Replacing the Case Study Model of Therapy

The sharing of women’s therapy stories here undoes present case study models that have been handed down to us, in which the client is objectified by the absence of her own words and theories. A case study presentation suggests that there is a “knower”— the therapist; and the patient, who can be “known”. It assumes there is a person who is a fixed entity, or an “object” that can be stilled and kept silent enough to be “objectively” observed, and that the therapist can “know” therapeutic “truth” when it emerges, as if the patient were under a glass lab dish.

The case presenters’ use of language as a vehicle for focusing us on what we are supposed to attend to keeps us in a particular state of consciousness, the consciousness of a consensus reality, an agreed-upon reality. It is, in my experience, an unresponsive language, dead. As Toni Morrison so eloquently reminded us in her acceptance speech upon receiving the Nobel Prize for Literature in 1993,

“...a dead language is not only one no longer spoken or written, it is an unyielding language content to admire its own paralysis. Ruthless in its policing duties, it has no desire or purpose other than to maintain the free range of its own narcotic narcissism, its own exclusivity and dominance. However moribund, it is not without effect, for it actively thwarts the intellect, stalls conscience, suppresses human potential.” Morrison reminds all of us that “…language is a living thing with agency. What we write and say has consequences.” Morrison warns us that …status languages censored and censoring purpose is to continue its own exclusivity and dominance. Its activity thwarts the intellect, stalls conscience, and suppresses human potential. Unreceptive to interrogation, it cannot form or tolerate new ideas, shape other thoughts, tell another story, fill baffling silences. When language dies out of carelessness, disuse, indifference, absence of esteem or is killed by fiat, all users and makers are accountable for its demise.”

We are all individually and collectively responsible for how and what we speak to each other as the caretakers of language whether we are speakers, readers, or writers.

Case study presenters frequently ignore research from the field of quantum physics and sub-atomic research and theories, for example, regarding the healing properties of music and other vibratory states, which inform us that in any dyad, both people are changed in and by the process of observing, listening, and participating. Not only the “object” being observed or studied is changed; reality is co-constructed, rather than imposed. We are both living human beings, responding to each other.

The case study presentation often acknowledges only one mode of knowing—empirical, abstract, and scientific—and ignores intuitive and metaphoric ways of knowing as legitimate modes of inquiry. It also ignores voluminous amounts of feminist research, particularly in the area of linguistic research, regarding the relationship between gender and language. Ample evidence is available regarding how language is created, who creates it, and under what conditions; what and whose words are considered worthy of being valued, and thus codified in our dictionaries; and how this language system operates as a form of social control in silencing women by keeping women’s talk between women and in private places, away from the public places dominated by white men.

In Therapeutic Ways With Words, Kathleen Warden Ferrara notes, “Despite a general awareness on the part of the public about the availability of mental health resources, the practice of psychotherapy is still opaque because almost no reports are available to the general public that contain samples of the actual words used.” She asks, “What is it about therapeutic discourse that is so therapeutic? Why is the therapy hour so powerful in the lives of troubled people if all they do is talk? What do clients receive for their money besides a few ‘Mmhmms? Who gets to talk and what do they talk about?”

The Nature of the Therapeutic Process
Therapy as Inquiry and Creativity

Good therapy, like good art, is restorative. Audrey Flack, the artist, has noted, It is through the transcendent imagery of womens art in all of its forms that we heal. This process cannot be rushed to full realization.

Good therapy is a complex journey involving a process of inquiry, of perception and of creativity. These processes are shaped by the use of authentic dialogue, the shared intelligences of women, the state of consciousness we are in, the ways that we represent ourselves as subjects, the different geographical spaces we utilize, and last, how we map or describe some of these experiences both textually and materially. Additionally, each therapist is influenced by those women who came before her and those currently in her life.


The therapeutic process is, in part, a mode of inquiry in which the woman and her therapist examine not only words and meanings, but also reality, truth, values, and other concepts, which fall into the purview of philosophy.

While therapy is often viewed as primarily dealing with our emotions, it is very much a highly intellectual process as well. Women who engage in transdisciplinary therapy soon learn that their ability to think with critical consciousness is highly supported, as well as their individual ways of acquiring and using knowledge.

When a woman makes the decision to come into therapy she has already used her own will to set a process in motion. This decision to give attention to some aspects of her life is a critical decision. I see this gesture as a highly symbolic act and label it as such as I work with each woman. How this initial gesture of hers to participate—and the drive behind it—is labeled, and how other aspects of her therapy are labeled, will make a difference between whether she and I continue to feed, nourish, and sustain an irrelevant or externally constructed self, or nurture the development of a larger, more integrated human being.

There are at least two types of inquiry: discovery and validation. These are not as disparate as one might think. The method of discovery in science involves the formation and testing of hypotheses. The method of the artist in constructing her composition involves the same kind of repeated observations and critical appraisals that are made by the sensitive viewer of the finished work. They both reflect the logic of the particular discipline to which they belong.

 There are methods of teaching each type of inquiry. In therapy, there may be need to communicate information, to describe or explain something, or to help a woman to experience a clearer or more direct ‘aha moment.  The development of these intuitive powers in a woman are rich moments.  Frequently, in the manner in which I work, references to womens art, literature, or music have contributed greatly to this process.

Inquiry is also a guided discussion. We confront a problem. We acquire information, or a broader knowledge base. Then we generate ideas about cause and effect and test these new ideas. The power of an idea is the degree to which it can be used as a basis for explaining the past, present and predicting and controlling the future.

One important strategy is the use of teaching stories from the therapists own life that capture the imagination and involve a woman in the ongoing narrative. In these life stories, numerous examples of teaching stories from my own and Bettys life are included in Astras, Nancys, and Clares stories.

Therapy is more than a corrective emotional experience. It is a highly sophisticated way of working with women who are seeking to alleviate stress in their lives and finding explanations for this stress. It is a process of ongoing inquiry which involves shifts in a woman’s perception of herself, her world and her possible future.

Authentic Dialogue

The Brazilian educator and philosopher Paulo Freire's term authentic dialogue describes the process of relating and examining in which a woman and I are equally knowing subjects. This dialogue takes place in the context of the social reality of the womans life.  As we work together, the woman learns the relationship and unity between the overt or surface structure and the covert, deeper structure of her life situations. I ask for a concrete example of what she is describing to me, which creates a scene I am able to enter into with her. We then take this scene out of its present context or larger picture in which it has been embedded and critically examine it together.

The aim of this process is to arrive at a new level of knowledge, beginning with a womans description of her real life situation. Rather than receiving information about her life from an outside source, the woman analyzes aspects of her own experience. I add information to the scene that she had not previously considered. As we look together at the many scenes and stories in her life, she starts to see relationships she had not perceived before, meanings she had not examined. The woman is at first tentative, and sometimes doubting, but soon learns to engage in an ongoing reevaluation of what she had previously considered absolute truth.

As a woman simultaneously reflects on herself and the world, that which has existed objectively but had not been perceived in its deeper implications begins to stand out, assuming the character of a problem. She singles out elements from her background with a new awareness and reflects upon them. These elements are now objects for her cognition and action. She starts seeing the world not as a static reality, but as a reality in process, in transformation. As Friere states in Pedagogy of the Oppressed, the oppressed person must perceive her state not as fated and unalterable, but as merely limiting and therefore challenging.

Shared Intelligences

During earlier days in the field of psychology it was believed by most researchers that intelligence was a single entity that could be measured by a fixed IQ test. Today, many researchers agree with the educator Howard Gardner, who has proposed a theory of multiple intelligences. He challenges long-held assumptions about intelligence— especially about a single measure of intelligence.

In his book Human Intelligences, Gardner identifies seven areas of intelligences: 1, linguistic; 2, logical; 3, spatial (the appreciation of large spaces and /or local spatial layouts); 4, musical (the capacity to create and perceive musical patterns); 5, bodily kinesthetic (the ability to solve problems or create products using the whole body or parts of the body); 6 and 7, two forms of personal intelligence: one oriented toward the understanding of other persons, the other toward an understanding of oneself.  Later, Gardner added 8, the apprehension of the natural world and 9, existential intelligence.

I find his work of particular importance because it matches what I have learned and experienced as a therapist. The combined voices of all the women, those in therapy and those who have joined us, demonstrate many different kinds of intelligences.  Therapists need to attend to all these intelligences and the many talents and gifts that women bring to therapy—not only the first two, which have been emphasized and tested for in the past. The old method led to a narrowly constructed understanding of the person before us.

Gardner concludes: If one hopes to make an impact on a recognized domain of work, or upon individuals, one is well advised to engage in regular and searching introspective activities; to locate ones areas of strength and to build upon them as much as possible; and finally to interpret daily, as well as ‘peak and ‘trough experiences in ways that are revealing rather than defeating.

States of Consciousness

In his book States of Consciousness, psychologist Charles Tart writes, The prejudice that our ordinary state of consciousness is natural or given is a major obstacle to understanding the nature of the mind and states of consciousness. Our perceptions of the world, others and ourselves, as well as our reactions to them, are semi-arbitrary constructions. Although these constructions must have a minimal match to physical reality to allow survival, most of our lives are spent in a consensus reality, that specially tailored and selectively perceived segment of reality constructed from the spectrum of human potential. We are simultaneously the beneficiaries and the victims of our culture. Seeing things according to a consensus reality is good for holding culture together, but a major obstacle to personal and scientific understanding of the mind.     


Perception is a constructive process that involves interpreting sensory data along expected and pragmatic dimensions. Each woman sees through an agreed-upon reality about what it is important to see, hear, taste, touch and smell. It is a highly constructed world we are taught to see. But the fact that something is present to a womans senses does not give it a claim on her attention. As a conscious and enlightened being she is free to decide what she shall choose as the focus of her attention.

Harriet Shorr in The Artist’s Eye: A Perceptual Way of Painting notes, “At the heart of representation is the problem of reconciling the experience of seeing with a fixed image of things seen.” Whatever we see is subject to our knowledge, our states of attention, and our method of questioning.

In Overlay: Contemporary Art and the Art of Prehistory, Lucy R. Lippard says, The culture requires significant blankness, because of the emblems, symbols, and signs which were adequate for the former method of organizing production are no longer efficient in carrying out the cultural roles we assign to them.” It is in the blankness of the mental state of each woman that there is a chance for renewal, an opportunity for reconstructing her life story.


Both the therapist and the woman with whom she is working are attending to some stories more than others. What determines one’s agreement to attend to one set of stories over another; that is, what controls attention itself? It is consciousness. Experience is determined by what attention can process through consciousness.

Historically, consciousness has had many definitions. According to the assumptions we make, we can think of consciousness as a complex set of mental activities, a succession of states, each real, yet different in quality and kind from each other, a personal participation in universal or cosmic consciousness, a flow of personal experience, an epiphenomenal byproduct of continuous brain functioning, a matter of schedules of reinforcement provided by our social environment, a subjective awareness correlated with brain functioning, or a set of emergent properties or characteristics, as Singer and Pope note in their book The Stream of Consciousness: The Scientific Investigations into the Flow of Human Experience.


As the therapist listens to a woman’s stream of consciousness, she gives attention to all of what it is in the field of her own awareness or consciousness. Mihaly Csiszentmihalyi defines attention as “the process that regulates states of consciousness by admitting or denying admission to various contents into consciousness.According to Singer and Pope, ideas, feeling, wishes or sensations can appear in consciousness and therefore become real to the person only when attention is turned to them. Attention as “a form of psychic energy needed to control the stream of consciousness and attention is a limited psychic resource. That means that if we want information to become available to consciousness…. We each have the ability to process only a certain amount of information at a time. What the therapist pays attention to, how intensely and for how long, are choices that will determine what both women will put into their consciousness.”

What are the ideal conditions for altering a person’s state of consciousness? A person feels fully alive when she and her environment can interact and when she chooses to voluntarily focus her attention on something.

So, as I work, I first try to discover what she is currently attending to—her current stories or life narratives—then we disrupt these narratives in order to examine them together. Eventually, this causes a change or shift in consciousness.

Temperamental Differences

Building on the research of Lois Murphy and Alice Moriarty in their work Vulnerability, Coping and Growth: From Infancy to Adolescence, we are reminded of temperamental differences in adult life. In each woman’s life there are differences in the rhythmicity, or regularity, of her day. The ways in which she responds to new or altered situations, her threshold of responsiveness—that is, her reaction to sensory stimuli, objects in her environment, and social contacts—as well as the energy level of her responses, the quality and intensity of her various moods, and her overall attention span and persistence and the continuance of the activity in the face of obstacles, are all aspects of her particular temperament. One of the greatest challenges I had as a writer of this text was to record these various rhythms, moods, and responses.

Going Beyond the Information Given

As a woman engages in self-reflection, she begins to single out elements of her own background and history with a new awareness. These elements become objects of her consideration, her cognition and, ultimately, action—she realizes that she can change aspects of her life story.

Perception prepares us for what to receive and accept, but we have the ability to go beyond the information that is given to us. Cognitive psychologist Jerome Bruner, in his book Beyond the Information Given, states that, analytically, perceiving is at least three-step process. It begins with an expectancy or hypothesis:  we not only see, we look for; we not only hear, we listen to. In other words, perception takes place in an already tuned organism: everything a woman has previously learned will determine her hypotheses, her orienting schema. The second step is the input of information from the environment. Third, the perceiver checks or confirms whether the information is congruent with the operative hypothesis.  If the information is not congruent, some sort of new hypothesis must be generated. This is a process of learning, unlearning, and relearning. How does each woman unlearn what is useless to her? Through what process does each woman go beyond the information that has been previously given to her?

In the process of therapy, a woman is challenged to become aware of her own thought processes, the parameters of her reality, and how she views herself. She experiences remarkable personal freedom; she can acknowledge the fact that all knowledge is ultimately both a personal and social construction, and that each of these informs the other. Personal beliefs and values represent her unique reaction and the processes of socialization in society.

As we work together, we can think about and ask these questions. How does each woman view herself in relation to the external world? Is she a silent witness, with little awareness of the power of language and symbols? Is she a passive listener who is intent only on soaking up information? Is she rigorously logical or analytical while minimizing her connectedness to her own reality and experience? I can ask these questions of myself as well.


As we continue our work, theories of meaning, truth, and value take on great importance. What is truth? How can I help each woman sort out what she believes and why she believes it? There are currently at least three ways to validate truth: 

First, the coherence theory—It fits into the world view. It coheres.

Second, the correspondence theory of truth—it’s true because its true. It corresponds to nature. It exists. The grass is green. Its a fact. It conforms to reality as we perceive it. Its a complete picture of absolute things.

Third, the pragmatic theory—This is a relative theory. Its true if it works. It has a controlled or predictive quality, or it stimulates and creates inquiry.

In the therapy process there are questions about truth and reality in general. What is truth and how is it validated? How is meaning constructed? What does it mean for a woman to ‘know’ in the therapeutic process? What is ordinary reality and how is it constructed? There are questions about how each woman transits from one state of consciousness to another—for what purpose?


Meaning is discussed more fully later in this text, to address questions about making meaning. How does a woman tell her particular life story? How does a woman construct her life, to make meaning of it? It doesnt matter what someone else thought or whether it is self-deceptive or true. Our interest is only in what each woman thought she was doing, and what kind of situation she thought she was in.   

In the therapeutic process, we strive to enlarge a womans perception of herself in the world. We can offer her new lenses with different optics, different colors and shapes to become a better perceiver, and we can offer new knowledge whenever appropriate.  She is free to accept this knowledge or not, to use it or not, to structure it as she sees fit. Generally, the women with whom I work not only accept it, but also transcend it and make it their own. That is, women incorporate new knowledge idiosyncratically, and apply it to their unique life situations quite often in marvelous and creative ways.

Active Learning

Additionally, I have been influenced by Jerome Bruner’s work because of his research about how people go about the act of learning. He has theorized on the place of motivation in the learning process, and how people choose the relevance of new ideas.

According to Bruner, learning involves three almost simultaneous processes.

  1. The acquisition of new knowledge; often, information that runs contrary to or is a replacement for what the person had previously known implicitly or explicitly.
  2. “Transformative” learning, the process of manipulating new knowledge to make it fit new tasks. We learn to unmask or analyze information, to order it in a way that permits extrapolation or interpolation or conversion into another form. Transformation compromises the ways we deal with information to go beyond it.
  3. Evaluation, which is checking whether the way we have manipulated information is adequate to the task. Is the generalization fitting? Have we extrapolated appropriately? Are we operating properly? The act of learning then involves getting facts, manipulating them, and checking one’s ideas.

How sustained an episode a learner is willing to undergo depends on what the person expects to get from her efforts, in the sense of a gain in understanding.

We unlearn by being given new information or by examining what has been given to us as truths, which we can then add to the act of perceiving. We are redoing or embedding another orienting schema. We are hypothesizing until we check it out for ourselves and decide on its truth or relevance for us.

Creative Process

In Creative People at Work, Doris Wallace and Howard Gruber use a systems approach to creativity. The authors believe each person—whether the patient or therapist—is a unique, organized system and must be understood in his or her uniqueness. In describing the creative person, they summarize five characteristics: 

  1. Her work is purposeful and evolves over long periods of time; 
  2. Her work is pluralistic.  She enjoys and exploits not one but many insights and metaphors;
  3. She works within some historical, societal, and institutional framework;
  4. She participates in choosing and shaping the surroundings within which the work proceeds.  In addition, she defines the skills needed for the work and the ensemble of tasks;
  5. She is not simply a doer of creative work, but also a person in the world. She would have emotions and aesthetic feelings as well as a social awareness of the relation of her work to the world's work and its needs.

In the process of therapy, these general characteristics can be visibly enhanced. All three stories presented in this book clearly demonstrate how all of us are engaged in a highly creative process. For example, the stories show how each woman was encouraged to think metaphorically and to develop skills and flexibility in decision-making. Critical thinking skills were enhanced by examining the use of language and the use of female iconography.

Each woman in therapy is helped to escape perceptual sets and entrenchment in particular ways of thinking that have been harmful to her. She finds some sense of meaning and order in the chaos that is created by the disparity between what she has been told or seen about herself, or experienced as a woman and, at many levels, who knows herself to be more than what has been reflected back to her.

As a woman becomes a witness to the telling of her life story, she learns to recognize recurrent themes and to create patterns and images of a wider scope. In the creative process, there is always a sense of tension, as well as surprise. A woman may be faced with the conflict between staying with tradition and breaking new ground at each step of the process. Tension may also lie in the ideas themselves, such that different paths to a solution or different goals may arise in the process.    

Creative women learn to question norms and assumptions. They develop a freedom of the spirit that rejects limits imposed by others. They become willing to confront hostility and to take intellectual risks.

Vera John-Steiner in Notebooks of the Mind asks the questions: How do creative people think? Do great works of the imagination originate in words or in images?

To answer these questions, John-Steiner went directly to the source, assembling the thoughts of experienced thinkers:artists, philosophers, writers, and scientists able to reflect on their own imaginative patterns. John-Steiner concludes that specific socio-cultural circumstances interact with certain personality traits to encourage the creative mind. From her research she notes the importance of childhood mentor figures; the lengthy apprenticeship of the talented person; and the development of self-expression through highly individualistic languages, whether in images, movement, or inner speech.

John-Steiner notes, The first and foremost sign of that an individual is committed to a life of creative endeavors is his or her sense of intensity; the need to see, explore, understand, experience, and go beyond what is already known.

An oft-ignored aspect of reflection is the visualization of ideas. The human need to order the flow of experience, to reshape it, or simply to remember it, requires a multiplicity of means; among them, according to John-Steiner, language and imagery are of particular interest.

In the course of our work, all three women frequently sought out information about how Betty and I as adult women had solved problems and met crises in our lives, both in our personal domains and the institutional settings in which we lived and worked. All three women used individualistic languages in images, movement, or inner speech.

There are several ways the reader might approach the creative process in the therapy illustrated in the three stories in this book. We can study each womans individual story, or the dyadic or triadic relationship of the woman and her therapist and, on occasion, a philosopher. We can study the three stories collectively; how they are constructed, and how they build upon each other. We can focus on the relationship and contributions of the therapist and philosopher, as resources to each woman's process, or as friends, or as the co-authors of this work. We can also study the entire network of women working together within the community and the larger world. A special creative synergy resulted from keeping fluid any artificial or fixed boundaries between the women, their therapist and philosopher, and all the other women in the community who participated in the entire process.

My task in the course of therapy is to develop in each woman an awareness of whose myths, whose theories, whose meanings, whose knowledge, whose truths, and whose remembering form the content and structure of her life story. My job is not to distribute answers and truths, but to nurture and cultivate minds skilled in inquiry, speculation, and creative thinking.

Mapping the Journey: Therapy as Cartography

Therapy is a journey. If a woman is willing to take me by the hand and show me her journey, I will try to understand it as if I am inside with her looking out. I will try to experience what she thinks, sees, hears, tastes, smells, touches, and sense along the way. I tell her that as I try to see it as she sees it, I will ask her questions to clarify the scenes she is describing.

As a woman and a therapist, I am certain that this woman sitting before me knows the stories of her own journey better than anyone else. She is the one who has given birth to these stories. She has been informed through her own unique chemistry, through the living cells of her own particular and unique body, from her outer skin to her innermost cells. Incorporated in her story is all she is, has been, or might be. And hidden in these stories, sometimes remembered but often forgotten, are not only the source of her pain, but also the source of her dreams, her gifts, her secrets, her talents, and her vision.

I pay attention to what the climate and weather have been like for her, whether she thrives in a particular season or a particular time of day or night. I notice which parts of the journey were gloriously smooth and which were stormy and treacherous. I listen for who has journeyed with her and whom she may have met along the way.

I listen for her reference points—the inner and outer ones—which direct her forward, retreating, or holding movements. I want to know what her orienting schema is like, whether she looks upward to the stars for direction, watches the movements of migrating birds, or looks over the waters to the formation of the clouds. Do the flora and fauna inform her, or the temperature and winds against her skin? I am curious about which of her senses informs her best and under what conditions. Many cultures have marked these experiences and knowledge base with their own devices.

I not only listen for which skills she values and practices, but also which situations discourage her, leave her dispirited, disarm her, confuse her, or disorient her. I listen for her moments of courage, wisdom, and creativity, passion, and kindness. I take note of which bridges she has constructed and for whom, from where to where, and how she made the journey safe for herself and others.

I like to learn where she keeps her treasure chest of photos, sketches, journals, future plans, recipes, books, poems, and unsung songs. I want to know which words she chooses to record her journey and what questions she asks herself along the way. I watch for the signs and symbols she has placed on the trail. I want to know if she brought or met any guides or mentors and how they nurtured her.

I want to know if she can relax to pray or nap, or if she must scan for strange or unexpected sounds. I wonder what her world is like as it moves along her stream of consciousness.

I listen for the themes she presents, and the subplots, knowing that her life is played out at many different levels. I wonder, but do not ask, how often she visits the places where time and space are suspended, and if anyone has journeyed there with her.

I want to go to as many places as she has been, to experience emotionally as much as she has felt, to think as she has thought, to monitor the sensations of her body and to dance the choreography of her actions. At the same time I want to discover if the language she uses, the rituals she performs, and the symbols and metaphors she images each day have expanded or limited future journeys. I want to see the maps she has created, and determine together which will get her where she wants to go, which need to be redrawn, and which need to be replaced.


In her book Images of Femininity in the Visual Arts and Media, Rosemary Meterton describes the process of representation as all those processes through which meaning is made and circulated through society.

How is the female image constructed in therapy? Through whose eyes am I describing her? Culturally, there are particular ways of seeing the female body. The question is not only how do I see her, but also how might you, the reader ‘see’ her through my eyes?

It is my belief that every therapist who writes is engaged in an exercise of representation, and in the production and circulation of cultural meanings and values. By identifying as a woman with the woman who is looked at, we engage in a process of representing ourselves through our own eyes.

In Nancy’s story, the bullet holes and the suture threads holding living tissue together are invisible to our visual senses. Will I use only skin surface? Body contour? Clothes worn, to describe Nancy? These are the usual surface layers we often see as representations of ourselves. Do I stay with these safe layers, keeping our experiences stereotyped and superficial? Or do I dig deep and expose the violence at its proper place?

How do we as women take control over our own images? Remember the face box story within Astra’s story? A narcissistic glance in a mirror by a woman would be socially legitimated, but the critical and investigative examination between Astra and myself of how a woman actually used the mirror might normally be ignored. Is the face box story only about a woman looking in the mirror? Is it a form of narcissism, or does she use the silvery surface as a way to plan an escape from conformity? Good therapy would examine both the use of the word narcissism in describing a woman’s behavior, and critically examine what other descriptions would be closer to our truths.

Sexual stereotypes are often linked to a woman’s appearance and make assumptions about her sexuality. Often her physical appearance is a sign of moral worth. As a pre-adolescent Astra chooses to spend her summer on the hammock and front porch, rather than allowing the painful gaze and comments of adult men about her growing body and breasts.

The rules of the church keep the contours of Clare’s growing body bound and hidden under ecclesiastical wraps for years. Wrapped in the hierarchical, man-made rules of the church she appears separate, different, and purer than the very women she wished to serve.

Remember again the two bodies of Nancy: one living in the discomfort of the public swimming pool, the other in the safety and privacy of her dance studio away from the gaze of men.

Femininity is not determined by biological sex but rather the reverse; sexual identities are formed within prevailing codes of femininity.

Historically, all cultures have surveillance and control systems over those who are considered inferior or deviant. How have traditional rules of reporting, or writing a woman’s therapy record, acted as a form of surveillance and control over both women? What kinds of words and imagery would address women’s experience or help to create new possibilities for looking? We are all engaged in a process of redefining and re-imaging ourselves.

The Use of Space

Another aspect of the process of therapy involves the geographical place in which it takes place.

Therapy work is done in private and enclosed spaces that the culture in which we live has sanctioned as a place where we may name, remember, and effect change. How do we define and name this space? How does a therapist use this space and privileged position? Whose interests and knowledge do we transmit and serve in this space? Who is doing the looking in this space? In a culture often split by gender and race how do we know if this or any space is his or hers, African-American, white, and all the other “others?” Is there a boundary between therapy space and communal space? Ought there to be?

First and foremost, therapy space is a confidential space with certain rules and regulations and a professional code of ethics. I am, however, immediately suspicious about any rules or edicts imposed on this space, which is used primarily by women in great numbers. It feeds into a long history about where women can and can’t speak, where we can and can’t gather, and where we can and can’t place our bodies.

It is my experience that there is an artificiality in our work when we stay physically only in this one space. There is a politics to space, a meaning, a history, and a set of restrictions imposed on our lives as women. It feels very much to me as a form of domestication that keeps two women out of the public domain. In this way we are separated from the larger community of people. However, we can take back the space. We can visit each other’s work places, homes, houses of prayer, and sanctuaries in nature. Each of these places nurtures a different part of ourselves and are places from which we can learn.

At various times, as these three stories indicate, I have broken with sterile tradition and gone to the woman’s home or office, conducted a ritual on the shores of the lake or in my own “Glass Room” at home, or gone to a convent infirmary. This emerged from my background as a public health nurse and my learnings in the schools and clinics of New York City. When I visited a African-American mother’s home in Harlem or a Puerto Rican woman’s home in East Harlem, she spoke with me differently when she was on her own turf and in her own space than when she was in my office. We experienced a more collateral role, and in the long run we accomplished more together. We must meet people where they are. We live and heal in this world community together. Going out into the community together undoes the power differential that women experience in the larger world and in some forms of therapeutic practice.

One of the earliest discussions in feminism was about the spaces of patriarchy and thus the need for feminists to consider geography. Shirley Ardner’s research in Blunt, Rose, Alison and Gillian Rose, eds. Writing Women and Space, notes that the social map of patriarchy created ground rules for the behavior of men and women, and that the gender roles and relations of patriarchy constructed some spaces as feminine and others as masculine, and relegated certain kinds of gendered activities to certain gendered places. Gender was seen as inscribing spatial difference. For us, there are no boundaries or limitations, mental or physical in the process of therapy.

In all the stories presented, each woman had special gifts and talents. She was determined to be whole. All three women did this despite the violence they experienced to their bodies and their spirit, the biases toward them as female children, the negative attitudes toward their continued education, the lack of adequate medical research on women’s health, and the hierarchy that worked against them in religious communities. All the stories reveal a drive to make a difference, to be innovative, to push the boundaries, to maintain a resiliency during difficult times, and an openness to new ideas despite their pain, speaks volumes.

Mapping the Journey

How might we map a woman's life story, and why it is important?

In Overlays: Contemporary Art and the Art of Prehistory, Lucy Lippard  notes, The map and map derived art is in itself fundamentally an overlay; simultaneously a place, journey, and a mental concept; abstract and figurative; remote and intimate. Our current fascination with them has to do with our need for a meaningful overview, for a way to oversee and understand our location.

A therapist must assess what the woman already knows, what her understanding is of early socialization patterns from home, school, religion and other institutions. What is this womans level of feminist consciousness? What are her understandings about gender issues? What transcendent experiences has she had that have not been acknowledged? Has she acknowledged the positive contributions of other women in her life? What does she need to learn or experience in therapy?

The therapeutic process is a kind of mapping of the backgrounds, life experiences, goals, knowledge, and values of each woman, and the various therapeutic interventions that carry the woman and her therapist to a more visionary place. Therapists, like musicians and other artists, vary in their degree of talents and creativity. How do we create adequate maps of human experience? Why was the map created, and what is the range of its application? How do we evaluate a map? Why use a map at all?

Often ideas, impressions, and feelings evoked in a woman seem scattered and disorganized and meandering. But there is an organization there, a way, and the therapist must be both surveyor and cartographer of her ongoing lifes map. A therapist must listen for whether a woman is recalling specific information, theorizing, or interpreting experience. And from this place she must design, sequence, and ask relevant questions, and create a context using words, images and sounds which expands the realms of possibilities.

In a very basic way interpretation in therapy is similar to musical interpretation. There are as many diverse and valid interpretations of the same score as there are artists to perform it. No composer can spell out exactly how she wants her creation to be performed. Therefore, the musician must be able to read between the lines and add her own convictions, based upon her own knowledge and experience and her own interpretive ideas until the resultant mix seems to be just right. As in music, there is never a definitive therapeutic interpretation of a woman’s life.

Our theoretical maps will always be less than the experiential life territory they are supposed to represent. In studying the social construction of our maps we can have some understanding of how instrumental our maps are in defining, directing, and sometimes distorting our explorations.

Sounding The Alarm:
Impact of Managed Mental Health Care

When I first imagined the writing and publication of these primary texts of women’s lives and had the lake talk with Betty, I imagined a sanctuary, some public place where we could house our rich cultural heritage, our narratives of creative inquiry. As consumers of current mental health services, we have to ask ourselves: Where will our stories be now, these rich texts and records of a woman’s capacity for transcending her personal and social oppression? Will new ones ever come to gestation now? We must ask ourselves: Who is it now that controls the production, distribution, and legitimization of knowledge in the field of psychology? Whose knowledge and whose values are we being asked to swallow and for what purpose? And who is being served by these changes?

Within the course of time that it took to write this journal, managed care has invaded the peace, quiet, and contemplative nature of the therapy experience as we have practiced it. The practice of good and creative thinking is being challenged now by lesser and more dangerous systems of care. Work is allowed only if it can fit through a net with very small holes.

It requires time to develop a woman’s critical consciousness; that is, her awareness of how societal beliefs and norms affect her mental, emotional, and spiritual development as a woman in a basically sexist and racist society. This new system thus supports the status quo, social institutions as they now exist. Who benefits from a woman not being given enough time to do this work? Who benefits when we silence a woman from telling the details and truths of her story? Whom does it serve?

The impact of managed mental health care affects us all, whether we are therapists, clients or prospective seekers of mental health care. It affects us as individuals and it affects all of the members of our family and the community at large. The rules for the treatment of people who are having problems in their lives or who are labeled mentally ill are seismographs of the political times and the culture in which we live.

In his book, Managed Mental Health Care, which is part of a series of books on managed care for practitioners, S. Richard Sauber notes, “We are now faced with control of mental health by business managers and investors, the exploitation of inexpensive labor in the form of reduced provider fees, and the use of lesser credentialed counselors and mental health technicians, standardized cookbooks of care where covered lives are channeled through predetermined treatment; mass delivery vehicles, such as group therapy; computerized assessment and treatment checklists; routine dispensing of psychotropic medications by nonpsychiatric physicians; mergers and acquisitions leading to semi-monopolies; and a mass exodus by private practitioners out of the profession.”

Karen Shore, a New York psychologist and organizer of the consumer advocacy group, Coalition of Mental Health Professionals and Consumers, compares the new mental health care industry to a totalitarian regime, subjugating patients and therapists and depriving them of freedom and democratic process. She concludes that managed care companies control both the woman who comes for help and her therapist, removing personal power; instills fear; re-traumatizes through the loss of privacy; preys on the most vulnerable; and puts money first. She makes an excellent case noting that the ethics of business is quite different from the ethics of mental health professionals. She believes, as I do, that the quality of care is destroyed. There is a loss of empathy, objectifying people and dehumanizing a human service. The insidious language and labeling reduces the real situation of women’s suffering. Lastly, she notes the abuse of language—for example, by insidiously renaming and replacing a professional’s identity with the term ‘provider’.

What does this all mean in terms of the impact of managed care on women? There are issues of control, empowerment, confidentiality, defining goal definition and meaning, and restrictions regarding the type of care. The managed care company is now the center of control and determines the number of sessions offered to the client, as well as the focus of the treatment.

Since the managed care company monitors the treatment planning report, the therapist cannot guarantee confidentiality of information concerning the client once it leaves her office. To make treatment plans, companies are asking for documentation of the therapy process. Providing this documentation raises important questions regarding a woman’s right to privacy and the possible consequences of this information being passed on to large corporations and insurers. Writing these reports takes up the therapist’s precious time that might be better spent working with a woman.

Note the following instructions: “During the first session, the therapist is required to prepare the clients for either short-term therapy or to complete therapy within a specific number of visits following the first session. Therapists should clarify goals of treatment and what can and cannot be accomplished in the limited time available. The clinician should be careful not to get into emotional areas of exploring problems that cannot be resolved in the number of sessions allowed.” (David Rice and Ira Polonsky, How to Write Treatment Planning Reports for Managed Care Companies. Oakland, CA: Professional Health Plan Publishers, 1993, p.7 of Managed Mental Health Care).

This narrow interpretation creates many problems for both therapist and client. For example, a woman with moderate to severe symptoms of anxiety who has somehow managed to cope with the anxiety at work and at home may seek treatment because she is no longer able to function adequately. It may require many therapy sessions before she can become aware of a past trauma in her life, such as having been the victim of incest or of a sexual assault, which may be the source of her anxiety. Short-term “band-aid therapy” could in fact lead to longer-term continued suffering.

Reimbursement for medical treatment is based on medical necessity, which is usually interpreted as functional necessity. Decisions are made by the very people who profit from less spending, so there is a clear conflict of interest.

Sauber notes that managed care companies hold the position that long-term or more intense work is an indulgence motivated more by therapists’ greed than by clinical rationale.

Treatment decisions are resolved within the exacting parameters of time, cost, and the theoretical orientation of a managed care system. Managed care curtails both women’s—the therapist’s and the client’s—freedom to decide about a woman’s goals for her therapy, how often to see each other, for how many sessions, and the negotiation of a fee for services.

The most popular modalities under most managed care systems are the use of cognitive and behavioral therapy, which teach a method for seeing what you currently do, but not the origins of the problem.

All three women whose stories appear in this book at different times in the course of their therapy could be identified as having depressive symptoms. However, the causes of their flawed thinking, using the cognitive model, are seen as flaws in the women themselves and in their own thinking. There is no analysis of the emotions that have informed them and the meanings they have constructed in a society bounded by race and gender that continues to devalue and demean their lives as women.

The various maps that Betty used with each woman were better and more useful schemas for helping to acquire information and understanding than the prototypes of cognitive and behavioral models, which would define the woman as having cognitive inadequacies. What we have done, in addition, is to replace the schemas that limit a woman’s understanding and movement with new understandings, knowledge, and imagery that come out of the lives and contributions of other women—women’s art, literature, music, and scholarship. These are the schemas that can truly free a woman and undo her feelings of being dispirited and prevent her from needing periodic “band-aid” managed care therapy throughout her life. Collectively, we must refuse to allow women to be silenced by systems of managed care.


Questions and Decisons: The Ethics of Womens Therapy

Ending the silence means taking the therapeutic record and turning it into an experimental text fully accessible to the larger community of women. In this process, critical decisions must be made. How much of each woman’s personal story do I tell? When do certain details become an invasion of privacy? At what point do concerns for other people’s privacy interfere with the authenticity of the woman’s own autobiography? What information has already been made public through the press, the judicial system, or police and prison records, and is no longer private at all? What responsibility do I have to the reader as the recorder and presenter of the truth of these women’s lives? How do I record and negotiate the silences that are also part of the story?

Every therapist asks questions such as these out of which come guiding principles for her work. For me, this means striving for right behavior, right speech, and right action. Borrowed from Buddhist teachings, these principles capture and transcend conventional codes of ethics focused on protection and confidentiality, as well as more recent feminist codes emphasizing egalitarianism and social action. This is not so much a matter of rules and regulations that are fixed and immutable, but rather a map of relationships and responsibilities—what knowledge and what action—core ethics of women’s therapy.

There are ethical codes for all the professions. Codes of ethics for the mental health professions are designed to protect the welfare of clients by requiring professional competence. They serve to clarify the rights and responsibilities of mental health professionals. They provide standards of conduct, common values, attitudes, and basic principles for using the knowledge and skills of the profession. In brief, ethical codes for mental health professionals provide a social contract between the profession and the public it serves.

The major existing traditional codes are part of the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct. The codes apply to psychologists as they carry out their diversified professional work. These documents are always under revision.

The problem with traditional codes of ethics, which date back to Hippocrates, is that it does not encourage social action. The Hippocratic oath, the cornerstone of practice for the medical profession, is a model of responsibility toward patients in the broadest sense, of not causing them harm, but says little to promote health or to activate social action.

What does the term ethics really mean? Ethics is a branch of philosophy. Philosophy has three major branches of study: metaphysics, the study of reality; epistemology, the study of knowledge; and axiology, which has two areas of study. The first is ethics, the study of values and moral obligation, and the second is aesthetics, the study of art and beauty.

Rave and Lerman, in Ethical Decision Making in Therapy (1995), note some of the ethical issues that might arise between a therapist and her woman client. What and how do we label a woman’s symptoms? How do we negotiate a fair fee? How do we deal with overlapping relationships? What are appropriate responses to violence in our lives? How do we balance self-care and the needs of the woman client?

Feminist therapists not only want a more inclusive code of ethics, we want a different basis for judgment. The field of traditional ethics has been dominated by rules, principles, and regulations thought of as fixed and immutable. However, Rosemary Tong, in Feminine and Feminist Ethics, writes, “For women, an evil event is a bad event—something that harms someone; for men, an evil event is a rule-breaking event—a violation of God’s commandments, or the state laws.”

For example, many—but not all— feminist therapists prefer the incorporation of a care perspective that stresses responsibilities and relationships, rather than rights and rules, and focusing on the context of moral situations, rather than the context of unchallenged rights and rules.

Winnie Tom and others have claimed that principles of so-called fairness have involved discrimination against women and tyrannized women in the name of justice. This reality is evident in the court system in the legal treatment of rape and other forms of violence against women. For example, mixed beliefs about morality often lead to blaming the victim.

Feminist morality is connected to practical everyday realities of a woman’s life rather than abstract hypothetical values that come out of a long tradition of male thinking and experience. Feminist ethics stresses the centrality of interdependence over individualism. Feminist morality generally describes morality as a balance of giving and receiving. It puts the emphasis on specific rights within a contextual framework instead of placing the exercise of individual rights as the highest focus of moral behavior.

Feminist ethics is an attempt to reformulate and rethink those aspects of traditional western ethics that depreciates or devalues women’s moral experience. Philosopher Alison Jaggar summarizes feminist ethics in this way:

There are three criteria to count as a feminist approach to ethics:

1. to articulate moral critiques of actions and practitioners that perpetuate women’s subordination;

2. to prescribe morally justifiable ways of resisting such actions and practices;

3. to envision morally desirable alternatives that will promote women’s emancipation

Feminist Theory and Therapy: An Overview

Feminist theory is not one but many theories and perspectives. Evolving feminist theories in all of the disciplines attempt to describe women’s conditions, to explain the causes, complexities, and consequences of women’s lives. The more skillfully a theory can combine description, explanation, and prescription, the more valuable it is in terms of changing the lives of women and the society in which they live.

In the process of theory building in feminist therapy, Hannah Lerman has described eight meta-assumptions as criteria for these theories:

• they are clinically useful,
• they encompass the diversity and complexity of women and their lives,
• they view women positively and centrally,
• they arise from women’s experience,
• they remain close to the data of experience,
• they recognize that the internal world is inextricably intertwined with the external world,
• they do not confine concepts by particularistic terminology or in terms of other theories, and they support feminist modes of psychotherapy.

Oliva Espín and Mary Ann Gawelek concluded that “in order for feminist theory to be inclusive, the following must occur:

• All women’s experiences must be explored, valued, and understood.
• Theory must be pluralistic, and differences must be appreciated for their potential to enrich our understanding of women’s lives.
• The belief in egalitarian relationships must include an understanding that women of diverse statuses can create theory and shape knowledge on their own behalf.
• Contexts and cultures must be understood as powerful influences that shape much individual behavior.”

Kaschak and Brown in Chin (1993) note that feminist theory and practice seek new models of human growth, development, and personality that transcend traditional models of the “self” and identity.

Goals of Feminist Therapy

The basic goal in feminist therapy is change, not adjustment. Traditional models of psychotherapy have historically focused on alleviating or removing pain and helping women adjust and live their lives according to current social values and norms. Often, this therapy taught and reinforced adjusting to a white man’s world. Currently, women themselves often present problems that are determined by a narrow band of options of how they might be or what they might become as human beings.

Over many years, women who have had therapy have suffered from diagnostic categories that have labeled them “sick” or “crazy,” sent them to bed for months on end, institutionalized them, and surgically removed organs from them, all in the name of both science and good health.

Feminist therapy has four major goals: 1) to help a woman recognize how her life circumstances and her pain and symptoms are connected; 2) to help a woman to realize and value her own personal development instead of focusing her energies on attempts to adjust to existing relationships and life situations that may not be good for her; 3) to help a woman develop and discomfort creative responses to the difficult problems that occur in her life; and 4) to encourage a woman to become involved in social change that fosters personal growth and to see the connections between her problems and concerns and those of other women.

These four statements are adapted from Marjorie Klein’s discussion of feminist and traditional goals of therapy.

Definition of Feminist Therapy

In her book Subversive Dialogues, Laura Brown defines feminist therapy as “the practice of therapy informed by political philosophy and analysis, grounded in multicultural feminist scholarship on the psychology of women and gender, which leads both therapist and client toward strategies and solutions advancing feminist resistance, transformation, and social change, in daily personal life, and in relationships with the social, emotional and political environment.” She reminds us that “what makes a practice feminist is not who the clients are but how the therapist thinks about what she does, her epistemologies, and underlying theoretical models rather than specific techniques, the kinds of problems she addresses, or the demographic makeup of the client population.”

In the therapeutic encounter, women relate their life experiences and the meanings that they ascribe to the events, people, and circumstances of their lives. The concept of meaning is central to feminist therapy.

Ellyn Kaschak, in Engendered Lives: A New Psychology of Women’s Experience, suggests her own model for feminist psychotherapy, with the following key concepts:

All experience is interrelated and is organized by meaning. Meaning is a cognitive or an intellectual term, but encompasses thought, feelings, and behaviors—or mind-heart-body.

Meaning is conveyed in this and many other cultures by all of the agents of socialization, including parents, siblings, other relatives, teachers, peers, and the visual and written media, and is also organized and reorganized by each woman.

The most centrally meaning principle on our culture’s mattering map is gender, which intersects with other culturally and personally meaningful categories such as race, class, ethnicity, and sexual orientation. Within all of these categories, people attribute different meanings to femaleness and maleness.