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New Perspectives on the Psychotherapy of Women
WOMEN’S MENTAL HEALTH
0095–4543/02 $15.00 + .00
NEW PERSPECTIVES ON THE PSYCHOTHERAPY OF WOMEN Cost Effective and Clinical Interventions Kathryn J. Zerbe, MD
Psychotherapy is a cost-effective treatment modality with demonstrated effectiveness in a variety of medical and psychiatric conditions. This article reviews contemporary trends in the psychodynamic understanding of and practice of psychotherapy for women. Emphasis is placed on practical interventions that the primary care clinician can use in the practice. “The physician’s duty is first and foremost that of healing and not altogether that of solving scientific problems. No scientific physician is pleased when he finds he has lost some of his patients because they have been discontented and annoyed at this lack of interest and sympathy for their minor functional disturbances, and that an arrant imposter has them in charge, because, by his tact and knowledge of human nature, he has already relieved their imaginary or trifling ailments.” T. J. MCGILLICUDDY, MD FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN WOMEN, 1896
In the medical care of women in the 21st century, McGillicuddy’s counsel20 is as relevant to physicians and other health professionals as when it was written over 100 years ago. Clinicians must pay as much attention to the mental health needs of their patients as they do for other medical and surgical difficulties. This does not mean that one must become a psychiatrist to effectively diagnose and intervene with the majority of functional abnormalities. It does mean that those clinicians who From the Behavioral Medicine Center for Womens’ Health; and Departments of Psychiatry and Obstetrics and Gynecology, Oregon Health and Science University; and Oregon Psychoanalytic Institute, Portland, Oregon; and The Menninger Clinic, Topeka, Kansas
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have a general working knowledge of the principles of psychotherapy— or a natural facility for attuning to the often unspoken, always important emotional concerns of patients—will have a more satisfied and healthier clientele. Psychotherapy Is Cost-Effective An emerging body of research reveals the significant cost-benefit ratio of psychotherapy.3, 12, 13 In the coming decades, this research will likely become even more robust. Already primary care clinicians are employing lessons from these studies in their daily practice. For example, because survival time for breast cancer patients increases significantly if they attend a support group, state-of-the-art care would include recommending this kind of program to every patient diagnosed with breast cancer.24–28 Similarly, two studies which followed patients with malignant melanoma found that group therapy increased survival and quality of life.9, 10 Improved diabetes control,6 enhanced stress reduction and anger management after diagnosis of cardiovascular disease,15, 16 and better coping and mastery of chronic pain syndromes7, 11 are among the first groups of medical disorders where a correlation between recovery and meaningful psychological care have been demonstrated in control studies. Primary care clinicians who are knowledgeable about the growing scientific base of psychotherapy will be in the best position to counsel their patients of its role and value in their overall treatment. Actual data have been gathered that suggest psychotherapy changes brain functioning and has long-term effects on quality of life measures. Moreover, even as insight about the genetic and environmental factors implicated in the causes of psychiatric and substance abuse disorders mounts, it also has been found that family environment contributes significantly to mental health. Primary care clinicians will not be surprised to learn that the practical aphorism, “Make sure you always know what is happening at home,” is validated by research attempting to clarify the distinct patterns of genetic and environmental factors that influence important dimensions of mental health in women. In a population study of 794 female-female twin pairs, Kendler et al18 used a multivariate structural equation modeling to examine six dimensions of mental health: perceived physical health, non-conflictual interpersonal relationships, anxious-depressive symptoms, substance use, social support, and self-esteem. They found that healthy psychological functioning derives from “complex and distinct” ways in which genetic and environmental factors interact. Far from being a simple equation that a “single set of mental health genes are responsible for the genetic contribution of the dimensions of mental health,” they found interpersonal relationships and social supports are key factors also in the emotional well-being of women. From an intuitive perspective, there are no surprises here. But these data have pragmatic value in aiding office interventions. While the
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clinician must clarify with the patient the biological and genetic factors implicated in any disorder, they must not give short shrift to the environmental and family factors that may factor into the presenting symptoms and which may be amenable to specific intervention. Those treatment interventions (in women’s mental health) many include individual, group, or family psychotherapy; stress management strategies, biofeedback therapy, or massage therapy; enhancement of social supports such as friendships, support groups, or finding a creative outlet. Given the growing scientific base that counseling and psychotherapy have measurable benefits in real-world medicine, it is especially unfortunate that current training programs in primary care and psychiatry offer less formal supervision and didactic teaching on psychotherapeutic principles than even a decade ago. Most clinicians instinctively know that patient compliance with medication and adherence to other medical advice is heightened when the doctor-patient relationship is nurtured. There is additional evidence that physicians who are better communicators and empathetically share even bad news or admit making a mistake have fewer malpractice claims.34 Recently diabetic self-management regimens were assessed using the conceptual model of attachment theory. This model derived from the pioneering work of psychiatrist John Bowlby and other researchers who expanded upon and solidified his basic conclusions that attachments were crucial for mental wellness. Attachment theory demonstrates how maintaining a secure base in one’s life is crucial for infants, children, and even adults.2 It looks at styles of communication and interaction based on early experience with parents and caregivers. These early experiences also have been found to have a profound impact on how one relates to others throughout life. In those diabetic patients with a dismissing attachment style, the glycosylated hemoglobin level was significantly higher and adherence to medication lower than those with fearful, preoccupied, or secure attachment.6 Ciechanowski and his co-investigators concluded that a dismissing attachment style on the part of the patient, and a provider who was unable to communicate well or connect, led to worse adherence of glucose monitoring and a significantly greater number of interruptions in treatment with oral hypoglycemics. In the future, this kind of research may throw new light on the factors important to the patient-clinician match. We may then be more able to rationally assign patients to a health care provider with a complementary attachment style, or at least teach clinicians how they might conduct treatment so as to enhance compliance based on the patient’s style and their own.12 First, however, the clinician must begin to see the psychotherapeutic qualities of their treatment relationships as essential and important, and take the time to cultivate them. Like mastering any technical or diagnostic procedure, the basics of psychotherapy as applied to primary care can be taught, but they must be practiced. When attention is not given to this art, the patient invariably moves on to another health care provider, fails to take the prescribed medicine or follow the plan of action,
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or like McGillicuddy’s bewildered patient, seeks solace with an “arrant imposter” who knows more about “human nature” and takes advantage of the patient by offering “interest and sympathy” that were not forthcoming elsewhere. Psychotherapy Recognizes a Woman’s Need for Attachment and Connection In the past quarter century, major transformations in social theory, psychology, and psychoanalysis have shaped how women and men are understood and treated psychotherapeutically. Care, concern, connection, and responsibility for others are attributes of women that shape their sense of morality and ethics and form the basis for what they hold most dear. While boys must individuate from their mothers and eschew feelings of dependency early on in order to become men, girls grow up with a greater sense of continuity and feelings of similarity to the mother. These broad generalities, derived from developmental studies and psychodynamic research, converge to indicate that women are more at ease with relational connections than men and will sacrifice their autonomy and needs to preserve attachments.5, 14, 18, 30 The pivotal importance of attachment and connection in a woman’s life have significant implications for aiding women in a primary clinician’s practice. On the one hand, a woman’s capacity for concern for others and her sensitivity for what others expect of her is a gender-specific characteristic, likely rooted in biology and socialization, with many positive consequences. A problem arises, however, when the woman disavows her own needs and makes so many sacrifices that her own aspirations go unattended. The stereotype of the selfless woman or mother may seem anachronistic in an age that has embraced many feminist ideals, but many women still appear for treatment with difficulties sorting out their own needs and finding fulfilling relationships that encourage development of self.23, 31 Dr. Jean Baker Miller and the self-in-relation theorists have developed a series of theoretical guidelines that aid clinicians in assessing and treating women.17 Their perspectives are buttressed by concomitant shifts in psychodynamic psychotherapy and psychoanalysis that emphasize how women can find greater mutuality in their relationships, can overcome work and success inhibitions, and can deal more constructively with anger and other dysphoric affects. The central thesis is that men and women have a need for relationships for their well-being, but women, in particular, get to know “their deepest sense of our inner reality”5, 18, 31 from interpersonal relationships. When the primary care clinician keeps these precepts in mind, some basic psychotherapeutic skills are immediately and beneficially employed in practice. For example, the clinician may be more likely to encourage a patient with anxiety or depression to attend a support group or to seek
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individual psychotherapy with a practitioner knowledgeable about gender biases and who encourages the individual’s growth. Such a clinician will not expect mere medication to alleviate the patient’s suffering. Instead, one might wonder with the patient how much the difficulties are derived from biological vulnerabilities alone or are (more likely) an interweaving of social, individual, and environmental factors. For example, has the patient been encouraged by anyone in her immediate family to take action on her own behalf? If she takes assertive actions or voices dissatisfaction, does she worry that others will only see her as an angry, irritable, destructive person? Has she been socialized to turn her anger inward, leading to anxiety when expressed or depression when suppressed, and can she be helped to identify her true feelings and learn to express them in ways that are comfortable to her and for her loved ones?5, 22, 23 The conceptual take-home point for primary care clinicians is that traditional assumptions about psychotherapy and psychoanalysis are being altered by taking into account women’s growth in and through connections to others. While independence and separation from one’s parents is still recognized as a developmental achievement of adolescence and early adulthood, now greater emphasis is placed on developing and maintaining healthy attachments over the entire life cycle. Additionally, the model of therapeutic anonymity and neutrality is being challenged; while still maintaining professional boundaries, therapists are modeling more empathic connections by providing an affirming environment and warmth in psychotherapeutic sessions. Patients are encouraged to use existing resources (see Section on Patient Guidelines) and learn to count on the supportive presence of others to help them cope physically and emotionally with experiences and challenges tasks encountered in the world. Psychotherapy Emphasizes Growth and Change over the Adult Life Cycle Obvious as it seems, sometimes we clinicians forget that just as the body undergoes physiological change over the course of life, so do the emotional requirements of individuals change as they inch forward from the 20s to the 40s, 50s, 60s, and beyond. The aspirations, desires, and tasks for a woman in her 20s or 30s who wants to start a family and blend it with career are profoundly different than those of a women in her 50s who may be facing the empty-nest syndrome and transitions and displacement in the workplace. Physicians who are sensitive to these facts will avoid making assumptions about what particular psychosocial stressors there might be in an individual’s life and instead ask the patient for her perspective. One fact about the adult life cycle is certain: No one passes through any transition and moves from one stage to the next without experiencing a sense of loss and a certain degree of mourning. Here is where many individuals get stuck and personal development is arrested. Sometimes
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the loss they must work through is obvious: death of a spouse or parent; miscarriage or death of a child; failure or displacement in the workplace. More commonly the losses are subtle but no less significant in terms of psychological growth. For example, just as a woman’s physiological requirements for food and exercise change as she ages, and medical follow up for certain diseases becomes more necessary, so must the image she has of her body also evolve. In our culture, midlife is a difficult time for many women specifically because they experience a sense of loss of control over their bodies. Despite a myriad of over-the-counter preparations and a woman’s steadfast investment in staying youthful, slim, and trim, skin loses elasticity, hips and waistline expands, and weight is more difficult to keep off for the majority of females. The rise in plastic surgery and liposuction treatment for women at midlife and beyond is an indication of the psychological wounds some women feel about the aging process of their bodies. Eating disorders, long felt to be disorders of adolescents and young adults, are seen with increasing frequency in women in their 40s, 50s, and 60s.34, 35 Across the lifestyle, women with anorexia or bulimia nervosa are preoccupied with how they look and by definition, their self worth inordinately derives from a quest to have a beautiful body. For women in young adulthood and middle age, the underlying psychological issues are quite different. While it always is hazardous to generalize, young women with eating disorders tend to be preoccupied with family conflicts, their struggle to establish and maintain peer relationships, and their need to solidify personal identity and sense of self in school or at work, apart from their immediate families. On the other hand, women in midlife feel that they are not valued in an increasingly youth-oriented culture. Food becomes a comfort tool if one cannot find solace in other ways (i.e., mature interpersonal relationships).22, 34 Finally, women must face the losses common to midlife—children leaving home, the death of a parent, possibly divorce—which also means they face their own mortality. Indeed, the acceptance of time limitation and personal death at midlife can, and often is, avoided by the misuse of substances, developing an eating disorder, or by workaholism. If this phase is successfully negotiated, the individual finds a new kind of generativity in life—that is, a sense of value in helping the next generation achieve their goals. Finding new creative outlets or deciding to fulfill long suppressed ambitions are more adaptive ways of traversing this bittersweet time. For the primary care provider, the main points are clear: 1. Never assume you know what an individual’s psychosocial stressors are. Ask. Let the patient inform you. 2. Remember that needs and developmental tasks shift over the adult lifecycle. This point has been under-emphasized in psychiatry until relatively recently. 3. Keep watch for issues of loss and grief. When they are not addressed, personal growth is stymied.
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4. Sometimes a loss may be overt and you will either know about it or the patient will tell you about it. Other times you will need to ask. You may be surprised by what you hear. What is taking a toll on your patient’s psyche and experience of joy and happiness in the world may be something you never expected. 5. Encourage the patient to find a way to process her loss, such as joining a support group, journaling, or beginning a psychotherapy process of her own. Psychotherapy Emphasizes Having New Tools: Importance of Providing Patient Guidelines Another concrete step to take to establish your alliance and aid the patient’s well-being without actually doing psychotherapy is to give the patient some printed sheets or booklets with instructions about how to address the problem. Whether the disorder be depression, anxiety, an eating disorder, mid-life transition, and so forth, there are some easily acquired guidelines that list tasks, opportunities, and coping strategies that might be helpful. While patients can acquire these on their own, it is a kind, personal gesture to hand them to the patient yourself or to have them readily accessible in your office or waiting area. In the author’s book, Women’s Mental Health in Primary Care,35 there are sets of guidelines for each major psychiatric disorder that can be printed out for patients. You might also consider listing some of the points made by Dr. Dickstein in her article on a printed sheet to encourage general mental wellness in all patients. Psychotherapy Is a Safe Haven for the Patient with a Physical or Emotional Disorder A simple way to understand one of the basic tenets of psychotherapy is that it provides a safe haven or safe place where the individual can be understood and permitted to speak their personal truth. From the perspective of more than 30 years’ experience in working psychotherapeutically with patients who were medically ill, psychiatrist Richard Druss found that “patients need [and benefit from] one place they can go and speak their minds about the disease, its care, and what it means to them.”8 Similarly, women with any one of a variety of medical concerns may benefit from having the opportunity to talk with a professional. But this is almost impossible for you to do within the confines of a busy primary care practice. Therefore, some clinicians have begun to employ a social worker or psychologist in a group practice setting who can provide this service.19 There are numerous benefits to this novel, contemporary idea. First, it de-stigmatizes mental illness; you simply tell the patient that there is someone down the hall you want them to meet and speak with. Most patients will comply with this suggestion, whereas they may
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not accept it if you simply suggested they find a therapist on their own. Secondly, having mental health services readily accessible will save you time. Some practitioners have handled billing as simply another medical service. Nurse practitioners and clinical nurse specialists with psychiatric expertise are quite skilled in the range of psychotherapies, psychotropic medication management, and the psychological factors of medical illness. No doubt every primary care clinician has a share of patients who make frequent visits or phone calls but for whom no bona fide physical illness can be found. These patients will less likely burden you if they have somewhere they can go and ventilate their concerns. One cost-effective strategy might be to have the patient meet weekly or biweekly for 20–30 minutes with the nurse; you follow up at the end with a brief greeting in order to help the patient feel connected and less alone.7, 11 Health care costs decline when mental health needs are addressed, even in patients with psychosomatic (e.g., somatoform) disorders.16, 22, 32, 33 PSYCHOTHERAPEUTIC CONCERNS SPECIFIC TO WOMEN Because women are usually the primary caretakers in the family, they feel the keen responsibility of meeting the needs of others and making sure loved ones have the personal requirements of medical care, school, and shelter met. While this characteristic likely derives from the survival advantage and genuine gratification derived from intimate attachments with others, particularly the family, it also leads to one of the greatest quagmires for the physician: Because the woman is so busy taking care of others, she neglects to take care of herself.22, 24, 25, 35 Therefore, even your best, most sensitively rendered advice may be forgotten, not because the woman is reluctant, but because she puts her own needs last. What can you do to correct this misjudgment? First, recognize that it is one of the greatest stumbling blocks to good patient care and address it with compassion. You might say something like, “Many women in my practice don’t take care of themselves because they are so busy taking care of others, and have so many things that need to be done at work at home. Could that be happening to you? Remember, you must take care of your own needs, too. If you get totally run down, you won’t be able to do for others in the way you want.” In essence, you are giving the patient permission to address her needs, too. You might also remind her that “medical research has demonstrated some women with illnesses like cancer often don’t go for treatment because they are so busy.” This lets the woman know that her plight is not uncommon and gets her thinking about what she might do to plan some personal time. After you have empathetically addressed the woman’s need for selfcare, point her in a direction that might be useful to her. Childcare concerns often get in the way of going for medical treatment and
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psychotherapy, but there may be some creative ways or community resources to provide support. Recommend respite care for women who are exhausted by shift work, or by holding down more than one job, which is a common predicament for women in the 21st century who have family and work responsibilities. Irritability and depression in women are sometimes miraculously corrected by making sure needs for sleep are addressed. Women have the gender-specific need for about one to one and a half hours more sleep per night than men, yet commonly get about one to one and a half hours less sleep than a man. Sleep deprivation is a major problem in our driven, avaricious culture for both genders. It should be particularly assessed in women because of their greater sleep requirements and the higher frequency with which they present with problems that may be sleep-deprivation related, such as anxiety, dysphoria, irritability and anger.23, 34 Once again, keep in mind that many “problems are psychiatric syndromes masquerading as general medical symptoms,”1 and encourage the woman to take advantage of your recommendation to visit with a psychiatrist or other trusted mental health professional. In this way, you are also facing down the stigma of mental illness and avoiding the tendency to stereotype or stigmatize mental health care in our society. Psychotherapy Is Balm for the Healer, Too The demands of a primary care practice are enormous. Physicians are expected to do more and more with less and less—in time, compensation, and the approbation of being a physician. Our once esteemed, noble profession is under derision in many quarters: by governmental investigations and restrictions, by increasing litigation, by the insurance industry and managed care, and by the patients themselves who express less gratitude and seem to have more complaints. We often are left feeling our efforts are futile, and we may get angry because we work hard but are not routinely appreciated. Professional burnout is at an all-time high as more doctors are choosing to leave their practices and move on to another line of work or retire early.1, 4, 17, 24 Remember that the majority of recommendations in this article apply not just to the patient, but also to the physician. Make sure you pay attention to your own needs, too, and when you experience one of the inevitable vicissitudes of life (e.g., loss, family conflict, demoralization, career or personal transition), have the courage to face the issue directly, perhaps by taking advantage of your own psychotherapy process.4, 11, 16, 22, 27 As one physician put it as he concluded his personal psychoanalysis and made a decision to change his specialty (and eventually the location of his practice), “You always learn the most when you are a patient yourself. But those lessons have to be learned over and over again in life. It helps to talk them out with someone who can be objective and tries to understand the meaning of it all for me. This space [the psychotherapy process] gives me perspective and hope to carry on, to go after what I really want in my life.”
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SUMMARY Psychotherapy is a cost-effective treatment modality that promotes health and well-being in a variety of medical and psychiatric conditions. There are gender-specific variables to consider when recommending psychotherapy to women in your practice. In the future, there will likely be more specialists in behavioral medicine (i.e., mental health professionals) who work in tandem with primary care physicians in an integrated health care setting. Anticipating and addressing the emotional needs of patients can be a rewarding and time-efficient strategy in primary care medicine. Referral to a skillful psychotherapist may be warranted not only for treatment of one of the major psychiatric disorders (e.g., depression; eating disorder; anxiety disorder; post-traumatic stress disorder), but as the patient makes a major life transition which, while bringing about opportunities for personal growth, also involves loss and mourning. Clinicians who are comfortable with making referrals to psychotherapists when the condition is warranted, must, in an age of managed care and restriction of benefits for psychotherapy, be prepared to join with the mental health professional to wage the good fight and secure the needed, cost-effective, and appropriate treatment. References 1. Andreasen A: Body and soul (editorial). Am J Psychiatry 153:89–90, 1996 2. Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. Am J Psychiatry 156:1563–1569, 1999 3. Borenstein DB: Response to the Presidential Address: APA enters the 21st Century. Am J Psychiatry 157:769–1770, 2000 4. Bulger R: The quest for the therapeutic organization. JAMA 283:2431–2433, 2000 5. Chodorow N: The Reproduction of Mothering. Berkeley, University of Berkeley, California Press, 1978 6. Ciechanowski PS, Katon WJ, Russo JE, et al: The patient-provider relationship: Attachment theory and adherence to treatment is diabetes. Am J Psychiatry 158:29–35, 2001 7. Coen SJ, Sarno JE: Psychosomatic avoidance of conflict in back pain. Am Acad Psychoanal 17:359–376, 1989 8. Druss RG: The Psychology of Illness in Sickness and in Health. Washington, DC, American Psychiatric Press, 1995 9. Fawzy FI, Fawzy NW, Hyun CS, et al: Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective states on recurrence and survival six years later. Arch Gen Psychiatry 50:681–689, 1993 10. Fawzy FI, Kemeny ME, Fawzy NW, et al: A structured psychiatric intervention for cancer patients: II. Changes over time in immunological measures. Arch Gen Psychiatry 47:729–735, 1990 11. Francis ME, Pennebaker JF: Putting stress into words: The impact on writing on physiological, absentee, and self-reported emotional well-being measures. Am J Health Promotion 6:280–287, 1992 12. Gabbard GO: Editorial: Empirical evidence and psychotherapy: A growing scientific base. Am J Psychiatry 158:1–2, 2000 13. Gabbard GO, Lazar SG, Hornberger J, et al: The economic impact of psychotherapy: A review. Am J Psychiatry 154:147–155, 1997 14. Gilligan C: In a different voice. Cambridge, MA, Harvard Univ Press, 1982
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15. Glassman AH, Shapiro PA: Depression and the course of coronary artery disease. Am J Psychiatry 155:4–11, 1998 16. Gullette ECD, Blumenthal JA, Babyak M, et al: Effects of mental stress on myocardial ischemia during daily life. JAMA 277:1521–1526, 1997 17. Holloway KL, Zerbe KJ: Simplified approach to somatization disorder: When less may prove to be more. Postgraduate Medicine 108:9–95, 2000 18. Jordan JV, Kaplan AG, Miller JB, et al: Women’s growth in connection: Writing from the Stone Center. Guilford, NY, 1991 19. Kendler KS, Myers JM, Neale MC: A multidimensional twin study of mental health in women. Am J Psychiatry 157:506–513, 2000 20. Lucas SF, Peek CJ: A primary care physician’s experience with integrated behavioral health care: What difference has it made. In Cummings NA, Cummings JL, Johnson JN (eds): Behavioral Health in Primary Care: A guide for Clinical Integration. Madison, CT, Psychosocial Press, 1997 21. McGillicuddy TJ: Functional disorders of the nervous system in women. New York, Willliam Wood and Co., 1896 22. Mitchell SA: Relationality: From attachment to intersubjectivity. Hillsdale, NJ, The Analytic Press, 2000 23. Moulton R: Professional success: A conflict for women. In Alpert J (ed): Psychoanalysis and Women: Contemporary Reappraisals. Hillsdale, NJ, Analytic Press, 1986, pp 161– 182 24. Nadelson C: Gender and health policy. Harvard Rev Psychiatry 5:6,340–343, 1998 25. Spiegel D: Can psychotherapy prolong cancer survival? Psychosomatics 31:361–366, 1990 26. Spiegel D: Effects of group support for metastatic breast cancer patients on coping, mood, pain and survival. In Ten-Have-de Labije J, Balner H (eds): Coping with Cancer and Beyond: Cancer Treatment and Mental Health. Amsterdam, Netherlands, Swets & Zeitlinger, 1991, pp 11–29 27. Speigel D: Living Beyond Limits. New York, Random House, 1993 28. Spiegel D: Healing words: Emotional expression and disease outcome. JAMA, 281:1328–1329, 1999 29. Spiegel D, Kato PM: Psychosocial influences on cancer incidence and progression. Harv Rev Psychiatry 4:10–26, 1996 30. Spieler S, The gendered self: A lost maternal legacy. In Alpert J (ed): Psychoanalysis and Women: Contemporary Reappraisals, Hillsdale, NJ, Analytic Press, 1986, pp 35–56 31. Stiver I: The meanings of “dependency” in female-male relationships. Stone Center for Developmental Studies, Wellesley College, Wellesley, MA, 1984 32. Stotland NL: Managing patients who “want” to have a disease. Journal Watch: Women’s Health 2:55–56, 1997 33. Whyte C: The need for dynamic psychotherapy. Psychiatric Bulletin 20:541–542, 1996 34. Zerbe KJ: The Body-Betrayed: Women, Eating Disorder and Treatment. Washington, American Psychiatric Press, 1993 (Soft cover edition: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Furze Books, Carlsbad, CA, 1995) 35. Zerbe KJ: Women’s mental health in Primary Care. Philadelphia, PA, W.B. Saunders, 1999 Address reprint requests to: Kathryn J. Zerbe, MD 1516 NW Benfield Drive Portland, OR 97229
0095–4543/02 $15.00 + .00
NEW PERSPECTIVES ON THE PSYCHOTHERAPY OF WOMEN Cost Effective and Clinical Interventions Kathryn J. Zerbe, MD
Psychotherapy is a cost-effective treatment modality with demonstrated effectiveness in a variety of medical and psychiatric conditions. This article reviews contemporary trends in the psychodynamic understanding of and practice of psychotherapy for women. Emphasis is placed on practical interventions that the primary care clinician can use in the practice. “The physician’s duty is first and foremost that of healing and not altogether that of solving scientific problems. No scientific physician is pleased when he finds he has lost some of his patients because they have been discontented and annoyed at this lack of interest and sympathy for their minor functional disturbances, and that an arrant imposter has them in charge, because, by his tact and knowledge of human nature, he has already relieved their imaginary or trifling ailments.” T. J. MCGILLICUDDY, MD FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN WOMEN, 1896
In the medical care of women in the 21st century, McGillicuddy’s counsel20 is as relevant to physicians and other health professionals as when it was written over 100 years ago. Clinicians must pay as much attention to the mental health needs of their patients as they do for other medical and surgical difficulties. This does not mean that one must become a psychiatrist to effectively diagnose and intervene with the majority of functional abnormalities. It does mean that those clinicians who From the Behavioral Medicine Center for Womens’ Health; and Departments of Psychiatry and Obstetrics and Gynecology, Oregon Health and Science University; and Oregon Psychoanalytic Institute, Portland, Oregon; and The Menninger Clinic, Topeka, Kansas
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have a general working knowledge of the principles of psychotherapy— or a natural facility for attuning to the often unspoken, always important emotional concerns of patients—will have a more satisfied and healthier clientele. Psychotherapy Is Cost-Effective An emerging body of research reveals the significant cost-benefit ratio of psychotherapy.3, 12, 13 In the coming decades, this research will likely become even more robust. Already primary care clinicians are employing lessons from these studies in their daily practice. For example, because survival time for breast cancer patients increases significantly if they attend a support group, state-of-the-art care would include recommending this kind of program to every patient diagnosed with breast cancer.24–28 Similarly, two studies which followed patients with malignant melanoma found that group therapy increased survival and quality of life.9, 10 Improved diabetes control,6 enhanced stress reduction and anger management after diagnosis of cardiovascular disease,15, 16 and better coping and mastery of chronic pain syndromes7, 11 are among the first groups of medical disorders where a correlation between recovery and meaningful psychological care have been demonstrated in control studies. Primary care clinicians who are knowledgeable about the growing scientific base of psychotherapy will be in the best position to counsel their patients of its role and value in their overall treatment. Actual data have been gathered that suggest psychotherapy changes brain functioning and has long-term effects on quality of life measures. Moreover, even as insight about the genetic and environmental factors implicated in the causes of psychiatric and substance abuse disorders mounts, it also has been found that family environment contributes significantly to mental health. Primary care clinicians will not be surprised to learn that the practical aphorism, “Make sure you always know what is happening at home,” is validated by research attempting to clarify the distinct patterns of genetic and environmental factors that influence important dimensions of mental health in women. In a population study of 794 female-female twin pairs, Kendler et al18 used a multivariate structural equation modeling to examine six dimensions of mental health: perceived physical health, non-conflictual interpersonal relationships, anxious-depressive symptoms, substance use, social support, and self-esteem. They found that healthy psychological functioning derives from “complex and distinct” ways in which genetic and environmental factors interact. Far from being a simple equation that a “single set of mental health genes are responsible for the genetic contribution of the dimensions of mental health,” they found interpersonal relationships and social supports are key factors also in the emotional well-being of women. From an intuitive perspective, there are no surprises here. But these data have pragmatic value in aiding office interventions. While the
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clinician must clarify with the patient the biological and genetic factors implicated in any disorder, they must not give short shrift to the environmental and family factors that may factor into the presenting symptoms and which may be amenable to specific intervention. Those treatment interventions (in women’s mental health) many include individual, group, or family psychotherapy; stress management strategies, biofeedback therapy, or massage therapy; enhancement of social supports such as friendships, support groups, or finding a creative outlet. Given the growing scientific base that counseling and psychotherapy have measurable benefits in real-world medicine, it is especially unfortunate that current training programs in primary care and psychiatry offer less formal supervision and didactic teaching on psychotherapeutic principles than even a decade ago. Most clinicians instinctively know that patient compliance with medication and adherence to other medical advice is heightened when the doctor-patient relationship is nurtured. There is additional evidence that physicians who are better communicators and empathetically share even bad news or admit making a mistake have fewer malpractice claims.34 Recently diabetic self-management regimens were assessed using the conceptual model of attachment theory. This model derived from the pioneering work of psychiatrist John Bowlby and other researchers who expanded upon and solidified his basic conclusions that attachments were crucial for mental wellness. Attachment theory demonstrates how maintaining a secure base in one’s life is crucial for infants, children, and even adults.2 It looks at styles of communication and interaction based on early experience with parents and caregivers. These early experiences also have been found to have a profound impact on how one relates to others throughout life. In those diabetic patients with a dismissing attachment style, the glycosylated hemoglobin level was significantly higher and adherence to medication lower than those with fearful, preoccupied, or secure attachment.6 Ciechanowski and his co-investigators concluded that a dismissing attachment style on the part of the patient, and a provider who was unable to communicate well or connect, led to worse adherence of glucose monitoring and a significantly greater number of interruptions in treatment with oral hypoglycemics. In the future, this kind of research may throw new light on the factors important to the patient-clinician match. We may then be more able to rationally assign patients to a health care provider with a complementary attachment style, or at least teach clinicians how they might conduct treatment so as to enhance compliance based on the patient’s style and their own.12 First, however, the clinician must begin to see the psychotherapeutic qualities of their treatment relationships as essential and important, and take the time to cultivate them. Like mastering any technical or diagnostic procedure, the basics of psychotherapy as applied to primary care can be taught, but they must be practiced. When attention is not given to this art, the patient invariably moves on to another health care provider, fails to take the prescribed medicine or follow the plan of action,
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or like McGillicuddy’s bewildered patient, seeks solace with an “arrant imposter” who knows more about “human nature” and takes advantage of the patient by offering “interest and sympathy” that were not forthcoming elsewhere. Psychotherapy Recognizes a Woman’s Need for Attachment and Connection In the past quarter century, major transformations in social theory, psychology, and psychoanalysis have shaped how women and men are understood and treated psychotherapeutically. Care, concern, connection, and responsibility for others are attributes of women that shape their sense of morality and ethics and form the basis for what they hold most dear. While boys must individuate from their mothers and eschew feelings of dependency early on in order to become men, girls grow up with a greater sense of continuity and feelings of similarity to the mother. These broad generalities, derived from developmental studies and psychodynamic research, converge to indicate that women are more at ease with relational connections than men and will sacrifice their autonomy and needs to preserve attachments.5, 14, 18, 30 The pivotal importance of attachment and connection in a woman’s life have significant implications for aiding women in a primary clinician’s practice. On the one hand, a woman’s capacity for concern for others and her sensitivity for what others expect of her is a gender-specific characteristic, likely rooted in biology and socialization, with many positive consequences. A problem arises, however, when the woman disavows her own needs and makes so many sacrifices that her own aspirations go unattended. The stereotype of the selfless woman or mother may seem anachronistic in an age that has embraced many feminist ideals, but many women still appear for treatment with difficulties sorting out their own needs and finding fulfilling relationships that encourage development of self.23, 31 Dr. Jean Baker Miller and the self-in-relation theorists have developed a series of theoretical guidelines that aid clinicians in assessing and treating women.17 Their perspectives are buttressed by concomitant shifts in psychodynamic psychotherapy and psychoanalysis that emphasize how women can find greater mutuality in their relationships, can overcome work and success inhibitions, and can deal more constructively with anger and other dysphoric affects. The central thesis is that men and women have a need for relationships for their well-being, but women, in particular, get to know “their deepest sense of our inner reality”5, 18, 31 from interpersonal relationships. When the primary care clinician keeps these precepts in mind, some basic psychotherapeutic skills are immediately and beneficially employed in practice. For example, the clinician may be more likely to encourage a patient with anxiety or depression to attend a support group or to seek
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individual psychotherapy with a practitioner knowledgeable about gender biases and who encourages the individual’s growth. Such a clinician will not expect mere medication to alleviate the patient’s suffering. Instead, one might wonder with the patient how much the difficulties are derived from biological vulnerabilities alone or are (more likely) an interweaving of social, individual, and environmental factors. For example, has the patient been encouraged by anyone in her immediate family to take action on her own behalf? If she takes assertive actions or voices dissatisfaction, does she worry that others will only see her as an angry, irritable, destructive person? Has she been socialized to turn her anger inward, leading to anxiety when expressed or depression when suppressed, and can she be helped to identify her true feelings and learn to express them in ways that are comfortable to her and for her loved ones?5, 22, 23 The conceptual take-home point for primary care clinicians is that traditional assumptions about psychotherapy and psychoanalysis are being altered by taking into account women’s growth in and through connections to others. While independence and separation from one’s parents is still recognized as a developmental achievement of adolescence and early adulthood, now greater emphasis is placed on developing and maintaining healthy attachments over the entire life cycle. Additionally, the model of therapeutic anonymity and neutrality is being challenged; while still maintaining professional boundaries, therapists are modeling more empathic connections by providing an affirming environment and warmth in psychotherapeutic sessions. Patients are encouraged to use existing resources (see Section on Patient Guidelines) and learn to count on the supportive presence of others to help them cope physically and emotionally with experiences and challenges tasks encountered in the world. Psychotherapy Emphasizes Growth and Change over the Adult Life Cycle Obvious as it seems, sometimes we clinicians forget that just as the body undergoes physiological change over the course of life, so do the emotional requirements of individuals change as they inch forward from the 20s to the 40s, 50s, 60s, and beyond. The aspirations, desires, and tasks for a woman in her 20s or 30s who wants to start a family and blend it with career are profoundly different than those of a women in her 50s who may be facing the empty-nest syndrome and transitions and displacement in the workplace. Physicians who are sensitive to these facts will avoid making assumptions about what particular psychosocial stressors there might be in an individual’s life and instead ask the patient for her perspective. One fact about the adult life cycle is certain: No one passes through any transition and moves from one stage to the next without experiencing a sense of loss and a certain degree of mourning. Here is where many individuals get stuck and personal development is arrested. Sometimes
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the loss they must work through is obvious: death of a spouse or parent; miscarriage or death of a child; failure or displacement in the workplace. More commonly the losses are subtle but no less significant in terms of psychological growth. For example, just as a woman’s physiological requirements for food and exercise change as she ages, and medical follow up for certain diseases becomes more necessary, so must the image she has of her body also evolve. In our culture, midlife is a difficult time for many women specifically because they experience a sense of loss of control over their bodies. Despite a myriad of over-the-counter preparations and a woman’s steadfast investment in staying youthful, slim, and trim, skin loses elasticity, hips and waistline expands, and weight is more difficult to keep off for the majority of females. The rise in plastic surgery and liposuction treatment for women at midlife and beyond is an indication of the psychological wounds some women feel about the aging process of their bodies. Eating disorders, long felt to be disorders of adolescents and young adults, are seen with increasing frequency in women in their 40s, 50s, and 60s.34, 35 Across the lifestyle, women with anorexia or bulimia nervosa are preoccupied with how they look and by definition, their self worth inordinately derives from a quest to have a beautiful body. For women in young adulthood and middle age, the underlying psychological issues are quite different. While it always is hazardous to generalize, young women with eating disorders tend to be preoccupied with family conflicts, their struggle to establish and maintain peer relationships, and their need to solidify personal identity and sense of self in school or at work, apart from their immediate families. On the other hand, women in midlife feel that they are not valued in an increasingly youth-oriented culture. Food becomes a comfort tool if one cannot find solace in other ways (i.e., mature interpersonal relationships).22, 34 Finally, women must face the losses common to midlife—children leaving home, the death of a parent, possibly divorce—which also means they face their own mortality. Indeed, the acceptance of time limitation and personal death at midlife can, and often is, avoided by the misuse of substances, developing an eating disorder, or by workaholism. If this phase is successfully negotiated, the individual finds a new kind of generativity in life—that is, a sense of value in helping the next generation achieve their goals. Finding new creative outlets or deciding to fulfill long suppressed ambitions are more adaptive ways of traversing this bittersweet time. For the primary care provider, the main points are clear: 1. Never assume you know what an individual’s psychosocial stressors are. Ask. Let the patient inform you. 2. Remember that needs and developmental tasks shift over the adult lifecycle. This point has been under-emphasized in psychiatry until relatively recently. 3. Keep watch for issues of loss and grief. When they are not addressed, personal growth is stymied.
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4. Sometimes a loss may be overt and you will either know about it or the patient will tell you about it. Other times you will need to ask. You may be surprised by what you hear. What is taking a toll on your patient’s psyche and experience of joy and happiness in the world may be something you never expected. 5. Encourage the patient to find a way to process her loss, such as joining a support group, journaling, or beginning a psychotherapy process of her own. Psychotherapy Emphasizes Having New Tools: Importance of Providing Patient Guidelines Another concrete step to take to establish your alliance and aid the patient’s well-being without actually doing psychotherapy is to give the patient some printed sheets or booklets with instructions about how to address the problem. Whether the disorder be depression, anxiety, an eating disorder, mid-life transition, and so forth, there are some easily acquired guidelines that list tasks, opportunities, and coping strategies that might be helpful. While patients can acquire these on their own, it is a kind, personal gesture to hand them to the patient yourself or to have them readily accessible in your office or waiting area. In the author’s book, Women’s Mental Health in Primary Care,35 there are sets of guidelines for each major psychiatric disorder that can be printed out for patients. You might also consider listing some of the points made by Dr. Dickstein in her article on a printed sheet to encourage general mental wellness in all patients. Psychotherapy Is a Safe Haven for the Patient with a Physical or Emotional Disorder A simple way to understand one of the basic tenets of psychotherapy is that it provides a safe haven or safe place where the individual can be understood and permitted to speak their personal truth. From the perspective of more than 30 years’ experience in working psychotherapeutically with patients who were medically ill, psychiatrist Richard Druss found that “patients need [and benefit from] one place they can go and speak their minds about the disease, its care, and what it means to them.”8 Similarly, women with any one of a variety of medical concerns may benefit from having the opportunity to talk with a professional. But this is almost impossible for you to do within the confines of a busy primary care practice. Therefore, some clinicians have begun to employ a social worker or psychologist in a group practice setting who can provide this service.19 There are numerous benefits to this novel, contemporary idea. First, it de-stigmatizes mental illness; you simply tell the patient that there is someone down the hall you want them to meet and speak with. Most patients will comply with this suggestion, whereas they may
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not accept it if you simply suggested they find a therapist on their own. Secondly, having mental health services readily accessible will save you time. Some practitioners have handled billing as simply another medical service. Nurse practitioners and clinical nurse specialists with psychiatric expertise are quite skilled in the range of psychotherapies, psychotropic medication management, and the psychological factors of medical illness. No doubt every primary care clinician has a share of patients who make frequent visits or phone calls but for whom no bona fide physical illness can be found. These patients will less likely burden you if they have somewhere they can go and ventilate their concerns. One cost-effective strategy might be to have the patient meet weekly or biweekly for 20–30 minutes with the nurse; you follow up at the end with a brief greeting in order to help the patient feel connected and less alone.7, 11 Health care costs decline when mental health needs are addressed, even in patients with psychosomatic (e.g., somatoform) disorders.16, 22, 32, 33 PSYCHOTHERAPEUTIC CONCERNS SPECIFIC TO WOMEN Because women are usually the primary caretakers in the family, they feel the keen responsibility of meeting the needs of others and making sure loved ones have the personal requirements of medical care, school, and shelter met. While this characteristic likely derives from the survival advantage and genuine gratification derived from intimate attachments with others, particularly the family, it also leads to one of the greatest quagmires for the physician: Because the woman is so busy taking care of others, she neglects to take care of herself.22, 24, 25, 35 Therefore, even your best, most sensitively rendered advice may be forgotten, not because the woman is reluctant, but because she puts her own needs last. What can you do to correct this misjudgment? First, recognize that it is one of the greatest stumbling blocks to good patient care and address it with compassion. You might say something like, “Many women in my practice don’t take care of themselves because they are so busy taking care of others, and have so many things that need to be done at work at home. Could that be happening to you? Remember, you must take care of your own needs, too. If you get totally run down, you won’t be able to do for others in the way you want.” In essence, you are giving the patient permission to address her needs, too. You might also remind her that “medical research has demonstrated some women with illnesses like cancer often don’t go for treatment because they are so busy.” This lets the woman know that her plight is not uncommon and gets her thinking about what she might do to plan some personal time. After you have empathetically addressed the woman’s need for selfcare, point her in a direction that might be useful to her. Childcare concerns often get in the way of going for medical treatment and
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psychotherapy, but there may be some creative ways or community resources to provide support. Recommend respite care for women who are exhausted by shift work, or by holding down more than one job, which is a common predicament for women in the 21st century who have family and work responsibilities. Irritability and depression in women are sometimes miraculously corrected by making sure needs for sleep are addressed. Women have the gender-specific need for about one to one and a half hours more sleep per night than men, yet commonly get about one to one and a half hours less sleep than a man. Sleep deprivation is a major problem in our driven, avaricious culture for both genders. It should be particularly assessed in women because of their greater sleep requirements and the higher frequency with which they present with problems that may be sleep-deprivation related, such as anxiety, dysphoria, irritability and anger.23, 34 Once again, keep in mind that many “problems are psychiatric syndromes masquerading as general medical symptoms,”1 and encourage the woman to take advantage of your recommendation to visit with a psychiatrist or other trusted mental health professional. In this way, you are also facing down the stigma of mental illness and avoiding the tendency to stereotype or stigmatize mental health care in our society. Psychotherapy Is Balm for the Healer, Too The demands of a primary care practice are enormous. Physicians are expected to do more and more with less and less—in time, compensation, and the approbation of being a physician. Our once esteemed, noble profession is under derision in many quarters: by governmental investigations and restrictions, by increasing litigation, by the insurance industry and managed care, and by the patients themselves who express less gratitude and seem to have more complaints. We often are left feeling our efforts are futile, and we may get angry because we work hard but are not routinely appreciated. Professional burnout is at an all-time high as more doctors are choosing to leave their practices and move on to another line of work or retire early.1, 4, 17, 24 Remember that the majority of recommendations in this article apply not just to the patient, but also to the physician. Make sure you pay attention to your own needs, too, and when you experience one of the inevitable vicissitudes of life (e.g., loss, family conflict, demoralization, career or personal transition), have the courage to face the issue directly, perhaps by taking advantage of your own psychotherapy process.4, 11, 16, 22, 27 As one physician put it as he concluded his personal psychoanalysis and made a decision to change his specialty (and eventually the location of his practice), “You always learn the most when you are a patient yourself. But those lessons have to be learned over and over again in life. It helps to talk them out with someone who can be objective and tries to understand the meaning of it all for me. This space [the psychotherapy process] gives me perspective and hope to carry on, to go after what I really want in my life.”
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SUMMARY Psychotherapy is a cost-effective treatment modality that promotes health and well-being in a variety of medical and psychiatric conditions. There are gender-specific variables to consider when recommending psychotherapy to women in your practice. In the future, there will likely be more specialists in behavioral medicine (i.e., mental health professionals) who work in tandem with primary care physicians in an integrated health care setting. Anticipating and addressing the emotional needs of patients can be a rewarding and time-efficient strategy in primary care medicine. Referral to a skillful psychotherapist may be warranted not only for treatment of one of the major psychiatric disorders (e.g., depression; eating disorder; anxiety disorder; post-traumatic stress disorder), but as the patient makes a major life transition which, while bringing about opportunities for personal growth, also involves loss and mourning. Clinicians who are comfortable with making referrals to psychotherapists when the condition is warranted, must, in an age of managed care and restriction of benefits for psychotherapy, be prepared to join with the mental health professional to wage the good fight and secure the needed, cost-effective, and appropriate treatment. References 1. Andreasen A: Body and soul (editorial). Am J Psychiatry 153:89–90, 1996 2. Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. Am J Psychiatry 156:1563–1569, 1999 3. Borenstein DB: Response to the Presidential Address: APA enters the 21st Century. Am J Psychiatry 157:769–1770, 2000 4. Bulger R: The quest for the therapeutic organization. JAMA 283:2431–2433, 2000 5. Chodorow N: The Reproduction of Mothering. Berkeley, University of Berkeley, California Press, 1978 6. Ciechanowski PS, Katon WJ, Russo JE, et al: The patient-provider relationship: Attachment theory and adherence to treatment is diabetes. Am J Psychiatry 158:29–35, 2001 7. Coen SJ, Sarno JE: Psychosomatic avoidance of conflict in back pain. Am Acad Psychoanal 17:359–376, 1989 8. Druss RG: The Psychology of Illness in Sickness and in Health. Washington, DC, American Psychiatric Press, 1995 9. Fawzy FI, Fawzy NW, Hyun CS, et al: Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective states on recurrence and survival six years later. Arch Gen Psychiatry 50:681–689, 1993 10. Fawzy FI, Kemeny ME, Fawzy NW, et al: A structured psychiatric intervention for cancer patients: II. Changes over time in immunological measures. Arch Gen Psychiatry 47:729–735, 1990 11. Francis ME, Pennebaker JF: Putting stress into words: The impact on writing on physiological, absentee, and self-reported emotional well-being measures. Am J Health Promotion 6:280–287, 1992 12. Gabbard GO: Editorial: Empirical evidence and psychotherapy: A growing scientific base. Am J Psychiatry 158:1–2, 2000 13. Gabbard GO, Lazar SG, Hornberger J, et al: The economic impact of psychotherapy: A review. Am J Psychiatry 154:147–155, 1997 14. Gilligan C: In a different voice. Cambridge, MA, Harvard Univ Press, 1982
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15. Glassman AH, Shapiro PA: Depression and the course of coronary artery disease. Am J Psychiatry 155:4–11, 1998 16. Gullette ECD, Blumenthal JA, Babyak M, et al: Effects of mental stress on myocardial ischemia during daily life. JAMA 277:1521–1526, 1997 17. Holloway KL, Zerbe KJ: Simplified approach to somatization disorder: When less may prove to be more. Postgraduate Medicine 108:9–95, 2000 18. Jordan JV, Kaplan AG, Miller JB, et al: Women’s growth in connection: Writing from the Stone Center. Guilford, NY, 1991 19. Kendler KS, Myers JM, Neale MC: A multidimensional twin study of mental health in women. Am J Psychiatry 157:506–513, 2000 20. Lucas SF, Peek CJ: A primary care physician’s experience with integrated behavioral health care: What difference has it made. In Cummings NA, Cummings JL, Johnson JN (eds): Behavioral Health in Primary Care: A guide for Clinical Integration. Madison, CT, Psychosocial Press, 1997 21. McGillicuddy TJ: Functional disorders of the nervous system in women. New York, Willliam Wood and Co., 1896 22. Mitchell SA: Relationality: From attachment to intersubjectivity. Hillsdale, NJ, The Analytic Press, 2000 23. Moulton R: Professional success: A conflict for women. In Alpert J (ed): Psychoanalysis and Women: Contemporary Reappraisals. Hillsdale, NJ, Analytic Press, 1986, pp 161– 182 24. Nadelson C: Gender and health policy. Harvard Rev Psychiatry 5:6,340–343, 1998 25. Spiegel D: Can psychotherapy prolong cancer survival? Psychosomatics 31:361–366, 1990 26. Spiegel D: Effects of group support for metastatic breast cancer patients on coping, mood, pain and survival. In Ten-Have-de Labije J, Balner H (eds): Coping with Cancer and Beyond: Cancer Treatment and Mental Health. Amsterdam, Netherlands, Swets & Zeitlinger, 1991, pp 11–29 27. Speigel D: Living Beyond Limits. New York, Random House, 1993 28. Spiegel D: Healing words: Emotional expression and disease outcome. JAMA, 281:1328–1329, 1999 29. Spiegel D, Kato PM: Psychosocial influences on cancer incidence and progression. Harv Rev Psychiatry 4:10–26, 1996 30. Spieler S, The gendered self: A lost maternal legacy. In Alpert J (ed): Psychoanalysis and Women: Contemporary Reappraisals, Hillsdale, NJ, Analytic Press, 1986, pp 35–56 31. Stiver I: The meanings of “dependency” in female-male relationships. Stone Center for Developmental Studies, Wellesley College, Wellesley, MA, 1984 32. Stotland NL: Managing patients who “want” to have a disease. Journal Watch: Women’s Health 2:55–56, 1997 33. Whyte C: The need for dynamic psychotherapy. Psychiatric Bulletin 20:541–542, 1996 34. Zerbe KJ: The Body-Betrayed: Women, Eating Disorder and Treatment. Washington, American Psychiatric Press, 1993 (Soft cover edition: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Furze Books, Carlsbad, CA, 1995) 35. Zerbe KJ: Women’s mental health in Primary Care. Philadelphia, PA, W.B. Saunders, 1999 Address reprint requests to: Kathryn J. Zerbe, MD 1516 NW Benfield Drive Portland, OR 97229