Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Discuss the research on the stressors that are more common in women.
- Describe how the new guidelines for girls and women encourage psychologists to help women tap their strengths.
- Discuss how the guidelines seek to raise awareness of how the intersectionality of different traits, including gender, race, class and age, can inform a woman's experience.
For more information on earning CE credit for this article, go to www.apa.org/ed/ce/resources/ce-corner.
In the decade-plus since APA released its first Guidelines for Psychological Practice With Girls and Women, the landscape of gender issues has shifted. The #MeToo movement has spotlighted the sexual assault and harassment endemic in many settings. The Women's March on Jan. 21, 2017, smashed records to become the largest single-day protest in U.S. history. And as transgender people have become more visible and politically active, they have spurred public conversation about the limits of the traditional binary view of gender.
These societal changes are reflected in APA's revised guidelines for girls and women, which encourage practicing psychologists to understand the challenges that women of diverse identities face and to support the empowerment of their patients. The guidelines replace the previous set of guidelines, which were released in 2007 and recently expired.
"An emphasis on resilience is embedded throughout all of the guidelines," says Lillian Comas-Díaz, PhD, a clinical professor of psychiatry and behavioral sciences at the George Washington University School of Medicine and the executive director of the Transcultural Mental Health Institute, who co-chaired the working group that developed the revised guidelines.
The new guidelines include new research on girls and on trans-identified and gender-variant women and a focus on intersectionality and global gender issues.
Understanding the intersections
The effort to revise the guidelines began in 2013, and a diverse group of more than three dozen practitioners, scholars and graduate students contributed to the new document. The project was co-chaired by Comas-Díaz; Debra Mollen, PhD, a professor of counseling psychology at Texas Woman's University; and Sharon Lamb, EdD, PhD, a professor of counseling psychology at the University of Massachusetts, Boston.
The overarching theme of the new guidelines is the importance of understanding girls and women within their social contexts. The authors urge psychologists to understand the way different aspects of identity such as gender, race, ethnicity, social class and age can inform a person's experience.
Overall, women and girls are diagnosed more often with certain disorders, particularly depression, anxiety disorders and eating disorders, than are men and boys. But the guidelines encourage a deeper understanding of the contribution of trauma to the development of many disorders affecting women and girls. For example, while United Nations data suggest that about 70 percent of women worldwide will experience some form of violence in their lives, trauma may be particularly pervasive among certain subgroups, including women and girls of color, refugees and transgender individuals.
Other gendered issues hit some groups of women harder than others. For example, pregnancy-related mortality in the United States is nearly four times higher for black women, with 40 maternal deaths per 100,000 live births, than for white women (Centers for Disease Control and Prevention, 2014opens in new window). Similarly, the gender pay gap differs by race and ethnicity, with Hispanic women earning the least as of 2017 (Institute for Women's Policy Research, 2018).opens in new window Scientific research often excludes nonwhite racial and ethnic groups, and discrimination against racial, ethnic or sexual minorities can negatively impact health-care access and treatment.
Girls of color or girls living in poverty may be particularly susceptible to having their mental health problems criminalized rather than treated. Epidemiological research suggests that two-thirds of girls incarcerated in the juvenile justice system meet the criteria for at least one psychiatric disorder ( Archives of General Psychiatry, Vol. 59, No. 12, 2002 opens in new window).
Social class, education, age and other attributes can put particular pressures on girls and women. According to U.S. Census Bureau data, women experience poverty at higher rates than men across the life span (Census Report, 2017). Being poor is a disadvantage in and of itself, but it can also leave people vulnerable to implicit and explicit bias by health-care professionals ( BMC Medical Ethics, Vol. 18, 2017 opens in new window).
Meanwhile, ageism is pervasive, research suggests. Older women are stereotyped as less competent than younger women ( Journal of Social Issues, Vol. 61, No. 2, 2005 opens in new window). They're also vulnerable to structural disadvantages. For example, because of women's lower lifetime earnings, they receive lower annual Social Security benefits than men, on average, even though more women rely on Social Security as their nearly sole source of income (Social Security Administration, 2018opens in new window). Thus, ageism can intersect with poverty for older women, and with race for women of color.
The guidelines attempt to combat a strict medical-model approach that puts the onus on individuals in struggling to cope with such challenges. Rather, Lamb says, psychologists should be aware of the systemic nature of these problems for girls and women.
The transition to parenthood is likewise a moment in which women may face unique pressures, both financial and psychological. Mollen's work has found a tension between the rose-colored discourse around the joys of parenting and the actual experience of parenting for many women. Multiple studies find, for example, that relationship satisfaction between partners declines across the transition to parenthood ( Analyses of Social Issues and Public Policy , Vol. 14. No. 1, 2014 opens in new window).
Women of color, poor women and single mothers are particularly disadvantaged because of limited income, lack of federal paid parental leave and insufficient maternal and fetal health care. The question of access to reproductive choice is particularly important for women of color, says Comas-Díaz. Meanwhile, parenting expectations have become more intense, especially among middle- and upper-class white women, Mollen says.
"This pressure that some women feel, that they need to present as though motherhood is only joyful and only satisfying, puts tremendous pressure on women," Mollen says. "We need to continue to study the lived experiences of women as mothers."
Supporting women's strengths
While understanding the challenges girls and women face is key, a new guideline also urges psychologists to recognize the strengths and resilience of girls and women and to honor and cultivate those strengths. Girls and women face many systemic challenges, Mollen says, from relationship violence to limits to reproductive freedom to unequal pay. But despite these challenges, girls and women can develop resources for coping.
For instance, many women are open to seeking support from friends or professionals when the going gets rough. Women are less socially isolated than men are in their older age, on average. Their increased social ties seem to contribute to their longevity advantage, according to research by University of North Carolina sociologist Yang Claire Yang ( Journal of Health and Social Behavior , Vol. 54, No. 2, 2013 opens in new window).
Reminders to support these advantages are peppered throughout the guidelines, especially in the recommendation to foster a practice that promotes agency, consciousness and choice and to avoid overdiagnosing or pathologizing the problems of girls and women. In practice, this involves being aware of potential biases in scales or assessments, as well as considering the context of a client's distress. A patient who has experienced betrayal trauma such as child abuse, for example, can present with symptoms of borderline personality disorder ( Psychological Trauma: Research, Practice, and Policy , Vol. 4, No. 4, 2012 opens in new window). However, understanding and addressing those traumatic experiences could be more fruitful than applying the "borderline" label.
Pathologizing can be a particularly tempting trap when women and girls present with sexual problems, the guidelines' authors write. A history of sexual trauma or exhaustion from juggling multiple roles (paid work, parenthood, domestic duties) can contribute to sexual issues that may be misattributed to medical or physical causes.
Thinking globally
The guidelines also reflect a trend, both within psychology and without, to look at how people function in a globalized world.
"Global approaches to psychological practice are needed as more transnational people, particularly girls and women, are leaving their countries," Comas-Díaz says. The guidelines urge practitioners to understand girls and women within their sociopolitical and geopolitical contexts.
In practice, the guidelines' authors say, this might mean understanding the stress put on immigrant families by uncertainty surrounding immigration laws and enforcement. It might require stepping outside of the U.S. individualist mindset to understand why the daughter of a refugee family might prioritize earning money to help support her parents over schooling. For refugee patients in particular, practitioners should be well-versed in assessment and treatment of trauma. Post-traumatic stress disorder (PTSD) symptoms are increasing among women and girls globally, Comas-Díaz says, and refugee women in particular may have experienced sexual violence or the threat of sexual violence as they fled their countries of origin. Globally, rape, other sexual assault and stalking are the traumas that leave the highest proportions of PTSD in their aftermath ( European Journal of Psychotraumatology , Vol. 8, 2017 opens in new window).
Given this global and intersectional understanding, psychologists should be aware that girls and women form their identities in the context of mixed and changing messages about what it means to be female. Tension can arise between norms expected by the dominant culture in the United States and the norms conveyed by minority sociocultural groups. Psychologists can help their patients explore these nuances and affirm their multifaceted identities. Meeting patients where they are is key to this process, Comas-Díaz says. A refugee mother who has risked everything to bring her children to a new country, for example, might need to be reminded of the importance of taking care of herself through the lens of her children's need for her to be strong and healthy.
"I try to use what they bring in as a way to connect," Comas-Díaz says. "Also, I need to be very culturally humble. Many times, we don't know it all."
Part of the process involves understanding the effects of discrimination and oppression, as well as reflecting on one's own internalized biases as a practitioner. It might also involve stretching oneself beyond the usual slate of therapies to consider the benefits of folk practices or alternative forms of healing. For example, Lamb visited a pueblo to supervise a student in training. There, she said, she observed indigenous healing practices combined with traditional cognitive-behavioral therapy.
"There are many things in the cultural backgrounds of our country that have histories of providing healing," Lamb says. "Therapists would be wise to work with those practices and indigenous practitioners, and not against them."
A call for action
Given the guidelines' focus on systemic issues facing women and girls, the recommendations also include inspiration to change the system. Part of this may involve supporting patients as they take on helping roles, Comas-Díaz says.
"Research has shown that once you go beyond yourself and start concentrating on others and contributing, that really helps the person with psychopathology," she says. "They feel like they're doing something."
This focus on action is exemplified in the final guideline in the new document, which recommends that psychologists work to change hostile environments and fight against systemic discrimination. This can mean many things, Comas-Díaz says, from becoming politically active to expressing oneself through creative endeavors. For researchers, it could mean working collaboratively with study populations through the liberation-psychology approach of participatory action research, rather than dropping in, taking measurements and leaving. For an employee of a school system or another institution, it might mean nudging the administration to make services more available for marginalized groups, like people with disabilities. All of that, Comas-Díaz says, is social activism.
Ultimately, Lamb says, this kind of action is needed to make "empowerment" for patients more than a toothless term. "Empowerment is a tricky word in psychology," she says. Too often, it refers to internal processes, like self-confidence, rather than to the sort of resistance to oppression that can win real power, she says.
In psychological practice, empowering female-identified patients can mean more than providing transparency and informed consent; it can include giving patients data about the effectiveness of varying therapeutic approaches and collaborating with them to decide on treatment strategies. It can also include expressing empathy for the external barriers to empowerment that girls or women might face.
"A girl feeling empowered has so much to do with whether society is giving them power, whether there is a basis for them to take that power and whether they're punished for expressing that power," Lamb says. "Empowerment is more than just self-improvement."
APA has developed several sets of guidelines for psychological practice with particular populations. All APA practice guidelines are developed by task forces of experts, reviewed by APA boards and committees, and shared with the public for comment before they are adopted. APA guidelines do not take precedence over a psychologist's informed professional judgment.
