How to help women with serious mental illness lead healthier, more rewarding lives

Serious mental illness, or SMI, is almost twice as common among women as it is among men: Some 7% of U.S. women have one or more of these disorders compared with 4% of U.S. men, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). The reasons are complex, ranging from gender-based violence to paternalistic practices within the medical and mental health systems to environmental circumstances that leave women in more vulnerable positions than men.

SMIs may include but are not limited to major depressive disorder, bipolar disorder, schizophrenia spectrum disorders, posttraumatic stress disorder, and personality disorders, sometimes with co-occurring substance use problems. In recent years, SAMHSA and the National Institute of Mental Health have defined SMI in functional terms as “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.”

Besides difficulties related to symptoms and activities of daily living, many women with SMI also face significant environmental hardships that can exacerbate these problems, including societal marginalization and stigma, gender discrimination and sexism, and high rates of domestic violence, homelessness, poverty, and single parenthood, according to psychologists who specialize in working with this population.

Despite their high level of need, however, women with SMI tend to be vastly underserved, and when they do receive treatment, it is often delivered in ways that fail to recognize their selfhood or optimize their recovery, these psychologists said.

This includes treatment by psychologists, said Erika Carr, PhD, an associate professor of psychiatry at the Yale School of Medicine and lead chair of the APA Guidelines for Psychological Practice with Women with Serious Mental Illness (PDF, 1.1MB) opens in new window, a set of 14 treatment recommendations approved by APA’s Council of Representatives in 2022.

“Psychologists have some of the best talents and skills and are probably the top profession equipped to work with women with serious mental illness,” Carr said, “yet there aren’t a lot of us doing this work.” Ironically, part of the reason is that psychologists themselves may stigmatize those with SMI (Stuber, J. P., et al., Psychiatric Services, Vol. 65, No. 4, 2014opens in new window), and anecdotally, even those who work with them.

Fortunately, there are excellent theoretical frameworks and interventions—including recovery-oriented care and trauma-focused and feminist approaches—that can help women with SMI get healthier, lead more fulfilling lives, and in some cases have symptoms remit entirely, Carr said. And now, psychologists who want to become more involved in this work can become board-certified in serious mental illnessopens in new window, through both the American Board of Serious Mental Illness Psychology and the American Board of Professional Psychology.

While it may seem counterintuitive, it is important to note that these approaches can be more cost-effective than treatment as usual, added Meaghan Stacy, PhD, an associate professor of psychiatry at Yale and a member of the guidelines task force. That is an important argument to make with institutions that say they cannot afford a change from more restrictive and prescribed forms of treatment to more egalitarian ones, she said. (See, for example, Bighelli, I., et al., World Psychiatry, Vol. 17, No. 3, 2018opens in new window; Rehabilitation for Adults with Complex Psychosis , National Institute for Health and Care Excellence, 2020 opens in new window; and Chandler, D., et al., Psychiatric Rehabilitation Journal, Vol. 22, No. 4, 1999opens in new window).

“There are feasible, effective, and cost-effective psychosocial interventions that are shown to reduce symptoms, improve quality of life, enhance community functioning, and promote recovery,” Stacy said.

Much of what psychologists need to learn about optimal treatment of women with SMI involves a shift in perspective, Carr said. That shift moves away from a hierarchical, paternalistic approach that sees these women as unruly patients who need to be controlled—sometimes literally with restraints, medication, and seclusion—toward a holistic, egalitarian approach that respects these women’s autonomy, nurtures their strengths, values their multiple identities, and gives them power over their own treatment.

Known as recovery-oriented care, this approach started as a consumer-driven social justice movement in the 1960s and 1970s in response to critiques of the prevailing medical model. In 2012, SAMHSA created an official definition of recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” It also noted 10 tenets of recovery-oriented service delivery: providing hope, offering person-driven mental health services, holding respect for the individual, recognizing and amplifying the person’s strengths and responsibilities, addressing trauma, understanding and integrating the role of culture, providing a relational approach, incorporating peer support, offering holistic treatment, and understanding that recovery and healing occur through many pathways.

This framework applies well to women with SMI, said Marcia Hunt, PhD, an adjunct associate professor in psychiatry at Yale and chair of APA’s task force on serious mental illness and serious emotional disturbance. “For me, recovery is about being most strongly led by the person I’m talking with,” Hunt said. “Although I might have training, experience, and expertise, the person knows themselves better than I do, and I will never know them in the same way that they know themselves. So that is the partnership, and that is where I think treatment needs to begin.”

For example, a provider’s treatment goals might be to support women with SMI in taking their medications and attending therapy, but the women themselves may seek goals more related to their daily lives, Carr explained.

“They may say, ‘I want a job again, I want my own apartment where I can lay my head and have my own privacy, I want to have a companion again.’” When a provider starts a relationship by helping them reach those goals, it may be easier for patients to see the potential benefits in more conventional forms of treatment, Carr said. They may come to see on their own that if they take their medications or attend support groups, it can help them feel more stable and better able to have relationships, or it may provide networking that can help them find better housing, for example.

Another key aspect of SMI recovery focuses on people’s functioning rather than on their diagnosis, Hunt noted. For example, one individual with an SMI may really want to develop friendships but rarely leaves her house because she is terrified of social interactions due to feelings of paranoia. For her, “working with her desire for friendships rather than specifically addressing feelings of paranoia and seeing where that conversation leads would be really important,” Hunt said. Conversely, if a woman with bipolar disorder who is prone to manic episodes says she is worried that those episodes might lead her to spend rashly and have indiscriminate sex, the focus should be “on those behaviors—on what she can do when those episodes kick in, how we can help her notice the signs of mania early enough, and how to protect her physically,” Hunt said. “A focus on functioning is typically more empowering and motivating than a focus on diagnoses, which can lead to feelings of hopelessness or helplessness and trigger biases that do not support recovery,” she added.

The recovery model also recognizes that the recovery process is not linear and will undoubtedly involve time, side paths, and bumps in the road, as well as progress, said Carr. In addition, it taps the involvement of peers and the community and supports people in engaging as citizens, “where in the past, people with SMI were very much ostracized,” she said. “Welcoming people with SMI fully into the community can greatly alter their experience of trauma, stigma, and oppression.”

Other important lenses for treating women with SMI, per the APA guidelines on treating women with SMI, include a feminist perspective, a trauma-informed perspective, and an intersectional perspective.

A feminist perspective recognizes that all women face forms of sexism and gender discrimination, and that those realities may lead to mental health problems that are often amplified for women with mental health vulnerabilities, said guidelines co-chair Lauren Mizock, PhD, a clinical psychologist in San Francisco who is on the doctoral faculty at Fielding Graduate University.

There is a long history of sexism in the medical and mental health fields, and research corroborates that these biases are alive and well, she added. For example, studies show that women are much more likely to be diagnosed with mental disorders than men, even when controlling for self-reported symptoms and symptom presentation (Riecher-Rössler, A., et al., Archives of Women’s Mental Health, Vol. 21, 2018opens in new window). Research also finds that being female in and of itself significantly predicts who is prescribed psychotropic medications for mood ( Women’s Mental Health: An Evidence-Based Review , World Health Organization, 2000 [PDF, 552KB] opens in new window).

In a related vein, many or most women with SMI have significant histories of gender-related trauma, but providers rarely acknowledge, assess for, or treat it, Mizock added. For example, one study found that 51% to 97% of women with SMI have a history of physical and/or sexual assault (Goodman, L. A., et al., Journal of Traumatic Stress, Vol. 14, 2001opens in new window), while another shows that 64% of women with SMI experienced sexual assault during their lifetime compared with 26% of men with SMI (Mueser, K., et al., Journal of Consulting and Clinical Psychology, Vol. 66, No. 3, 1998opens in new window). Research also suggests that childhood trauma seems to predict the onset of psychosis both in men and women (Mayo, D., et al., Frontiers in Psychiatry, Vol. 8, 2017opens in new window).

“It is important to be aware that a majority of these women have had experiences of abuse and violence and are at risk of various disadvantages and that providers attune their care based on their history and where it has led them,” Mizock said.

Also pertinent to treatment conceptualization for women with SMI, say the guidelines, is assessing the presence and significance of intersectional identities, including differences in race, ethnicity, class, privilege, sexuality, sexual orientation, age, disability, and religion. For example, a White, lesbian, affluent woman with SMI has far different experiences and resources than a Black trans woman with SMI who is living in poverty, has experienced a history of abuse, and has limited access to quality care. It is also important to consider that some women with SMI may be at even greater risk of mental health problems given their environmental circumstances, including those in the criminal justice system and women who are immigrants or refugees, say the guidelines: “Psychologists are encouraged to facilitate treatment options that...help women realize that their experience is fraught with a sociopolitical context, rather than seen singularly through a pathological lens, where the problem is thought to only reside in the person.”

There are many ways psychologists can get involved in improving care for women with SMI, said Stacy. A good start is getting educated on the topic: She and the other SMI guidelines authors encourage psychologists to read the SMI guidelines as well as related guidelines (see APA guidelines helpful in treating women with SMI). These documents and the recovery approach in general are aligned with the social justice aspects of APA’s strategic plan, Stacy added.

For individual treatment, several successful evidence-based interventions are compatible with a recovery-based approach, many of which psychologists are familiar with in other applications, Carr said. An example is cognitive behavioral therapy for psychosis, or CBTp, which helps people with schizophrenia and related disorders examine and challenge their experiences of psychosis and develop coping strategies to manage their symptoms. Studies show the treatment helps improve depression, self-esteem, and psychological well-being and leads to fewer hospitalizations. It has also been found to prevent first-episode psychosis in those at elevated risk of developing it (Agbor, C., et al., Cureus, Vol. 14, No. 9, 2022).

Another successful treatment for some forms of SMI is dialectical behavioral therapy, particularly for those who have borderline personality disorder, substance use disorder, or exhibit suicidal behavior (Peprah, K., & Argaez, C., Dialectical Behavioral Therapy for Adults with Mental Illness: A Review of Clinical Effectiveness and Guidelines, Canadian Agency for Drugs and Technologies in Health, 2017opens in new window). And if a patient has a history of trauma, evidence-based treatments for trauma can also be highly effective, Carr noted.

It is also important to help women with SMI create plans in case things get out of control, such as behavior health advance directives, Hunt added. Like health advance directives, these directives (also called psychiatric or mental health advance directives) allow people to express their preferences on where and with whom they want to receive care and what treatments they are willing to receive, she explained.

Establishing these plans can give patients a sense of security and autonomy and psychologists a road map to help them feel more confident about providing these more egalitarian forms of treatment, Hunt added. That’s because the plans allow patients and providers to discuss in detail, ahead of time, any repercussions that may come about in relation to a patient’s expressed decisions.

“Talking about these things, not being afraid to talk about them, can help providers feel less worried about advocating for patients’ treatment wishes in times of crisis,” she said. (See Resources for more.)

Environmental interventions that address systemic barriers are at least as important as individual treatments, the SMI guidelines also point out. Programs such as supported employment and supported housing can help women with SMI gain greater stability in their lives, which in turn can aid their mental health (Killaspy, H., et al., World Psychiatry, Vol. 21, No. 1, 2022opens in new window). And in general, the guidelines note that “psychologists are recommended to take on diverse roles rather than staying fastidious to traditional roles.” For example, they are encouraged, when possible, to act as case managers who get involved in women’s activities of daily living and to work on interdisciplinary teams, which can help to ensure that women with SMI get the help, care, and resources they need to thrive.

On a larger scale, psychologists can become involved in advocacy efforts for this population, as well as in efforts to change the thinking and practices in systems that may negatively affect women with SMI. Stacy, for example, trains Yale postdocs as part of an interdisciplinary curriculum on SMI; consults with mental health organizations on how to incorporate these models into their systems and performance; and gives talks nationally and abroad on gender differences in mental health, biases within the mental health system, and sociocultural factors that precipitate and perpetuate SMI.

Learning more about women with SMI is important for the field at large, Stacy added. All psychologists will encounter women with SMI at various points in their career, and given their expertise in human behavior, the mind, and sociocultural influences, it makes sense for clinicians, researchers, and administrators to take a deeper dive.

On a personal level, there is great satisfaction in helping women who face significant challenges to gain better health and greater autonomy, Carr added.

“The reason people do this work is because they’re passionate about it,” she said. “They believe in the value of cultural responsiveness and the reality that people with SMI are marginalized. The work may be harder than other kinds of work, but it’s also rewarding. And if we’re not there, we’re not the voice for the change that needs to occur.”

A practical guide to psychiatric advance directivesopens in new window
Substance Abuse and Mental Health Services Administration

Advance directives for behavioral healthopens in new window
Substance Abuse and Mental Health Services Administration