Clinical Practice, Counseling, and Feminist Therapy 257shapes stressful life experiences, patterns of distress and dys-
function, and coping efforts. They have also examined prac-
tices of diagnosis, assessment, and treatment (Worell &
Remer, 1992).
Biases in Diagnosis and Clinical Judgment
The history of mental health treatments is replete with exam-
ples of diagnostic classifications that reflected and repro-
duced cultural stereotypes about women, as well as ethnic
minority group members, immigrants, and poor people. From
the middle of the nineteenth century until well into the twen-
tieth, for example, women and girls whose sexual desire was
deemed excessive risked being diagnosed with nymphoma-
nia (Groneman, 1994). In some cases, clitoridectomy was the
treatment. Neurasthenia, a condition involving diffuse symp-
toms of low mood, nervousness, and fatigue, was diagnosed
in large numbers of American women. The treatment was a
prolonged period of enforced bed rest and social isolation,
during which reading, writing, and other forms of intellectual
stimulation were banned.
Our own times have spawned a jumble of diagnostic
categories. The Diagnostic and Statistical Manual of the
American Psychiatric Association (DSM)(American Psychi-
atric Association, 1994) lists the diagnoses that are officially
recognized. Feminists and other critics are concerned that the
scope of the DSMhas widened appreciably each time it has
been revised. The first edition, published in 1952, contained
198 entries. The fourth one, published in 1994, contains 340.
The power of mental health professionals to judge, catego-
rize, and label has come to encompass more and more
domains of human experience. In addition, unofficial diag-
nostic classifications proliferate freely in popular culture and
psychotherapy vernacular—Sex Addiction, Battered Woman
Syndrome, Codependency, Abortion Trauma Syndrome, In-
ternet Addiction, and ACOA (Adult Child of an Alcoholic), to
name a few. Although such diagnoses have no official status
and little or no systematic research to substantiate them, they,
too, exert considerable cultural influence.
Feminists have looked askance at the burgeoning list of
diagnoses and pseudodiagnoses. These categories impose a
particular way of understanding one’s own and others’ suffer-
ing. They make psychological disorders akin to physical dis-
orders, seeming to exist separately from the social context in
which they arise and to be unrelated to its politics and values.
Feminists have raised additional concerns about several
specific diagnostic categories. Along with other progres-
sive social groups, they mobilized in the early 1970s to ex-
punge homosexuality from the list of psychiatric diagnoses
in theDSM.(Ultimately, the membership of the American
Psychiatric Association voted to remove homosexuality from
theDSM.However, a category called “ego-dystonic homo-
sexuality” was substituted instead.) The 1980 edition reflected
this change. Many feminists have been concerned that the di-
agnostic criteria for Premenstrual Dysphoric Disorder do not
distinguish it from premenstrual distress, a condition experi-
enced in some degree by as many as 80% of women. Mary
Parlee’s (1994) elegant account of the struggle over this diag-
nostic category reveals how the economic interests of phar-
maceutical companies and the biomedical profession handily
overruled the scientific and social-scientific evidence.
Borderline Personality Disorder (BPD) is another diagnos-
tic category of special concern, if only because three times as
many women as men receive this diagnosis (Becker, 1997).
This diagnosis carries with it a variety of negative expec-
tations: Individuals with BPD are said to be difficult and trou-
blesome therapy clients, unlikely to make progress. Yet the
criteria for BPD are vague: for example, “inappropriate”
anger, “marked” reactivity of mood, “markedly unstable”
self-image. It is left to therapists to judge whether clients’
behavior reaches the threshold for diagnosis. Also, the symp-
toms overlap with the symptoms of other disorders. A diag-
nosis of BPD is often mistakenly given to women who have
experienced sexual or physical abuse and who should be di-
agnosed as suffering from post-traumatic stress disorder
(Herman, 1992). This diagnostic error prevents women from
receiving appropriate treatment.
Apart from formal diagnoses, therapists continually make
judgments in the course of treatment: They set goals for ther-
apy, they evaluate clients’ progress, and they specify what is
healthy functioning for individuals, couples, and families.
Feminists have investigated how gender meanings and ethnic
and class differences inflect these judgments. Judgments
about healthy sexual functioning, for example, rest on the
theory of the Human Sexual Response Cycle put forward by
Masters and Johnson in 1966. Indeed, the DSMdiagnostic
categories of sexual dysfunction, though purportedly atheo-
retical, rest on this implicit foundation. As Leonore Tiefer
(1995) has shown, this theory privileges forms of sexual be-
havior preferred by men and overlooks or trivializes many
sources of pleasure that women say are important. Also,
counselors and therapists who work with clients from impov-
erished backgrounds may unwittingly presume that such in-
dividuals have access to resources for coping and to avenues
of judicial redress that in fact are limited to affluent and white
members of society (Fine, 1983). Some feminists have chal-
lenged definitions of autonomy and its centrality as a cri-
terion of mental health. Autonomy may not be possible for
individuals in subordinated positions. Nor is it universally re-
garded as desirable; in many cultural groups, collective