Patient and Patriarch: Women in the Psychotherapeutic Relationship

PART II Woman is made, not born

A paper presented at the annual convention of the American Psychological Association,
September 1970, Miami Beach, Florida.

  • Like all sciences and valuations, the
    psychology of women has hitherto been
    considered only from the point of view of men.
    It is inevitable that the man's position of
    advantage should cause objective
    validity to be attributed to his subjective,
    affective relations to women . . .
    the question then is how far
    analytical psychology also, when its researches
    have women for their object,
    is under the spell of this way of thinking.[1]

Although Karen Horney wrote this in 1926, very few psychiatrists and psychologists seem to have agreed with and been guided by her words. Female psychology is still being viewed from a masculine point of view. Contemporary psychiatric and psychological theories and practices both reflect and influence our culture's politically naive understanding and emotionally brutal treatment of women  Female unhappiness is viewed and »treated« as a problem of individual pathology, no matter how many other female patients (or nonpatients) are similarly unhappy - and this by men who have studiously bypassed the objective fact of female oppression. Woman's inability to adjust to or to be contented by feminine roles has been considered as a deviation from »natural« female psychology rather than as a criticism of such roles.
I do not wish to imply that female unhappiness is a myth conjured up by men; it is very real. One of the ways white, middle-class women in America attempt to handle this unhappiness is through psychotherapy. They enter private therapy just as they enter marriage - with a sense of urgency and desperation. Also, black and white women of all classes, particularly unmarried women, comprise the largest group of psychiatrically hospitalized and »treated« Americans. This paper will present the following analysis:

  1. that for a number of reasons, women »go crazy« more often and more easily than men do; that their »craziness« is mainly self-destructive; and that they are punished for their self-destructive behavior, either by the brutal and impersonal custodial care given them in mental asylums, or by the relationships they have with most (but not all) clinicians, who implicitly encourage them to blame themselves or to take responsibility for their unhappiness in order to be »cured«.
  2. that both psychotherapy and marriage, the two major socially approved institutions for white, middle-class women, function similarly, i.e., as vehicles for personal »salvation« through the presence of an understanding and benevolent (male) authority. In female culture, not being married, or being unhappily married, is experienced as an »illness« which psychotherapy can, hopeful ly, cure.

This paper will discuss the following questions: What are some of the facts about women as psychiatric or psychotherapy patients in America? What »symptoms« do they present? Why are more women involved, either voluntarily or involuntarily with mental health professionals than are men? Who are the psychotherapists in America and what are their views about women? What practical implications does this discussion have for women who are in a psychotherapeutic relationship?

General Statistics

A study published in 1970 by the U.S. Department of Health, Education, and Welfare [2] indicated that in both the black and white populations significantly more women than men reported having suffered nervous breakdowns, having felt impending nervous breakdowns, »phychological inertia« and dizziness. Both black and white women also reported higher rates than men for the following symptoms: nervousness,* insomnia, trembling hands, »nightmares,«[3] fainting,*3 and headaches* (See Table 17-1). White women who were never married reported fewer symptoms than white married or separated women. These findings are essentially in agreement with an earlier study published in 1960, by the Joint Commission on Mental Health and Illness.[4] The Commission reported the following information for non-hospitalized American adults: (1) Greater distress and symptoms are reported by women than by men in all adjustment areas. They report more disturbances in general adjustment, in their self-perception, and in their marital and parental functioning. This sex difference is most marked at the younger age intervals. (2) A feeling of impending breakdown is reported more frequently by divorced and separated females than by any other groups of either sex. (3) The unmarried (whether single, separated, divorced or widowed) have a greater potential for psychological distress than do the married. (4) While the sexes did not differ in the frequency with which they reported »unhappiness,« the women reported more worry, fear of breakdown, and need for help.
What such studies do not make clear, is how many of these »psychologically distressed« women are involved in any form of psychiatric or psychological treatment. Other studies have attempted to do this. William Schofield [5] found that the average psychiatrist sees significantly more female than male patients. A study published in 1965 reported that women patients outnumbered men patients 3 to 2 in private psychiatric treatment.[6] Statistics for public and private psychiatric hospitalization in America do exist and of course, are controversial. However, statistical studies have indicated certain trends. The National Institute of Mental Health has reported that from 1965-1967 there were 102,241 more women than men involved in the following psychiatric treatment facilities: private psychiatric hospitals, state and county psychiatric hospitals, inpatient psychiatric wards in General and Veterans' Administration hospitals, and General and Veterans' Administration outpatient psychiatric facilities. This figure excludes the number of Americans involved in various forms of private treatment. Earlier studies have reported that admission rates to both public and private psychiatric hospitals are significantly higher for women than for men.[8] Unmarried people (single, divorced or widowed) of both sexes are disproportionately represented among the psychiatrically hospitalized.[9] Thus, while according to the 1970 HEW report, single, white women in the general population report less psychological distress than married or separated white women,10 women, (as well as men) who are psychiatrically hospitalized tend to be unmarried.
Private psychotherapy, like marriage, is an integral part of middle-class female culture. Patients entering private therapy betray significantly different attitudes toward men and women therapists. A number of them indicate that they feel sex is important in the therapeutic relationship by voluntarily requesting a therapist of a particular sex.
I have recently completed a study of 1,001 middle-income clinic outpatients (538 women and 463 men) who sought therapeutic treatment in New York City from 1965 to 1969. Patient variables, such as sex, marital status, age, religion, occupation, and so forth, were related to patient requests for a male or a female therapist at the time of the initial interview. These findings are based on a sample of 258 people (159 women and 99 men) who voluntarily requested either a male or a female therapist or who voluntarily stated that they had no sex-of-therapist preference. Twenty-four percent of the 538 women and 14 percent of the 463 men requested a therapist specifically by sex. The findings were as follows:

  1. The majority of patients were single (66 percent) and under thirty (72 percent). Whether male or female, they overwhelmingly requested a male rather than a female therapist. This preference was significantly related to marital status in women but not in men (Tables 17-2 and 17-3). This suggests that a woman may be seeking therapy for very different reasons than a man; and that these reasons are generally related to or strictly determined by her relationship (or lack of one) to a man. The number of requests for female therapists was approximately equal to the number of »no preference« requests for both men and women.
  2. Single women, under or over thirty, of any religion, requested male therapists more often than married or divorced women did. Married women requested female therapists more often than any of the other sample groups.
  3. While all of the male patients regardless of their marital status, requested male therapists rather than female therapists, some differential trends did exist. A higher percentage of divorced men requested male therapists, as compared with either divorced women (53 percent vs. 35 percent), married women (53 percent vs. 41 percent) married men (53 percent vs. 25 percent), or single men (53 percent vs. 44 percent). There was a significant relation between a male patient's request for a male therapist and his age (under thirty) and his religion: specifically, 63 percent of the Jewish male patients (who composed 40 percent of the entire male sample and 73 percent of whom were under thirty) requested male therapists - a higher percentage than in any other group.
  4. Some of the most frequent reasons given by male patients for requesting male therapists were: greater respect for a man's mind; general discomfort with and
mistrust of women; and specific embarrassment about »cursing« or discussing sexual matters, such as impotence, with a woman.[11] Some of the most common reasons given by female patients for requesting male therapists were: greater respect for and confidence in a man's com potency and authority; feeling generally more comfortable with and relating better to men than to women; and specific fear and mistrust of women as authorities and as people, a reason sometimes combined with statements about dislike of the patients' own mothers.[12] In general, both men and women stated that they trusted and respected men - as people and as authorities - more than they did women, whom they generally mistrusted or feared.
    Patients who requested a female therapist generally gave fewer reasons for their preference; one over-thirty woman stated that »only a female would understand another female's problems«; another woman stated that she sees »all males as someone to conquer« and is »less open to being honest with them«. Almost all of the male patients who gave reasons for requesting a female therapist were homosexual.[13] Their main reasons involved expectations of being »sexually attracted« to a male therapist, which they thought would distract or upset them. One non-homosexual patient felt he would be too »competitive« with a male therapist.
  5. Thirty-six percent of the male and 37 percent of the female patients reported generally unclassifiable symptoms during the initial clinic interview. Thirty-one percent of the female and 15 percent of the male patients reported depression as their reason for seeking therapy; 25 percent of the male and 7 percent of the female patients reported active homosexuality; 15 percent of the female and 14 percent of the male patients reported anxiety; 8 percent of the female and 7 percent of the male patients reported sexual impotence; 4 percent of the male and 3 percent of the female patients reported drug or alcoholic addiction. The fact that twice as many female as male patients report depression, and almost four times as many male as female patients report homosexuality accords with previous findings.
  6. Male and female patients remained in therapy for approximately equal lengths of time (an average of thirty-one weeks for males and twenty-eight weeks for females). However, men requesting male therapists remained in therapy longer than other patient groups, an average of forty-two weeks) compared to an average of thirty weeks for females requesting a male therapist; an average of thirty-four weeks for male and thirty-one weeks for female patients requesting a female therapist; an average of twelve weeks for male and seventeen weeks for female patients with a stated »no preference«.[14]

In other words, male patients who requested (and who generally received) a male therapist remained in treatment longer than their female counterparts. Perhaps one of the reasons for this is that women often get married and then turn to their husbands (or boy friends) as authorities or protectors, whereas men generally do not turn to their wives or girl friends as authorities, but rather as nurturing mother-surrogates, domestics, sex objects, and perhaps, friends. They usually do not turn to women for expert advice; hence, when they decide they need this kind of help, they tend to remain in therapy with a male therapist. Female patients can transfer their needs for protection or salvation from one man to another. Ultimately, a female patient or wife will be disappointed in her husband's or therapist's mothering or saving capacities and will continue the search for salvation through a man elsewhere.

Presenting Symptoms

From clinical case histories, psychological studies, novels, mass magazines, and from our own lives, we know that women are often chronically fatigued and/ or depressed; they are frigid, hysterical, and paranoid; and they suffer from headaches and feelings of inadequacy.
Studies of childhood behavior problems have indicated that boys are most often referred to child guidance clinics for aggressive, destructive (antisocial), and competitive behavior; girls are referred for personality problems, such as excessive fears and worries, shyness, timidity, lack of self-confidence, and feelings of inferiority.[15] This should be compared with adult male and female psychiatric symptomatology: »the symptoms of men are also much more likely to reflect a destructive hostility toward others,[16] as well as a pathological self-indulgence. . . . Women's symptoms, on the other hand, express a harsh, self-critical, self-depriving and often self-destructive set of attitudes.[17] A study by E. Zigler and L. Phillips, comparing the symptoms of male and female mental hospital patients, found male patients significantly more assaultive than females and more prone to indulge their impulses in socially deviant ways like robbery, rape, drinking, and homosexuality.[18] Female patients were more often found to be self-deprecatory, depressed, perplexed, suffering from suicidal thoughts, or making actual suicidal attempts.[19]
According to T. Szasz, symptoms such as these are »indirect forms of communication« and usually indicate a »slave psychology«:

Social oppression in any form, and its manifestations are varied, among them being ... poverty ... racial, religious, or sexual discrimination ... must therefore be regarded as prime determinants of indirect communication of all kinds (e.g. hysteria).[20]

At one point in The Myth of Merited Illness, Szasz refers to the »dread of happiness« that seems to afflict all people involved in the »Judeo-Christian ethic«. Although he is not talking about women particularly, his analysis seems especially relevant to our discussion of female psychiatric symptomatology:

In general, the open acknowledgment of satisfaction is feared only in situations of relative oppression (e.g. all-suffering wife vis-a-vis domineering husband). The experiences of satisfaction (joy, contentment) are inhibited lest they lead to an augmentation of one's burden. ... the fear of acknowledging satisfaction is a characteristic feature of slave psychology.
The »properly exploited« slave is forced to labor until he shows signs of fatigue or exhaustion. Completion of his task does not signify that his work is finished and that he may rest. At the same time, even though his task is unfinished, he may be able to influence his master to stop driving him - and to let him rest - if he exhibits signs of imminent collapse. Such signs may be genuine or contrived. Exhibiting signs of fatigue or exhaustion - irrespective of whether they are genuine or contrived (e.g., »being on strike« against one's boss) - is likely to induce a feeling of fatigue or exhaustion in the actor. I believe that this is the mechanism responsible for the great majority of so-called chronic fatigue states. Most of these were formerly called »neurasthenia,« a term rarely used nowadays. Chronic fatigue or a feeling of lifelessness and exhaustion are still frequently encountered in clinical practice.
Psychoanalytically, they are considered »character symptoms«. Many of these patients are unconsciously »on strike« against persons (actual or internal) to whom they relate with subservience and against whom they wage an unending and unsuccessful covert rebellion.[21]

The analogy between »slave« and »woman« is by no means a perfect one. Women are probably the prototypes for slaves;[22] they were probably the first group of human beings to be enslaved by another group. In a sense, a woman's »work« is in exhibiting the signs and »symptoms« of slavery - as well as, or instead of, doing slave labor in the kitchen, the nursery, and the factory.[23]

Why Are There More Female Patients?

Psychiatrists and psychologists have traditionally described the signs and symptoms of various kinds of real and felt oppression as mental illness. Women often manifest these signs, not only because they are oppressed in an objective sense, but also because the sex role (stereotype) to which they are conditioned is composed of just such signs. For example, Phillips and Segal report that when the number of physical and psychiatric illnesses were held constant for a group of New England women and men, the women were more likely to seek medical and psychiatric care. They suggest that women seek psychiatric help because the social role of women allows them to display emotional and physical distress more easily than men. »Sensitive or emotional behavior is more tolerated in women, to the point of aberration, while self-assertive, aggressive, vigorous physical demonstrations are more tolerated among men«.[24]
It may be that more women than men are involved in psychotherapy [25] because it - along with marriage - is one of the only two socially approved institutions for middle-class women. That these two institutions bear a strong similarity to each other is highly significant. For most women the psychotherapeutic encounter is just one more instance of an unequal relationship, just one more opportunity to be rewarded for expressing distress and to be »helped« by being (expertly) dominated.
Both psychotherapy and marriage isolate women from each other; both emphasize individual rather than collective solutions to woman's unhappiness; both are based on a woman's helplessness and dependence on a stronger male authority figure; both may, in fact, be viewed as reenactments of a little girl's relation to her father in a patriarchal society;[26] both control and oppress women similarly - yet, at the same time, are the two safest havens for women in a society that offers them no others.
Both psychotherapy and marriage enable women to safely express and defuse their anger by experiencing it as a form of emotional illness, by translating it into hysterical symptoms: frigidity, chronic depression, phobias, and the like. Each woman as patient thinks these symptoms are unique and are her own fault. She is neurotic, rather than oppressed. She wants from a psychotherapist what she wants - and often cannot get - from a husband: attention, understanding, merciful relief, a personal solution - in the arms of the right husband, on the couch of the right therapist.[27] The institutions of therapy and marriage not only mirror each other, they support each other. This is probably not a coincidence, but is rather an expression of the American economic system's need for geographic and psychological mobility, i.e., for young, upwardly mobile »couples« to »survive«, to remain more or less intact in a succession of alien and anonymous urban locations, while they carry out the function of socializing children.
The institution of psychotherapy may be used by many women as a way of keeping a bad marriage together, or as a way of terminating it in order to form a good marriage. Some women, especially young and single women, may use psychotherapy as a way of learning how to catch a husband by practicing with a male therapist. Women probably spend more time during a therapy session talking about their husbands or boy friends - or lack of them - than they do talking about their lack of an independent identity or their relations to other women.
The institutions of psychotherapy and marriage both encourage women to talk - often endlessly - rather than to act (except in their socially prearranged roles as passive women or patients). In marriage the talking is usually of an indirect and rather inarticulate nature. Open expressions of rage are too dangerous, and too ineffective for the isolated and economically dependent women. Most often, such »kitchen« declarations end in tears, self-blame, and in the husband graciously agreeing with his wife that she was »not herself«. Even control of a simple - but serious -  conversation is usually impossible for most wives when several men, including their husbands, are present. The wife-women talk to each other, or they listen silently while the men talk. Very rarely, if ever, do men listen silently to a group of women talking; even if there are a number of women talking and only one man present, the man will question the women, perhaps patiently, perhaps not, but always in order to ultimately control the conversation from a superior position.
In psychotherapy the patient-woman is encouraged - in fact directed - to talk, by a therapist who is at least expected to be, or is perceived as, superior or objective. The traditional therapist may be viewed as ultimately controlling what the patient says through a subtle system of rewards (attention, interpretations, and so forth) or rewards withheld - but, most ultimately, controlling in the sense that he is attempting to bring his patient to terms with the female role, i.e., to an admission and acceptance of dependency. Traditionally, the psychotherapist, has ignored the objective facts of female oppression. Thus, in every sense, the female patient is still not having a »real« conversation - either with her husband or her therapist But how is it possible to have a »real« conversation with those who directly profit from her oppression? She would be laughed at, viewed as silly or crazy, and if she persisted, removed from her job - as secretary or wife, perhaps even as patient.
Psychotherapeutic talking is indirect in the sense that it does not immediately or even ultimately involve the woman in any reality-based confrontations with the self. It is also indirect in that words - any words - are permitted, so long as certain actions of consequence are totally avoided. (Such is not paying one's bills.)

Who Are the Psychotherapists and
What Are Their Views about Women?

Contemporary psychotherapists, like ghetto schoolteachers, do not study themselves or question their own motives or values as easily or as frequently as they do those of their neurotic patients or their culturally deprived pupils. However, in a 1960 study Schofield found that 90 percent of psychiatrists were male; that psychologists were predominantly males, in a ratio of two to one; and that social workers (the least prestigious and least well-paying of the three professional categories) were predominantly females, in a ratio of two to one. The psychologists and psychiatrists were about the same age, an average of forty-four years; the social workers' average age was thirty-eight. Less than 5 percent of the psychiatrists were single; 10 precent of the psychologists, 6 percent of the social workers, and 1 percent of the psychiatrists were divorced. In other words, the majority of psychiatrists and psychologists are middle-aged married men, probably white, whose personal backgrounds were seen by Schofield as containing »pressure toward upward social mobility«.[28] In 1960 the American Psychiatric Association totaled 10,000 male and 983 female members.
What must further be realized is that these predominantly male clinicians are involved in (a) a political institution that (b) has taken a certain traditional view of women. A great deal has been written about the covertly or overtly patriarchal, autocratic, and coercive values and techniques of psychotherapy.[29] Freud believed that the psychoanalyst-patient relationship must be that of »a superior and a subordinate«.[30] The psychotherapist has been seen - by his critics as well as by his patients - as a surrogate parent (father or mother), savior, lover, expert, and teacher - all roles that foster »submission, dependency, and infantilism« in the patient: roles that imply the therapist's omniscient and benevolent superiority and the patient's inferiority.[31] (Szasz has remarked on the dubious value of such a role for the patient and the »undeniable' value of such a role for the »helper«.) Practicing psychotherapists have been criticized for treating unhappiness as a disease (whenever it is accompanied by an appropriately high verbal and financial output); for behaving as if the psychotherapeutic philosophy or method can cure ethical and political problems; for teaching people that their unhappiness (or neurosis) can be alleviated through individual rather than collective efforts; for encouraging and legitimizing the urban middle-class tendency toward moral irresponsibility and passivity; for discouraging  emotionally  deprived  persons  from  seeking »acceptance, dependence and security in the more normal and  accessible  channels  of  friendship«.[32]  Finally,  the institution of psychotherapy has been viewed as a form of social and political control that offers those who can pay for it temporary relief, the illusion of control, and a self-indulgent form of self-knowledge; and that punishes those who cannot pay by labeling their unhappiness at psychotic or dangerous, thereby helping society consign them to asylums where custodial care (rather than therapeutic illusions) is provided.
These criticisms, of course, apply to both male an female therapy patients. However, the institution of psychotherapy differentially and adversely affects women to the extent to which it is similar to marriage, and insofar a it takes its powerfully socialized cues from Freud and hit male  and  female  disciples  (Helene  Deutsch,  Marie Bonaparte, Marynia Farnham,  Bruno  Bettelheim,  Eril Erikson, Joseph Rheingold), viewing woman as essentially »breeders and bearers,« as potentially warm-hearted creatures, but more often as simply cranky children with uteruses, forever mourning the loss of male organs and male identity. Woman's fulfillment has been couched -  inevitably and eternally - in terms of marriage, children, and the vaginal orgasm.[33]
In her 1926 essay entitled »The Flight from Womanhood,« Karen Horney says:

The  present  analytical  picture  of feminine  development (whether that picture be correct or not) differs in no case by a hair's breadth from the typical ideas that the boy has of the girl.
We are familiar with the ideas that the boy entertains. I will therefore only sketch them in a few succinct phrases, and for the sake of comparison will place in a parallel column our ideas of the development of women.

  • THE BOY' IDEAS Naive assumption that girls as well as boys possess a penis
    Realization of the absence of the penis
    Idea that the girl is a castrated, mutilated boy
    Belief that the girl has suffered punishment that also threatens him
    The girl is regarded as inferior
    The boy is unable to imagine how the girl can ever get over this loss or envy
    The boy dreads her envy
    For both sexes it is only the
    male genital which plays any
    Sad discovery of the absence
    of the penis
    Belief of the girl that she once
    possessed a penis and lost it
    by castration
    Castration is conceived of as
    the infliction of punishment
    The girl regards herself as inferior.
    Penis envy The girl never gets over the sense
    of deficiency and inferiority and has constantly
    to master afresh her desire to be a man.
    The girl desires throughout life to avenge herself
    on the man for possessing something which she lacks [34]

The subject of women seems to elicit the most extraordinary and yet authoritative pronouncements from many »sensitive« psychoanalysts:

Sigmund Freud:
(Women) refuse to accept the fact of being castrated and have the hope of someday obtaining a penis in spite o everything. ... I cannot escape the notion (though hesitate to give it expression) that for woman the level of what is ethically normal is different from what it is in man. We must not allow ourselves to be deflected from such conclusions by the denials of the feminists who are anxious to force us to regard the two sexes as completely equal in position and worth.[35]
We say also of women that their social interests are weaker than those of men and that their capacity for the sublimation of their interests is less . . . the difficult development which leads to femininity [seems to] exhaust all the possibilities of the individual.[36]

Erik Erikson:
For the student of development and practitioner of psychoanalysis, the stage of life crucial for the understanding of womanhood is the step from youth to maturity, the state when the young woman relinquishes the care received from the parental family and the extended care of institutions of education, in order to commit herself to the love of a stranger and to the care to be given to his or her offspring. . . . young women often ask, whether they can »have an identity« before they know whom they will marry and for whom they will make a home. Granted that something in the young women's identity must keep itself open for the peculiarities of title man to be joined and of the children to be brought up, I think that much of a young woman's identity is already denned in her kind of attractiveness and in the selectivity of her search for the man (or men) by whom she wishes to be sought.[37]

Bruno Bettelheim:
... as much as women want to be good scientists and engineers, they want first and foremost to be womanly companions of men and to be mothers.[38]

Joseph Rheingold:
.. . woman is nurturance . . . anatomy decrees the life of a woman. . . . When women grow up without dread of their biological functions and without subversion by feminist doctrines and therefore enter upon motherhood with a sense of fulfillment and altruistic sentiment we shall attain the goal of a good life and a secure world in which to live.[39]

These are all familiar views of women. But their affirmation by experts indirectly strengthened such views among men and directly tyrannized women, particularly American middle-class women, through the institution of psychotherapy and the tyranny of published »expert« opinion, stressing the importance of the mother for healthy child development. In their view, lack of - or superabundance of - mother love causes neurotic, criminal, psychiatric, and psychopathic children! The blame is rarely placed on the absence of a father or on the intolerable power struggle at the heart of most nuclear monogamous families - between child and parent, between wife and husband, between the whole economic unit and the struggle to survive in an urban capitalist environment.
Most child development research, like most birth control research, has centered around women, not men: for this is »women's work,« for which she is totally responsible, which is »never done,« and for which, in a wage-labor economy, she is never directly paid. She does it for love and is amply rewarded - in the writings of Freud et al.
The headaches, fatigue, chronic depression, frigidity, »paranoia,« and overwhelming sense of inferiority that therapists have recorded about their female patients have not been analyzed in any remotely accurate terms. The real oppression (and sexual repression) of women remains unknown to the analysts, for the most part. Such symptoms have not been viewed by most therapists as »indirect communications« that reflect a »slave psychology«. Instead, such symptoms have been viewed as hysterical and neurotic productions, as underhanded domestic tyrannies manufactured by spiteful, self-pitying, and generally unpleasant women whose inability to be happy as women probably stems from unresolved penis envy, an unresolved Electra (or female Oedipal) complex, or from general, intractable female stubbornness.
In a rereading of some of Freud's early case histories of female »hysterics,« particularly his Case of Dora, what is remarkable is not his brilliance or his relative sympathy for the female »hysterics«;[40] rather, it is his tone: cold, intellectual, detective-like,[41] controlling, sexually Victorian. He really does not like his »intelligent« eighteen-year-old patient. For example, he says: »For several days on end she identified herself with her mother by means of slight symptoms and peculiarities of manner, which gave her an opportunity for some really remarkable achievements in the direction of intolerable behavior«. The mother has been diagnosed, unseen, by Freud, as having »housewife's psychosis«.[42]
L. Simon reviews the plight of Dora:

... she had been brought to Freud by her father for treatment of ». . . tussis nervosa, aphonia, depression, and taedium vitae«. Despite the ominous sound of these Latinisms it should be noted that Dora was not in the midst of a symptom crisis at the time she was brought to Freud, and there is at least room for argument as to whether these could be legitimately described as symptoms at all. If there was a crisis, it was clearly the father's. Nevertheless, Freud related the development of these »symptoms« to two traumatic sexual experiences Dora had had with Mr. K., a friend of the family. Freud eventually came to explain the symptoms as expressions of her disguised sexual desire for Mr. K., which he saw, in turn, as derived from feelings she held toward her father. Freud attempted, via his interpretations, to put Dora in closer touch with her own unconscious impulses.
. . . Indeed, the case study could still stand as an exemplary effort were it not for a single, but major, problem having to do with the realities of Dora's life. For throughout his therapeutic examination of Dora's unconscious Freud also knew that she was the bait in a monstrous sexual bargain her father had concocted. This man, who during an earlier period in his life had contracted syphilis and apparently infected his wife . . . was now involved in an affair with the wife of Mr. K. There is clear evidence that her father was using Dora to appease Mr. K., and that Freud was fully aware of this. ... At one point Freud states: »Her father was himself partly responsible for her present danger for he had handed her over to this strange man in the interests of his own love-affair«. But despite this reality, despite his full knowledge of her father's predilections, Freud insisted on examining Dora's difficulties from a strictly intrapsychic point of view, ignoring the manner in which her father was using her, and denying that her accurate perception of the situation was germane.
. . . Freud appears to accept fully the willingness of these men to sexually exploit the women around them. One even finds the imagery of capitalism creeping into his metapsychology. Freud's work with Dora may be viewed as an attempt to deal with the exploitation of women that characterized that historical period without even an admission of the fact of its existence. We may conclude that Freud's failure with Dora was a function of his inappropriate level of conceptualization and intervention. He saw that she was suffering, but instead of attempting to deal with the conditions of her life he chose - because he shared in her exploitation - to work within the confines of her ego.[43]

Although Freud eventually conceded (but not to Dora) that her insights into her family situation were correct, he still concluded that these insights would not make her »happy«. Freud's own insights - based on self-reproach, rather than on Dora's reproaching of those around her -  would hopefully help her discover her own penis envy and Electra complex; somehow this would magically help her to adjust to, or at least to accept, her only alternative in life: housewife's psychosis. If Dora had not left treatment (which Freud views as an act of revenge), her cure presumably would have involved her regaining (through desperation and self-hypnosis) a grateful respect for her patriarch-father; loving and perhaps serving him for years to come; or getting married and performing these functions for a husband or surrogate-patriarch.
Szasz comments on the »hysterical« symptoms of another of Freud's female patients, Anna O., who fell »ill« while nursing her father.

Anna O. thus started to play the hysterical game from a position of distasteful submission: she functioned as an oppressed, unpaid, sick-nurse, who was coerced to be helpful by the very helplessness of a (bodily) sick patient. The women in Anna O.'s position were - as are their counterparts today, who feel similarity entrapped by their small children - insufficiently aware of what they valued h life and of how their own ideas of what they valued affected their conduct. For example, young middle-class  women in Freud's day considered it their duty to take care of their sick fathers. They treasured the value that it was their role to take care of father when he was sick. Hiring a professional servant or nurse for this job would have created a conflict for them, because it would have symbolized to them as well as to others that they did not love (»care for«) their fathers. Notice how similar this is to the dilemma in which many contemporary women find themselves, not, however, in relation to their fathers, but rather in relation to their young children. Today, married women are generally expected to take care of their children; they are not supposed to delegate this task to others. The »old folks« can be placed in a home; it is all right to delegate their care to hired help. This is an exact reversal of the social situation which prevailed in upper middle-class European circles until the First World War and even after it. Then, children were often cared for by hired help, while parents were taken care of by their children, now fully grown.[44]

To Freud, it was to Anna's »great sorrow« that she was no longer »allowed to continue nursing the patient«.
We may wonder to what extent contemporary psychotherapists [45] still view women as Freud did, either because they believe his theories, or / and because they are men first and so-called objective professionals second: it may still be in their personal and class interest to (quite unmaliciously) remain »Freudian« in their treatment of women. Two studies relate to this question.
As part of Schofield's 1960 study, each of the psychotherapists were asked to indicate the characteristics of his »ideal« patient, »that is, the kind of patient with whom you feel you are efficient and effective in your therapy«. Schofield reports that »for those psychotherapists who did express a sex preference, a preference for females was predominant in all three professional groups«. The margin of preference for female patients was largest in the sample of psychiatrists, nearly two-thirds of this group claiming the female patients as »ideal«.[46] From 60 to 70 percent of each of the therapist groups place the ideal patient's age in the twenty to forty year range. Very rarely do representatives of any of the three disciplines express a preference for a patient with a graduate degree (M.A., M.D., Ph.D.).
Summarizing his findings, Schofield suggests that the efforts of most clinical practitioners are »restricted« to those clients who present the Yavis syndrome - youthful, attractive, verbal, intelligent, and successful. And, we may add, hopefully female.[47]
A recent study by Broverman et al. supports the hypothesis that most clinicians still view their female patients as Freud viewed his.[48] Seventy-nine clinicians (forty-six male and thirty-three female psychiatrists, psychologists, and social workers) completed a sex-role stereotype questionnaire. The questionnaire consists of 122 bipolar items, each of which describes a particular behavior or trait. For example:

very subjective    very objective
not at all aggressive    very aggressive

The clinicians were instructed to check off those traits that represent healthy male, healthy female, or healthy adult (sex unspecified) behavior. The results were as follows:

  1. There was high agreement among clinicians as to the attributes characterizing healthy adult men, healthy adult women, and healthy adults, sex unspecified.
  2. There were no differences among men and women clinicians.
  3. Clinicians have different standards of health for men and women. Their concepts of healthy mature men do not differ significantly from their concepts of healthy mature adults, but their concepts of healthy mature women do differ significantly from those for men or for adults. Clinicians are likely to suggest that women differ from healthy men by being: more submissive, less independent, less adventurous, more easily influenced, less aggressive, less competitive, more excitable in minor crises, more easily hurt, more emotional, more conceited about their appearance, less objective, and less interested in math and science.

Finally, what is judged healthy for adults, sex unspecified, and for adult males, is in general highly correlated with previous studies of social desirability as perceived by nonprofessional subjects.
It is clear that for a woman to be healthy she must »adjust« to and accept the behavioral norms for her sex even though these kinds of behavior are generally regarded as less socially desirable. As the authors themselves remark, »This constellation seems a most unusual way of describing any mature, healthy individual«.
Obviously, the ethic of mental health is masculine in our culture. Women are perceived as childlike or childish, as alien to most male therapists. It is therefore especially interesting that some clinicians, especially psychiatrists prefer female patients. Perhaps their preference makes good sense; a male therapist may receive a real psychological »service« from his female patient: namely, the experience of controlling and feeling superior to a female being upon whom he has projected many of his own forbidden longings for dependency, emotionality, and subjectivity and from whom, as a superior expert, as a doctor, he is protected as he cannot be from his mother, wife, or girl friend. And he earns money to boot!
Private psychoanalysis or psychotherapy is a commodity available to those women who can buy it, that is, to women whose fathers, husbands, or boy friends can help them pay for it.[49] Like the Calvinist elect, those women who can afford treatment are already »saved«. Even if they are never happy, never free, they will be slow to rebel against their psychological and economic dependence on men. One look at their less-privileged (poor, black, and/or unmarried) sisters' position is enough to keep them silent and more or less gratefully  in  line.  The  less-privileged women have no real or psychological silks to smooth down over, to disguise their unhappiness; they have no class to be »better than«. As they sit facing the walls, in factories, offices, whorehouses, ghetto apartments, and mental asylums, at least one thing they must conclude is that »happiness« is on sale in America - but not at a price they can afford. They are poor. They do not have to be bought off with illusions; they only have to be controlled.
Lower-class and unmarried middle-class women do have access to free or sliding-scale clinics, where, as a rule, they will meet once a week with minimally experienced psychotherapists. I am not suggesting that maximally experienced psychotherapists have acquired any expertise in salvation that will benefit the poor and/or unmarried woman. I am merely pointing out that the poor woman receives what is generally considered to be »lesser« treatment.
Given these facts - that psychotherapy is a commodity purchasable by the rich and inflicted on the poor; that as an institution, it socially controls the minds and bodies of middle-class women via the adjustment-to-marriage ideal and the minds and bodies of poor and single women via psychiatric incarceration; and that most clinicians, like most people in a patriarchal society, have deeply anti-female biases - it is difficult for me to make practical suggestions about »improving« therapeutic treatment. If marriage in a patriarchal society is analyzed as the major institution of female oppression, it is logically bizarre [50] to present husbands with helpful hints on how to make their wives »happier«. Nevertheless, wives, private patients, and the inmates of mental asylums already exist in large numbers. Therefore, I will make several helpful suggestions regarding women, »mental illness,« and psychotherapy.
Male psychologists, psychiatrists, and social workers must realize that as scientists they know nothing about women; their expertise, their diagnoses, even their sympathy is damaging and oppressive to women. Male clinicians should stop treating women altogether, however much this may hurt their wallets and/ or sense of benevolent authority. For most women the psychotherapeutic encounter is just one more power relationship in which they submit to a dominant authority figure. I wonder how well such a structure can encourage independence - or healthy dependence - in a woman. I wonder what a woman can learn from a male therapist (however well-intentioned) whose own values are sexist? How free from the dictates of a sexist society can a female as patient be with a male therapist? How much can a male therapist empathize with a female patient? In Human Sexual Inadequacy Masters and Johnson state that their research supported unequivocally the »premise that no man will ever fully understand a woman's sexual function or dysfunction . . . (and the same is true for women). ... it helps immeasurably for a distressed, relatively inarticulate or emotionally unstable wife to have available a female co-therapist to interpret what she is saying and even what she is attempting unsuccessfully to express to the uncomprehending husband and often to the male co-therapist as well«. I would go one step further here and ask: what if the female co-therapist is male-oriented, as much of a sexist as her male counterpart? What if the female therapist has never realized that she is oppressed as a woman? What if the female therapist views marriage and children as sufficient fulfillment for women - except herself?
All women - clinicians as well as their patients - must participate in and/ or think seriously and deeply about the woman's liberation movement. Women patients should see female clinicians who are feminists. Female clinicians, together with all women, should create a new or first psychology of women, and as a group, act on it. This might include politically educating and supporting females in mental asylums and in other ghettos of the mind. Perhaps all-female therapeutic communities can be tried as a necessary, interim alternative to female economic and psychological dependence on patriarchal structures such as marriage, psychotherapy, and mental asylums. In such a communal setting, it is not unlikely that friendship, understanding, or objectivity may be desired on a private basis, and that such an interchange might resemble or draw upon psychoanalytic or psychotherapeutic »knowledge« or practice. Who will be - or whether there will be -  »experts« of understanding is unknown; who will be - or whether anyone will be - considered »mentally ill« and treated by isolation and ostracism is unknown.