Cognitive-behavioural therapy with a feminist orientation: A perspective for therapy with depressed women.

Abstract

AbstractThe 2:1 ratio of depression among women compared to men has received little attention in the cognitive therapy literature. It has been established that this difference is not artifactual and likely represents, at least partly, differences between women's and men's socialization experiences and environments. Some explanations focus on the contribution of the prototypical female sex-role, through social devaluation of both the female sex-role and of women's abilities. Other explanations for women's susceptibility centre on women's powerlessness, on women's relational focus, which is labelled dependency, in relationships lacking mutuality. Another theme of feminist writings concerning women's depression deals with environmental differences faced by women. Stressors that are unique to women, the chronicity of stressful conditions, the strains of marital and work roles are given significance. Cognitive-behavioural therapy (CBT), which constitutes the most prominent approach to treating depression, has attended little to such issues. The implications of such formulations for treatment, therapeutic goals, and the role of the therapist are discussed.Cognitive-behavioural (CB) therapeutic approaches comprise the most widespread non-pharmacological treatment tailored specifically for depression (Beck, Rush, Shaw & Emery, 1979). One might expect, therefore, that cognitive theory would address gender differences in the prevalence of depressive disorders and treatment considerations indicated by these differences. Yet the reasons for these gender differences have not been seriously considered by most cognitive writers (Stoppard, 1989). Although discussions of this issue among clinicians (e.g., informally, and in such fora as convention workshops) are increasing, until gender differences become incorporated into theory and treatment manuals, CB approaches will continue to imply that they are gender-neutral. Underestimating the importance of gender disparity in the incidence of depression is an example of sexism of omission (Collier, 1982). This paper reviews gender issues relevant to therapy with depressed women and suggests how a feminist orientation can address issues usually overlooked by CBT and how CB therapeutic techniques can assimilate feminist concerns. Our goal is to help incorporate gender differences into both theory and practice. We attend to related research literatures and also to writings based on clinical and theoretical viewpoints, some of which do not yet have strong empirical foundation.PrevalenceAn average 2:1 prevalence ratio of women to men with depression has been found consistently for both diagnosed cases of unipolar depression and community surveys of depressive symptoms (Nolen-Hoeksema, 1987, 1990). The lifetime risk of unipolar depression is 8% to 12% for men and 20% to 26% for women (Boyd & Weissman, 1981). Women are much more likely to be depressed in most countries except in some developing nations; consistent sex differences are not found among college students, the Old Order Amish, the bereaved, or the elderly (Nolen-Hoeksema, 1987, 1990).Although the consistency with which gender differences are found is striking, understanding gender differences in depression is complicated by definitional issues, such as the distinction between clinical and subclinical depression. The APA National Task Force on Women and Depression concluded that gender differences were well-established for both major depression and dysthymia (but not bipolar disorder), and also noted that gender differences are largest for less severe symptoms (McGrath, Keita, Strickland, & Russo, 1990). Can it be assumed that the same risk factors underlie gender differences regardless of clinical severity? Nolen-Hoeksema (1990) argues that gender differences should be studied at all levels of severity because no matter how you define depression, after puberty more women are depressed, and even moderate levels of depression significantly impair functioning. …