professional issues were politicized and publicized as local proponents and opponents formulated their positions.

The popular literature was replete with quotes about what various psychiatrists have said about the roles of women. 1_3 These classic theories and statements did not inspire confidence in methods of psychiatric treatment. Women began to suspect that psychiatrists perceived career independence, other than that of homemaker, as frivolous at best or, at worst, as pathologic. Patients began to ask for feminist psychotherapists with increasing frequency, and patients in treatment began to question the beliefs and values of their psychiatrists.

The course was born in this milieu. It was a provocative political and often polemical milieu. As the questions regarding the relevance of treatment to the realities of women's lives grew in frequency and intensity, it became obvious that residents were ill equipped to deal with these issues. No matter how earnestly they wanted to respond, these ideas and issues were new and complex. Thus, some perspective was urgently needed on the historical evolution of a woman's role, its current state, and its relevance to therapy.

Development of this course, like all others in the program, had to include (1) a statement of educational objectives, including relevance to psychiatric education; (2) selection of the methods of teaching; (3) definition of core content; and (4) delineation of an optimum sequence of presentation of the relevant material.

OBJECTIVES AND RELEVANCE TO PSYCHIATRIC EDUCATION

The objectives, defined following a year's review of the literature, are simply (1) to provide historical facts that clarify the changing role of women in America and (2) to permit the residents to begin developing some awareness of their personal attitudes about women so that personal preferences will not be unwittingly forced on patients who are entitled to consideration of all available options.

The relevance to psychiatric education is implicit in these objectives. Women constitute more than one-half of the American population and a proportionate number of patients. The fact that a topic is a contemporary social issue does not per se establish it as suitable for a psychiatric curriculum. However, when this issue affects the majority of patients receiving service, it becomes a legitimate professional issue, and it was accepted as such by our faculty.

Preliminary informal discussions with the faculty about these seminars were enlightening in several ways. They served to crystallize what the course could not be. It could not profitably be emotionally provocative. Even if such an approach can be buttressed with facts that are logically unassailable, it has the effect of solidifying emotional judgments to the absolute exclusion of rational thought. John Stuart Mill, who was a leader in Parliament for women's suffrage, accurately noted that opinion rooted in strong feelings…

Since 1972, a seminar series focusing on psychologic issues pertinent to women has been under development in the Emory University Department of Psychiatry. This series of four one-and-a-half-hour seminars is now a part of the curriculum for third-year residents.

The course arose as a natural concomitant of the women's movement. It did not evolve out of either confrontation or conflict in the Department of Psychiatry. It arose from persistent questions and informal discussions in numerous situations between many people. These discussions were undoubtedly a response to everyone's increasing awareness of women and their individuality.

The national climate undoubtedly contributed to the rising interest about appropriate roles for women. The debates about Equal Rights Amendment are a pertinent example of national interest in the legal basis for a woman's role. After 50 years of dormancy, the ERA was voted out of Congress and sent to the states for ratification. Substantive professional issues were politicized and publicized as local proponents and opponents formulated their positions.

The popular literature was replete with quotes about what various psychiatrists have said about the roles of women. 1_3 These classic theories and statements did not inspire confidence in methods of psychiatric treatment. Women began to suspect that psychiatrists perceived career independence, other than that of homemaker, as frivolous at best or, at worst, as pathologic. Patients began to ask for feminist psychotherapists with increasing frequency, and patients in treatment began to question the beliefs and values of their psychiatrists.

The course was born in this milieu. It was a provocative political and often polemical milieu. As the questions regarding the relevance of treatment to the realities of women's lives grew in frequency and intensity, it became obvious that residents were ill equipped to deal with these issues. No matter how earnestly they wanted to respond, these ideas and issues were new and complex. Thus, some perspective was urgently needed on the historical evolution of a woman's role, its current state, and its relevance to therapy.

Development of this course, like all others in the program, had to include (1) a statement of educational objectives, including relevance to psychiatric education; (2) selection of the methods of teaching; (3) definition of core content; and (4) delineation of an optimum sequence of presentation of the relevant material.

OBJECTIVES AND RELEVANCE TO PSYCHIATRIC EDUCATION

The objectives, defined following a year's review of the literature, are simply (1) to provide historical facts that clarify the changing role of women in America and (2) to permit the residents to begin developing some awareness of their personal attitudes about women so that personal preferences will not be unwittingly forced on patients who are entitled to consideration of all available options.

The relevance to psychiatric education is implicit in these objectives. Women constitute more than one-half of the American population and a proportionate number of patients. The fact that a topic is a contemporary social issue does not per se establish it as suitable for a psychiatric curriculum. However, when this issue affects the majority of patients receiving service, it becomes a legitimate professional issue, and it was accepted as such by our faculty.

Preliminary informal discussions with the faculty about these seminars were enlightening in several ways. They served to crystallize what the course could not be. It could not profitably be emotionally provocative. Even if such an approach can be buttressed with facts that are logically unassailable, it has the effect of solidifying emotional judgments to the absolute exclusion of rational thought. John Stuart Mill, who was a leader in Parliament for women's suffrage, accurately noted that opinion rooted in strong feelings not only is unchanged by facts, logic, and argumentative discussion but becomes a more deeply entrenched conviction. 4

Therefore, in order to avoid polemical emotional responses as much as possible and to facilitate an inquiring attitude, the course on women was carefully designed to provide information before challenging general assumptions.

EFFECTS OF ATTITUDE OF RESIDENTS

It quickly became apparent that, unlike most courses, this course could not have a fixed sequence, or fixed content, beyond certain broad areas of discussion. The teacher can anticipate that each resident will bring to this course well-established attitudes toward women. These attitudes vary so widely that it is impossible to address them fairly with a rigid course outline. For example, some residents do not believe that there has been any significant discrimination. It is impossible to discuss the types and effects of discrimination when there is doubt about whether or not discrimination exists.

The first task is to identify "where residents are" with regard to facts and opinions. Once this has been done, it is necessary to know the literature so well that discussion can begin at the level of the resident who has the fewest facts and has given the least thought to the issues. The discussion then advances through increasing levels of sophistication until each resident has been provided with useful facts and a situation in which to apply them. From that point, the residents can proceed in concert, with the content being adjusted to meet the needs of the particular group.

CONTENT AND SEQUENCE OF CONTENT

In 1972 the recent professional literature was scant indeed, but what was available was intellectually provocative. Masters and Johnson,5 Mary Jane Sherfey,6 Erickson,7 Stoller,8 Salzman,9 and Broverman et al.10 were particularly helpful. A review of these articles and the classic works of Freud and Helene Deutsch, including her more recent comments, " confirmed that the variously defined healthy roles of women were intimately entwined with the characteristics of a particular culture. This knowledge demanded a historical framework to account for and give dimension to this concept.

The initial course was organized into three broad sections in the following sequence: (1) historical overview; (2) an overview of psychologic theories about women as formulated by Freud, Deutsch, Thompson, Homey, Adler, and Erickson, a critique of theories about women by Stoller, K and a book, edited by Miller, 13 focusing on therapy issues; and (3) examination of the substantive issues involved in contemporary criticisms of psychiatry. The last section focused on (1) considerations of the various psychodynamic definitions of femininity, sex roles, and stereotypes as contrasted with the various definitions of normality; (2) the effects of theory on setting treatment goals; and (3) how a therapist's personal bias might be manifested in the process of psychotherapy. Obviously, the breadth of the approach called for a rapid pace, even though residents were presumed to arrive knowing the various theories of development and the substantive issues involved in defining normality. Nevertheless, it was possible to permit discussion of topics of interest to the group, such as child rearing, rape, and the attitudes of nonpsychiatric physicians toward women.

Since the content of the course must vary widely from year to year to accommodate the wide differences among groups of residents, description of the subjects discussed is impossible. The usefulness of the historical approach may, however, be illustrated by outlining one topic commonly found to be of interest to the residents - the right of women to vote.

Table

TABLE 1HISTORICAL EVENTS CONCERNING WOMEN'S SUFFRAGE AND CLASSIC PUBLICATIONS ON THE PSYCHOLOGY OF WOMEN

TABLE 1

HISTORICAL EVENTS CONCERNING WOMEN'S SUFFRAGE AND CLASSIC PUBLICATIONS ON THE PSYCHOLOGY OF WOMEN

The presentation begins with the selection of a few significant historical events that unequivocally affected the right of women to vote and compares them chronologically with outstanding classic publications on the psychology of women (Table 1). This sequence serves to emphasize the dramatic difference between the developing status of women in the United States and Freud's seemingly contrary observations in a European culture.

Once the factual outline of some of the developments of women's voting rights has been established, it is amplified by offering expanded and graphic comparisons of the treatment accorded women in American subcultures. For example, in 1902 women in Georgia found that they had fewer privileges of citizenship than they had thought when they signed a petition that would permit a "blind tiger" (a pub or tavern) to be licensed in the town of Ball Ground. The Georgia Supreme Court18 concluded that the women's signatures did not count towards the required two-thirds, and the quaint language of the opinion is informative:

To authorize a female citizen to exercise any civil function there must also be an express statute conferring this authority. Therefore, when the words of a statute are ambiguous or equivocal, that construction must be placed upon it which will relieve the female citizen from the exercise of civil political functions.

The Georgia Supreme Court's attitude toward women was clearly stated: "The settled policy of this State is that female citizens shall not be harassed and annoyed with matters relating to governmental affairs."

The distinction between the legal status of women in Georgia in 1902 and that of women 30 years earlier in Wyoming is dramatic. Women first voted in Wyoming Territory in 1870. When statehood for Wyoming was considered in 1890, u its citizens insisted on retaining this right. The remarks19 of its leaders at that time stand in stark contrast to the comments of the Georgia Supreme Court more than a decade later. Governor Warren was explicit about the status of women in Wyoming:

Here in the open air, near the crest of the continent, Wyoming . . . celebrates an event significant in the extreme, new in the history of our country, and without precedent in the world; this is to say, a State, in adopting its constitution, extends free and equal suffrage to its citizens, regardless of sex.

Judge Brown, the president of the constitutional convention, said:

. . . There springs into existence a new state and the watchwords of its people are "Justice, Equality" to this new State. ... It is permitted to achieve the highest excellence in government yet attained by man. Here, unmoved by selfishness, the dangers of war or the appeals of non-resident reformers, but moved alone by the spirit of divine justice, it was ordained by the people of Wyoming that each citizen of the State should enjoy the same right guaranteed to every other citizen, whether high or low, black or white, male or female. . . .

From this Nebo of history we look forward to the promised land. Whether it shall flow with milk and honey of prosperity and happiness for woman, depends solely upon herself.

When the right to suffrage was conferred, Wyoming acknowledged the liberty and demanded responsibility. Like man, woman had the right to pursue happiness, and the corollary that catching it depends "solely upon herself" was explicit.

Comparisons such as these between the appropriate role of woman as defined by two American subcultures are informative to the residents in formulating their own views on what is "normal" for women. This comparison is enhanced and brought into context with classic psychiatric theory by the observation that the cultural roles in America grew closer together and merged by 1920, five years before Freud's later classic observations.

The relationship of these historical events to roles, stereotypes, customs, definitions of femininity, allowable developmental choices, and psychologic issues of independence and dependence is apparent. Delineation of issues in education and economics is similarly traced in the course.

RESPONSE OF RESIDENTS TO THE SEMINARS

Initially, the residents' knowledge and response reflected the fact that in 1972 these issues were new to all. The residents questioned the relevance of the course to psychiatric practice and pointedly observed that they had been treating women for three years without getting into "women's issues." Some residents did not believe significant discrimination existed; others saw it as the "status quo," a necessary evil. Residents, then, had given little thought to distinguishing between personal preferences and therapeutic issues. It was explicitly stated by a few residents that, since they expected their wives to keep house, they could hardly recommend working to a woman patient, unless this was crucial for her mental health. To these residents, the emerging independence of women would automatically increase the burden on men, and they could not accept increasing the options for women without somehow ensuring that the burden on men was not simultaneously increased. It is crucial to recognize that this response focused on the disruption of a traditional role balance: responsible men were taught to protect and provide for women, and this role relationship was a necessary value in a society that fostered dependency in women.

In more recent years, the residents have tended to take the viewpoint that increased opportunity requires women to assume increased responsibility for themselves. With this change in thinking, the residents' concerns seem to have appreciably diminished. Residents are now likely to have more awareness from a personal perspective of the many roles and choices open to women as well as men. Thus, there is a genuine awareness of the difference between personal preferences and therapeutic issues, which has been enhanced by experiences during training with the increasing number of competent women residents.

Residents now no longer doubt that discrimination has occurred. Nonetheless, even with a dim appreciation of the effects on the individual woman, many residents still want simplistic answers to complex clinical issues. A realistic assessment of the course finds that it can only establish a framework for future understanding by illuminating the cultural factors that impinge on individual biology and dynamics. One interesting product is the issue of whether or not a therapist is ethically bound to "liberate" all women patients in psychotherapy and the gradual recognition of this concept as yet another stereotype.

There has been no clear difference in response between men and women residents. In general, women have always responded more sympathetically to women's criticisms than men have. In the early years, when data were lacking, the women voiced their sympathies and gave examples deliberately attempting to provide anecdotal illustrations of the issues. Men were frequently puzzled about the relevance of the discussion, but women seldom were. It is my opinion that we are just beginning to be aware of the extent to which the tremendous differences in background and experience between men and women result in dramatically different perspectives and perceptions. Only limited substantive progress can be made until we can acknowledge that men and women are often unable to understand, without explanation, the perspective of the other because there has been too little broad exchange of perspectives.

IMPACT ON FACULTY

Initially, a few faculty members acknowledged that the course was needed . Beyond that, no response was stated openly, although the faculty contributed by discussing related issues.

The importance of such support was made apparent by one instance of its loss. The chairman of the department always assigned an article20 and devoted part of his series of lectures to Freud's views about women. He noted that considering new views is not the same as attacking Freud's views. When this series was changed, the article was deleted. Years later, unexpectedly, attendance at the course fell to a dramatically low level. The residents who missed this discussion viewed the course quite negatively, even to the point of being surprised that the readings were psychiatric literature. In his discussion of Freud's views about women, the chairman had obviously been facilitating an inquiring attitude as well as emphasizing the importance of the psychology of women.

CONCLUSIONS

It is impossible to demonstrate whether this course has had any impact or, if it has, what the quantitative effects are. The course cannot be separated from the effects of professional activities and the proliferating literature, which have focused attention on substantive issues and added crucial data. Nevertheless, there are a few indicators of the specific impact of this course.

First, we have verified that the course does successfully impart facts. Third-year residents do score better on related comprehensive examination questions than first- and second-year residents. Second, and more important, there are indications that the residents are interested in what they learn. Comments by residents in their program evaluations are positive, and they recommend that the course be given more time, entail more discussion, and state more conclusions. Third, the facts are being applied. Graduates of the program have informed us that they have encountered these issues in clinical practice, and that their contact with these issues in their residency has prepared them to respond better. Whether or not the efficacy of the course can be demonstrated, its presence is clearly being felt. We have made a beginning.

BIBLIOGRAPHY

1 . Millett. K. Sexual Politics. New York: Avon Books. 1969.

2. Greer, G. The Female Eunuch. New York: Bantam Books, 1972.

3. Morgan, R. Sisterhood Is Powerful: An Anthology of Writings from the Women's Liberation Movement. New York: Vintage Books, 1970.

4. Mill, J. S. The Subjection of Women. Cambridge. Mass.: The M.I.T. Press. 1970.

5. Masters. W., and Johnson, V. Human Sexual Response. Boston: Little, Brown and Company. 1966.

6. Sherfey, M. The evolution and nature of female sexuality In relation to psychoanalytic theory. J. Am. Psychoanal. Assoc. 14 (1966). 28-128.

7. Erickson, E. Identity, Youth and Crisis. New York: W. W. Norton and Company, 1968.

8. Stoller. R. Sex and Gender: The Development of Masculinity and Femininity. Volume I. New York: Jason Aronson, 1968.

9. Salzman, L Sexuality in psychoanalytic theory. In Marmor, J. (ed.). Modem Psychoanaiysis: New Directions and Perspectives. New York: Basic Books. 1968. pp. 123-145.

10. Broverman. I. K., et al. Sex-role stereotypes and clinical judgments of mental health. J. Consult. Clin. Psychol. 34 (1970), 1-7.

1 1 . Roiphe, A. R. What women psychoanalysts say about women's liberation (reprinted from the New York Times Magazine). Reflections 8:1 (1973). 8-27.

12. Stoller. R. J. Overview: The impact of new advances in sex research on psychoanalytic theory. Am. J. Psychiatry 130 (1973), 241-251.

13. Miller, J. Psychoanalysis and Women. Baltimore: Penguin Books. 1973.

14. Flexner, E. Century of Struggle: The Woman's Rights Movement in the United States. New York: Antheneum Publishers, 1968.

15. Chaff in. L Sons of the West. Caldwell, Idaho: Caxton Printers, 1941.

16. Tyson, A., and Strachey, J. A chronological hand-list of Freud's works. Int. J. Psychoanal. 37 (1956), 19-33.

17. Deutsch. H. The Psychology of Women, Volumes I and II. New York: Grune and Stratton. 1944, 1945.

18. Wray v. Harrison. 116 Ga. 93 (1902).

19. Chaff in. L. Op. cit., pp. 266-267.

20. Gilman, R. The femlib case against Sigmund Freud. New York Times Magazine, Jan. 31, 1971.

TABLE 1

HISTORICAL EVENTS CONCERNING WOMEN'S SUFFRAGE AND CLASSIC PUBLICATIONS ON THE PSYCHOLOGY OF WOMEN

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