Author: lindagask

We need to talk about women’s centres

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‘Women’s centres should not be part of the criminal justice system.’

‘The idea that if something is painted pink and has the tagline of ‘empowering women’ then it is helping women, is not only harmful but is simplistic and dangerous.‘

So says Dr Gemma Ahearne from the University of Liverpool in her blog  The Problem with Women’s Centres. I discovered her work when trying to understand what is happening to women’s centres now, having been aware of them right from the heady days of the second wave of feminism, when women were out there in the community doing things for themselves in the 1980s, setting up services for women. I’ve always found them to be an important resource for the women I saw in my clinic. A place where they could not only get the emotional support they needed in a relaxed, ‘women only’, non-institutional environment but also get practical help with the key issues facing them, from sexual abuse, domestic violence to benefits advice and hunger. Some women I knew attended long-running groups in the local centre. Some centres and services were specifically set up to provide help with mental health such as the, now sadly closed, Women’s Therapy Centre in London and Self-Injury Support in Bristol, still going strong and nationally, on-line. Others provided and still do offer counselling and group work based on the kind of feminist psychotherapy interventions developed by people such as Pamela Trevithick who pioneered groups for working class women experiencing depression with the organisation, Womankind. (as an aside I met a psychiatrist recently who had never heard of feminist psychotherapy…am I just old??).

 We know that women’s centres provide important effective support for women. They do work. Outside of what is offered by NHS Talking Therapies and limited counselling available from voluntary organisations they are the only other free resource available for women who experience significantly more common mental health disorders, anxiety and depression, than men, and are prescribed twice as many antidepressants. If we are really serious about helping women to find alternatives to medication, they are absolutely key. But there have always been funding problems, so it was disappointing but not surprising to hear from a friend of the demise of Salford Woman’s Centre, based in the city where I used to work. Ruth Hunt wrote about this, and the need to keep women’s centres going in the Morning Star recently.

Baroness Corston also recommended them as key in keeping women out of prison in her 2007 report, prompted by the increasing rate of suicide in women in custody. As a result there was a considerable increase in criminal justice funding and involvement in women’s centres, of different hues, in the community. They can all be found simply by typing in https://www.womensservicesmap.com – some are traditional women’s centres open to allcomers but also receiving funding, sometimes the majority, from criminal justice. Others are doing entirely criminal justice focussed work and require a professional referral. Then there are the ones in-between that are primarily focussed on helping ‘vulnerable’ women who have been or are at risk of being involved with criminal justice, but anyone is welcomed, as continued funding depends on keeping up the numbers.  I learned much more about the conflicting roles that many women’s centres now perform from reading Gemma Ahearne’s book chapter Sister’s Keepers: the Case of Women’s Centres also reproduced on her blog here. 

This was not an easy read:

..’.the centre performs conflicting roles, on one hand it is there to support women by offering domestic violence support, education courses, free food, sanitary products, counselling and free legal advice, and on the other hand it is there to punish women. This paradox cannot be ignored, for women who go there on a statutory basis experience many of the pains of imprisonment, simply displaced on this alternative site. The idea that if something is painted pink and has the tagline of ‘empowering women’ then it is helping women, is not only harmful but is simplistic and dangerous.’  Ahearne  2022

Gemma spent some time working in one of the centres that is primarily focussed on criminal justice referrals but also anyone else can also attend. Her blog is a sobering read. This is not the kind of women’s centre that the pioneer women who set up services in the 1980s had in mind. Far from it. Yes, women can get many different types of advice and support in a ‘one-stop-shop’ but she describes an atmosphere of surveillance, a place where therapeutic groups including those on domestic violence are not run by qualified staff, with limited one-to-one work to develop trust and where, for heaven’s sake, making friends to meet outside is actively discouraged! Those doing community payback work were required to wear bright orange tabards which seemed a demeaning form of punishment.  To be honest, what came to my mind was a new workhouse – a system of controlling women (as ever) from deprived communities who are being catalogued as the new ‘undeserving’ and ‘deserving’ poor. There is a focus on recognising that your lifestyle is your ‘choice’ regardless of what you’ve been through and learning how to not question the trauma that the state itself is inflicting on you too, as a woman. It’s certainly not aimed at supporting women to become activists, as the original women’s centres did and still do. Rather the opposite, to encourage you to conform. Attending somewhere like this may well help some women but could retraumatise many others.  Women experiencing complex mental health problems of the kind that many attendees at women’s centres face, especially those who have been in the criminal justice system, require skilled help from trained and supervised staff, not simply warehousing in the community (a term that is also sometimes used in relation to long term in-patient wards for problematic women with a diagnosis of personality disorder).

We need more and better women’s centres with safe funding not dependent on criminal justice to keep them going. 

Thanks to Dr Gemma Ahearne for the conversation!

Out of Her Mind: How we are failing women’s mental health and what must change is on sale now.

Further reading:

Ahearne G. Empowerment or punishment? The curious case of women’s centres. In Experiences of Punishment, Abuse and Justice by Women and Families 2023 Mar 28 (pp. 32-47). Policy Press.

Elfleet H. NEOLIBERAL FEMINISED GOVERNMENTALITY: THE ROLE AND FUNCTION OF A POST CORSTON REPORT (2007) WOMEN’S CENTRE IN THE NORTH-WEST OF ENGLAND. British Journal of Community Justice (BJCJ). 2022 Jan 1;18(1)

We need gender-sensitive mental health care

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My medical education, more than 40 years ago, was centred around the male body as the normative human being.  

As the American feminist and legal activist Catherine Mackinnon wrote only a few years later in Difference and Dominance: on sex discrimination:  ‘A male body is the human body; all those extra things women have are studied in ob/gyn’. That was at a time when there was no imperative even to include women in randomised controlled trials of treatment, and they were excluded for many more years because the impact of their pesky hormonal fluctuations got in the way of standardising groups and making comparison between subjects. 

My psychiatry education was similarly centred around the normative male patient, even though so many of the patients I cared for were female. I learned nothing of the impact of hormones and the different effects of psychotropics on the male and female bodies. The psychiatric equivalent of ‘ob/gyn’ became perinatal psychiatry.

 Mackinnon wrote:

…’man has become the measure of all things. Under the sameness standard, women are measured according to our correspondence with man, our equality judged by our proximity to his measure. Under the difference standard, we are measured according to our lack of correspondence with him, our womanhood judged by our distance from his measure. Gender neutrality is thus simply the male standard, and the special protection rule is the female standard, but do not be deceived: masculinity is the referent for both.’

This came to mind last week, when I was speaking to an audience in Manchester, discussing the difference between suicide rates in men and women, and hearing how being a woman is almost viewed as ‘protective’ in comparison to being a man, because men, who take their lives at three times the rate of women, are the reference point. Then again, this week, when reading Emma Pryce Jone’s fantastic piece for World Suicide Prevention day in Australia last month about how all the suffering of those who are ‘othered’ is somehow disregarded in public education around suicide: 

…‘the phrase’ don’t suffer in silence’ is central to messaging around men’s suicide, but for many women that is precisely what defines womanhood: suffering in silence.’ 

When researching and writing Out of Her Mind the gender neutrality of not only mental health research but also care provision itself, and the reporting of mental health issues in most of the media, soon became apparent. It was sometimes very difficult to get sex/gender breakdowns from government documents of even simple things like who was on a waiting list for psychological therapies. Reports in the press and on TV of suicides and abusive care in mental health units and the extent of sexual assault taking place in our hospitals usually feature photographs or film of young women (for example the Panorama programme about the unit in Manchester, or the young people’s unit in Glasgow) yet whether, or how much, this might be a gendered issue is not discussed. Agenda Alliance’s research with young women, Pushed Out Left Out their final Girls Speak  demonstrated in 2022:  

…when statutory services, and some non-specialist youth services, assume so called “gender-neutral” or “gender-blind” approaches, this leads to the specific and gendered needs of young women being overlooked and underestimated. Ultimately, there is nothing neutral about “gender-neutral” policy that fails to consider the distinct needs of girls and young women.’

This is true of so much of mental health care from the lack of attention until recently of the failure to provide adequate period products in wards to the disregard of the sexual health needs of women with severe mental illness.

Gender neutrality is a concept that attempts to remove the notion of being male or female from a person or entity. It also encourages people, regardless of their sexual orientation or identity to feel accepted, hence the adoption of gender-neutral language in recent years. But it is problematic when applied across the board to something like the provision of mental health care. Care must be informed by knowledge and understanding of gender differences and how they relate to childhood and adult life experiences, social, cultural and realities of family life, the experience and course of illness and treatment needs and responses. Some places have already begun to consider this – for example the Republic of Ireland. In contrast, women were barely mentioned in the last mental health strategy where I live in Scotland. 

We need not only gender sensitive research, with sex/gender disaggregation of data, but gender sensitive mental health care and we need it now.

It’s long overdue. 

Out of Her Mind: How we are failing women’s mental health and what must change is on sale now.

Menopause, moods – and me

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There are times when traditional feminist thought does women no favours. In her recent ‘against the stream’ article ‘The Menopause transition, a call for a holistic approach’ Rachel Gibbons quotes from Germaine Greer – a heroine of mine in the 1970s:

‘[There is] a view of menopause as a catastrophe […]. If women on the youthful side of climacteric could glimpse what this state of peaceful potency might be, the difficulty of this transition would be lessened.’

If only it were always so simple, particularly for those of us who have already experienced mental health problems earlier in our lives. In writing Out of Her Mind one of my aims was to try and move beyond the idea that women are somehow lessened by the idea that our hormones might be affecting our minds, ‘driving us crazy’. I wanted to bring feminism up to date with the current science that shows exactly how much our minds and bodies are connected, and it’s essential that psychiatrists and all women understand this – because so many women consulting do not get even asked about their reproductive cycle at all. It cannot be a coincidence that the peak suicide rate for women is between the ages of 50 and 54 – just around the time of the menopause. They want help.

During my career we have moved completely through the cycle from biological theories about depression in older women, through the rise of psychosocial and back again to a clearer understanding about the importance of both. I remember as a young consultant an elderly colleague acting as a locum while I was on leave, diagnosing a woman patient with involutional melancholia. I was horrified. It had been clear that she had numerous life events contributing to how she was feeling and relationship problems. ‘Empty Nest Syndrome,’ was a commonly used term. The relationship issues revealed by the disappearance of children from the nest were less likely to get considered. I wasn’t taught anything about the impact of hormones on mood other than they probably had ‘something’ to do with the onset of post-partum psychosis and depression. The research hadn’t been done. It is being done now. As a second wave feminist in the 80s I was focussed on the psychosocial issues my patients faced and saw those as the primary reason for the problems they had with menopause. Meanwhile I was experiencing my own recurrent episodes of depression.

What puzzles me, in retrospect, in that those people involved in my care during the period leading up to my perimenopause and beyond didn’t consider that my hormonal state might be worsening my mental state, but then I didn’t either did I? I was struggling, not only with persistent hot flushes, and night sweats, along with heavy bleeding that resulted in anaemia but also with some serious interpersonal problems at work. I’ve no doubt now that both hormones and what was happening in my life caused my unbearable state of mind. I know that people found me impossible. I believe that the hormonal changes increased my vulnerability to depression and physically exhausted me. I took early retirement at 58. It took a few years for my mood to stabilise. Antidepressants work less well in post-menopausal women, and I still feel more tired and weaker than I suspect I should do. I don’t feel ‘more authentically me’ because it’s hard to know what that is when you are on multiple pills for your different ills – almost all physical and/or genetically transmitted – although my hair is now authentically grey after lockdown, and I’m very happy with it. I am not mourning the loss of my ‘womanhood’. I’m as engaged as ever – if not more- with life, letters and thought.

I absolutely agree that our approach to menopause should be holistic and biopsychosocial, and that means genuinely so, considering all the recent research into the relationship between moods and hormones. Let’s get it right, especially for the sake of those women who require holistic care, both mental health care and hormonal treatment, to help them recover.  That means mental health services and gynaecology/endocrinology working together. No-one should feel ashamed either, if they don’t have a transition that fills you, apparently like Michelle Obama did – with a sense of power!  Nor should they feel ashamed to want to try Hormone Replacement Therapy. Menopause is much more significant for some of us than others.

Listen to women and take their concerns seriously.

P.S. I thought I couldn’t have HRT because of my physical health problems, but I can. I’ll let you know whether it helps me to feel any better than I do now.

Out of Her Mind: How we are failing women’s mental health and what must change is available now.

Antidepressants are a feminist issue

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It’s 35 years now since I first took antidepressants, and I’ve been on them continuously for 31, the last 25 years or so on an SNRI (Serotonin and Noradrenaline Reuptake Inhibitor). So, it can be more than a little disturbing to reflect that just like my mother (who took Ativan and Valium long-term) I’ve ended up on psychotropic medication for much of my life. Particularly when I read an article Are antidepressants a feminist issue? published 3 years ago by Halima Jibril in Dazed Magazine, which cites NHS data from 2021/2 that 5.5 million women in England and Wales were prescribed antidepressants compared to 2.8 million men. That’s twice as many. Its woman who are much more likely to be taking them. 

Women are more likely to get diagnosed with depression than men, but there are several reasons for this, many of which I’ve discussed in a previous blog. Jibril also mentions the issue of over-medicalisation of distress, which has been a key theme in feminist critiques of psychiatry over the decades. It’s been suggested that not only are women’s emotions pathologized, but also that medication is used as a tool of control. Both have been true in the past, and in some places they still are. My profession has yet to acknowledge the full extent of its past and continuing poor treatment of women. However, if you are a person who believes there is no such thing as ‘depression’, as many do, it seems logical you are unlikely to believe there is a place in the world for antidepressants. 

I recognise depression to be real and very disabling in its severe forms. I’ve suffered from it much of my life and I’ve met and tried to help many other women, patients and friends, who have too. So, I’ve no doubt we have been the key market for antidepressants, just as we were in the past with benzodiazepines: 

Jan, ‘single and psychoneurotic’ because ‘she had never found a man to match up to her father,’ as the ideal candidate for Valium. [from an advert Archives of General Psychiatry 1970]

My mother didn’t fit this description, but she suffered with chronic anxiety. Something I inherited.

Many of us have benefited from antidepressants. I wouldn’t have been able to engage with some of the psychotherapy I received unless I had recovered sufficiently first by taking the pills. Nice recommends a combination of therapy and medication for severe depression. However, we do know much more now about antidepressants than when I began to use them in the early 90s. We’ve learned about the problems they can cause – particularly difficulties in withdrawing which can be severe for some people and also sexual dysfunction – including PSSD (Post SSRI sexual dysfunction). 

Women respond better to SSRIs than they did to the older Tricyclic Antidepressants (which I took at first), and younger women respond better than postmenopausal women. Hormonal fluctuations affect how our bodies metabolise them.  However, women have also been found to experience more severe sexual side effects from some antidepressants than men do. I’d like to know much more about sex/gender differences in both how we respond to and experience withdrawal from antidepressants, given that they are taken much more commonly by women. 

We still don’t know enough either about the impact on younger women of beginning and continuing on medication for long periods in their lives. Having started pills at 35 after the failure of therapy to prevent a severe relapse, I know how difficult it is for me to answer the question, ‘Who am I really?’ The person I was before I took the medication, whose mood fluctuated sometimes to extremes, or the person I am now, calmer, more level, able to focus (I’ve never experienced emotional blunting although I know some people do) but also not quite the person I was. Is this me or is it the medication? I’ve managed to cut my duloxetine dose in half without too many problems (I am well familiar with brain zaps) but what would happen if I tried to cut further given the length of time that I’ve taken them? I share Awais Aftab’s measured opinion on what we know, and don’t yet know, about withdrawal. We cannot be complacent. 

However neither can we be complacent about how many women are being prescribed antidepressants. It isn’t a decision women take lightly but I know from my own time in practice how antidepressants are prescribed when therapy, if it were available, would be effective. I also know that some, like me, would benefit from medication when therapy and other options, just don’t work. They were far from my first choice in my early life. However, alternative treatments – including any kind of therapy without waiting for months – but particularly, longer-term psychodynamic therapy for women who have experienced early trauma and therapy for depression associated with PTSD related to domestic violence, are all difficult to access quickly if at all in the UK unless you pay. The specific issues facing women who experience depression, either in terms of better access to care other than pills, or politically in the multiple problems in our misogynistic society that make women more likely to get depressed, are not being adequately addressed.

                  Depression is real. As women we need to campaign not only for changes in society to help prevent it, but demand access to more effective and a wider range of treatments for it, when it happens, than simply a prescription. 

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is available now.

The embodied woman

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The recent USA Food and Drug Administration (FDA) expert panel on the use of SSRIs in pregnancy, was a hard watch for various reasons, but, be assured, I’m not going to get into any discussion here about the risks of medication in pregnancy for reasons of my own sanity. No. My concerns were fourfold. The serious shortage of people with experience of actually caring for women with perinatal depression on the panel; the absence of evidence from anyone who has suffered, and I really stress that word suffered with it, who might share their views (The National Institute for Health and Care Excellence, NICE, in England and Wales, always hears from people with lived experience at its deliberations); and, relating to the last point, the denial of some of the panel about the reality of, and the need to treat (yes, I’m using the word – it doesn’t have to mean medication) perinatal depression, even though suicide is the leading cause of death in the first perinatal year in the UK. If anyone feels strongly this is due to prescription of SSRIs, please present the evidence. I can only say that having cared for a mother who was pregnant again after having survived attempting to take her own life and that of her new baby (who tragically died), the risk of this happening a second time was something we all took very seriously indeed. The women I listened to as a clinician convinced me of the reality of postnatal depression and psychosis, and while working on Out of Her Mind, the stories shared with me and reproduced in the book with their permission, moved me to tears.  

Finally, however, it was the suggestion by one of the panel, that depression is more common in women because we naturally experience our emotions more intensely- that this is one of our gifts, not a symptom of ‘disease’. This has stayed with me. Really? None of the women I have met, or I who have had problems with my mood for most of life, experienced depression as a gift. More of a burden. And to suggest we are more emotional… I’ll leave that one with you. 

But what is being really being said here? 

First, let’s get rid of the ‘disease’ word. I don’t talk about depression as a disease, but I do think it’s an illness, a period of being unwell which for me doesn’t have to imply a biological cause. Having said that, as I wrote in my own memoir of depression The Other Side of Silence there is no single thing I’d call ‘depression’. The DSM checklist confined us to counting symptoms rather than trying understand and recognise what it’s really like to feel depressed. Depression can take different forms and have multiple causes. They can be biological, psychological, social, and to that I’d add the wider political environment too, very pertinent to women’s lives. There are factors that make us vulnerable, such as our genes, early environment, and for women especially, abuse and trauma. Then there are the stresses and life events that can trigger depression. In my recent blog on the mental health of young women, I described the multiple social factors that are contributing to their poor mental health, so I won’t repeat them here. Pregnancy and motherhood, particularly when there is little family support in a society where there is an epidemic of violence against women, and in an economic environment where women are struggling to hold families together, or parent alone, is, you would say enough to make any woman depressed. But it doesn’t happen to everyone, and that is where not only the presence of plentiful social support but also underlying vulnerability, biological, psychological and social, comes in. Your previous life experiences, your ways of coping, your family history and, guess what, your hormones.  Men have those too, only they are (mostly) different ones, and they don’t go up and down all the time like ours do. That’s important. Some of us are much more sensitive to those hormonal changes than others. If you have post-natal depression you are more likely to have depression at the menopause too. Hell, there’s more than enough reasons for us to have more depression than men without us just being more emotional!

We know much more now than we did about how, for women, it is sometimes their hormones causing problems. In the past, feminists like me were angry at being ‘written off’ because of our hormones, somehow viewed as weak and less capable, but we cannot ignore our bodies. My generation of feminists were dismissive of biological explanations which generally painted us as inferior. Many feminists are still mistrustful of the life sciences, but according to the American biologist and feminist theorist Anne Fausto-Sterling we have a choice. We either push back against each claim about the causal role of the biological body, or we: 

‘grapple with the reality of a body made up of cells and nerves and tissues, but still look critically at how bodies absorb and are inscribed by culture – how physiology and society, nature and nurture, are constantly co-creating each other, to the point where it doesn’t make sense to look at either of them in isolation.’ (From Sally Davies in Aeon)

Let’s not ignore the part that our bodies play too in how we experience the world. Yes we are steeped in our culture, but as women, we are surely more than this, we are ‘embodied.’

My latest book: Out of Her Mind: How we are failing women’s mental health and what must change is out now.

Walking with dinosaurs

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It’s been quite a week for the grandees of my profession. 

First they’ve been sharing their views on why today’s resident doctors shouldn’t strike and then telling us why we should return to limiting the number of women who should go into medicine.

It’s embarrassing belonging to the same professional generation as those recently sharing these views. I started medical school in 1974 in Edinburgh and qualified in 1979, so I’ve been a doctor for 46 years this year, although I retired from my full-time job as an academic psychiatrist in 2013. Professor Sikora, who has been a doctor for more than 50 years told the Telegraph he was appalled at doctors striking. The sub-heading of the piece is Money buys you neither love or happiness. I cannot tell if that is a direct quote as the rest is behind a paywall. However, I can tell you that when you are poor, money helps.

I very much doubt that I would have gone to medical school today. I come from a working-class family. No-one had been near a university or had ever wanted to. My father worked repairing seaside amusements, and my mother in a radio factory. It was a real step up when she got the job at the Coop greengrocers counter. She always borrowed to get through the week. Everything in the house was bought on tick. I had a full grant for every year except my first, when my parents had to contribute £50, and my fees were all paid. I lived frugally but well. Better than friends whose wealthy parents didn’t fulfil their parental contribution. After I left university, having found house jobs (FY1 now) near Edinburgh, I moved down to England. I had low-cost hospital accommodation when I needed it, hot meals at night, free parking, and no debt. We (I was married by then) were able to get a mortgage immediately, although my ex-husband’s salary took precedence. I bought my own home without difficulty when we divorced. I worked long hours, and it was tough but as a consultant I had great secretarial support. I suspect that has all gone now too, though managers seem to still have PAs?

I met those with views about women in medicine like Dr Meirion Thomas, during my career. I think I was supposed to feel grateful that at least I had been allowed to graduate in the first place, unlike the Edinburgh Seven, heroines of my alma mater, who were unable to, despite out-performing  the men. The consultant orthopaedic surgeon in Falkirk Royal Infirmary would not speak directly to me because I was a woman. All instructions were relayed via the ward sister. The postgraduate tutor in the general hospital where I became a consultant expressed similar views to our medical students even in the 1990s. 

There were times I thought about emigrating (to Canada) but I stayed. There was a cohort of us in my generation from the working class, who, after the second world war, benefited from free first-class education from secondary school through university. Despite the valiant efforts of those trying to widen access only 5% of those entering medical school still come from the lowest socioeconomic group. If I was making that journey today, I personally could not have coped with having to work throughout my degree, as many now do, nor the huge amount of debt afterwards.  We also know the NHS has never been a good employer. I not only treated many employees, some episodes of my own severe depression were triggered by my interactions with management. I gave evidence against one Chief Executive at an inquiry into his behaviour, which didn’t help my career at the time. Seeing resident doctors being asked to pay for their accommodation when on-call (see recently on social media) suggests to me that concern for their welfare remains low in many places.

I never went on strike during my career, because I never needed to, but if I were working today as a resident doctor, I have no doubt that I would. I would also have considered emigrating to anywhere that would value my skills and treat me with more respect – and pay me better. If there are now more women doctors than men, so be it. Get more men to apply to medical school. When and if women have children is up to them. The NHS must change to support them. They are the future, and if they drop out, leave medicine, or leave the country, they will be gone. We cannot have dinosaurs still telling them they shouldn’t be here. 

I support striking doctors unreservedly. 

Professor Linda Gask

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is published by Cambridge University Press

What is happening to the mental health of young women?

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Society seems to have great difficulty in talking about the mental health of women just now. That’s problematic when the latest figures show the gender gap between men and women remains and is especially stark for young girls and women. The proportion of all those aged 16-24 with a common mental health condition rose from 17.5% in 2007 to 25.8% in 2023-4. However, the proportion of young women reporting a mental health condition is now the highest on record, at 36.1% in comparison with 16.3% of men. This news went almost unregistered by the media in Britain at the end of June.

It’s just girls isn’t it?

The authors of the latest iteration of the Adult Psychiatric Morbidity Survey (2023-4) say in their Conversation article, ‘Mental health in England really is getting worse. One in five adults are struggling.’ They also challenge the claim of overdiagnosis. “The APMS has been conducted with consistent methods over decades, using the same robust mental health assessments with large, random samples of the population. This means the results are largely not affected by changes in levels of mental health awareness or stigma, and changes in levels of diagnosis or service contact.”  These data are epidemiological estimates based on official criteria. (Helpfully the survey also shows self – diagnosis rates too for comparison, and these are higher).

So what is happening for young women? And why do we seem to find it so hard to discuss it? 

We know this is a worldwide phenomenon and in many countries suicide rates are increasing more rapidly in young women than in men. A recent Australian study reported an annual prevalence of nearly 50% for mental disorder in young women. Socioeconomic factors play a significant part in why both men and women develop mental health conditions – debt, unemployment, chronic ill-health, homelessness – but women are more likely than men to be in precarious work, to be reliant on benefits to survive, be single-parents and unpaid carers. Poverty matters, and if you add in intersectional factors such as being from an ethnic minority and/or LGBTQA+ risks to mental health multiply. Women are also more likely to have faced early traumas such as sexual abuse and then must deal with sexual harassment and gender-based violence in their everyday lives.  If in doubt, look at the pages of Everyone’s Invited which spells out the experiences of many young women very clearly. We have rising levels of misogyny, which is rightly leading us to question what is happening to young men and what needs to change for them. But this fails to take into account what happens to those who experience and survive the damage caused by the behaviour of boys and men, and the harm this is causing to the psychosocial development of young women. Gender based violence and abuse alongside being in poverty creates a web of adversity and mental ill-health in women’s lives.

Growing up now as a girl is very different from how it was for me in the 1960s and 70s. The pressures in terms of getting an education, feeling good about your body image, navigating sex and relationships and discovering and developing an identity are considerable and amplified by social media, which I’m so relieved I never had to contend with. 

Women are more often seeking help for anxiety, depression, eating disorders and self-harm but their mental health issues are not being considered through a gender specific lens. The menstrual cycle plays an important part in the mental health and well-being of young women but has been largely disregarded in the past in mental health care. We still need to know, for example, much more about the interactions between ovarian hormones and early life trauma in women. The APMS reveals that more men are getting access to care than they previously did. However, waiting times for psychological therapy remain long, the majority on those lists are women and the therapy provided will most likely not be tailored to the specific needs of women who have experienced trauma and violence. It is all too easy, as a young woman, to receive a diagnosis of Borderline Personality Disorder when you have been subject to repeated abuse and trauma.

 Is it surprising that new claimants for disability benefits in the UK are more likely to be younger, for mental health related problems and to be women? Limiting access to those benefits will increase poverty and continue the cycle of despair and adversity. Instead, we must rethink the way we support women and girls. Many will need access to a tailored, person-centred, biopsychosocial assessment, designed around their needs and preferences but its most definitely not a problem to be solved with more medication. To stem the increasing problems young women are facing demands that society recognises it, talks about it and has the political will to address the serious challenges young women currently face such as gender-based violence and misogyny. As women we are expected to not complain too much, ‘put up and shut up’ and if we do need help, ask for it ‘appropriately’ which doesn’t include harming ourselves, even though our needs often go unnoticed anyway. We often are accused of exaggerating or faking it. There is a continuing pattern of raising concerns about women’s mental health and society failing to act.

Isn’t it time we listened to young women, believed what they are telling us about their lives and talked about it rather than just let each new report drift by and disappear into the ether?

Then let’s get together and do something about it. 

My latest book: Out of Her Mind: how we are failing women’s mental health and what must change, is on sale now.

Reflections on reading Unshrunk by Laura Delano

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Forty years ago, Carol Gilligan, the veteran feminist psychologist wrote about how young women may lose their ‘voice’ during adolescence as they navigate the pressures of society. We women resist these pressures to disengage from our honest voices but are told that we must repress our anger and questioning selves and conform to societal norms if we are going to succeed in the world. We are told that it is wrong to resist.

Laura Delano’s world was a privileged one, but it was a life which nevertheless came with quite firm expectations. At the age of 13 she looked in the mirror and began to question what was happening to her in this somewhat gilded existence. ‘I had no idea who that girl was anymore. All I knew was that she was someone else.’  

The tragedy of the next couple of decades is that, instead of having an opportunity to try and voice these thoughts, feelings and fears through conversations over time with a therapist skilled enough to both engage and work with her (she is sadly declared too serious a case for the one she does see), Delano is diagnosed with bipolar disorder by a psychiatrist at the age of 14 and given the bleak prognosis that she will need to take medication for the rest of her life. She is started on both Depakote (a mood stabiliser) and Prozac. This leaves her feeling betrayed, alone and ‘in a battle to protect myself’. 

Reading about what happened left me feeling both full of compassion for her  and anger that a fellow shrink could ever consider this to be good psychiatric practice. But that is only the beginning of this shocking story of multiple diagnoses and dangerous polypharmacy.

Oddly, I wasn’t surprised by the experiences Delano describes with each subsequent psychiatrist because I’ve read some similar accounts in recent years, notably Rachel Pruchno’s moving account of trying to help her daughter obtain good mental health care for bipolar disorder. I’m not going to pass any judgement on the diagnosis of bipolar that Delano received other than in my opinion coming to any such conclusion in one so young should take much more time and caution. Its also stunning how it sounds as though the diagnosis first provided is then taken as read – something that I was taught never to assume. Diagnoses are only working hypotheses which change over time, and as Allen Frances says, should be written in pencil. However, further additional diagnoses and medication are added to the list over the following years. 

The period that Delano spends at McLean Hospital in the unit for Borderline Personality Disorder is however, for me, the most disturbing. It’s hard not to see this as some sort of place where it feels like attempts were made to overcome her resistance and get her to ‘behave’, in order perhaps to restore the ‘promise’ for society that she once showed as a New England debutante. I know many therapists will disagree but it’s a diagnosis some of us intensely dislike – rooted in a misogynist perception of how women and girls behave when extremely distressed, and here there are so many of them, collected together and regularly judged as to their ‘progress’. 

The polypharmacy is chaotic and dangerous. I have some skin in the game here, both as a (now retired) psychiatrist and as a patient. I’ve prescribed many of those drugs but also taken quite a few of them too. I know about the side effects – the weight gain caused by Seroquel, the terrible thirst and tremor of lithium (I was never able to discontinue the thyroxine after lithium damaged my thyroid gland), the constant gut problems and the difficulties of coming off SSRIs and SNRIs. I’ve had episodic depression throughout my adult life, which at times has proved difficult to shift but I benefited from excellent care from colleagues in whom I trusted, and medication did help me to survive and thrive, even lithium. 

One reviewer of this book has criticised it as a study in ‘black and white’ thinking. But I’m old enough to remember the change from ‘black’ to ‘white’ that came about in American Psychiatry, when it shifted from reliance on psychoanalytic interpretation to declaring the dawn of ‘decade of the brain’ accompanied by a hefty dose of psychopharmacology. Psychiatrists treating Delano seem to keep these modalities quite separate too. Never wanting to ‘see’ the whole person in the round – a young woman getting minimal benefit from treatment and experiencing what is desperate and suicidal anguish – to find out what she really needs.

However, Laura Delano did ultimately resist the ‘psychiatricization’ of her life and triumphantly survived to found the non-profit Inner Compass Initiative which helps people withdraw from medication. It probably goes without saying that I don’t share her view that psychiatry is the main problem though I’ve met people over my career, and some of my personal friends, for whom it certainly has been a significant part of it and who have only thrived when away from it completely. I believe it can do great harm but can also do much good too. In my professional and personal experience mental illness not only exists but can benefit from medication and psychotherapy. Some will say, of course I would say that, but I do also acknowledge the importance of the existence of the ‘other’, outside of psychiatry and mental health care, to whom people can turn if they need to, for advice, support and advocacy. 

I have known people who have been diagnosed with severe mental illness who have been able to come off all medication and live a drug free life, and others for whom this was quite impossible. I still take duloxetine to stay well and often wonder what I would be like if I didn’t. The medication free me is a person I’ve not known for many, many years. But having reduced the pills considerably I know that last few milligrams will be hard to withdraw from given the decades for which I’ve taken it. Support is vital, and, even if we disagree, ‘inside’ and ‘outside’ psychiatry might benefit from working together for the very sake of those we are trying to help. 

Laura Delano fought to rediscover her voice. 

Even if you disagree with what she has to say, it is indeed a powerful one.

*Laura Delano Unshrunk : How the mental health industry took over my life and my fight to get it back. Monoray 2025.

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is published by Cambridge University Press and is a PROSE award winner (American Association of Publishers) in the USA.

Addendum to ‘Three times more common in women.’

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I promised I would reply to the comments on this blog which were posted on X, mostly by psychotherapists working in the USA, so, after a holiday and an intensive week of public events (conducted from my desk in Orkney whilst wearing my slippers) here we are.

In response to Mark Ruffalo’s comments about the ‘Borderline Wars’ which prompted the discussion I can only say that debate does continue, as does research and psychiatric science is always evolving and modifying our views of the world – as it should do.  My views have changed over my career in response to listening to the stories of many, many women who have received the diagnosis, but I still found the observations and insights provided by reading the great psychoanalytic researchers in the field very helpful in my work. Although I disagree with Peter Tyrer’s view that diagnosis of personality disorder should be broadened – in fact I’d much prefer to limit it very considerably – his work on ICD-11 brought together world experts in the field and they arrived at somewhat of a compromise to still include the ‘borderline pattern specifier’. He notes in a recent review in World Psychiatry:

‘The features of borderline personality disorder are not traits, but symptoms and fluctuating behaviours, and – like many symptomatic conditions – improve steadily over time. When borderline symptoms are examined in factor analytic studies, they are scattered over a range of both personality and other mental disturbance and have no specificity’. All attempts to find a borderline trait have failed. While borderline symptoms appear coherent when examined in isolation, they disappear into a general personality disorder factor when modelled alongside other personality disorder symptoms.’

            I’d recommend this open access article to anyone interested in a different perspective on ‘borderline’. I realise it contrasts with that held by many therapists, especially in the USA (hence the inclusion of the ‘borderline pattern specifier’).

            I’ve questioned why the diagnosis is more common in women. I certainly agree that more men get diagnosed with anti-social personality disorder, and many of them are indeed in prison. But I suspect some men are also more likely to get diagnosed with cPTSD instead? Do we know? Women with the diagnosis of BPD are also overrepresented in the prison population too, (including some that are frankly misdiagnosed – which is certainly a major problem as I’ve discussed in the blog). Women are more likely to seek help for mental health problems, but I do think we need to consider, (as someone commented but I can no longer find their post!) how much the criteria used to diagnose BPD reflect emotions and behaviours that are more associated with women in extreme distress.  I also really appreciated the comments about the menstrual cycle, which affects and colours just about all mental health problems that women experience, not just those given a diagnosis of BPD.

It’s very difficult for me to know how different care is for those diagnosed with Borderline Personality Disorder across the Atlantic. Reading Laura Delano’s book Unshrunk includes a description of her care under John Gunderson at McLean Hospital and has been fascinating in many ways (review to come). Such residential care with intensive therapy has, as far as I’m aware, pretty much disappeared now from the UK, but I’d be interested to hear whether this is true.

 Awais Aftab, in his review of Out of Her Mind, has said, in response to my views about BPD that:

 ‘In a system where such attitudes are pervasive, it is easy to see how one would conclude that misogyny is baked into the very concept of BPD. Working as a psychiatric clinician in an entirely different health care system in a different country with a different patient population whose experiences with the diagnosis are more favorable, I can afford to say in return that it is more complicated than that.’

I really appreciate his different perspective but would like to know what happens to those in the USA given this diagnosis, especially women, without access to the kind of expertise that families or good health insurance can purchase. And elsewhere around the world too.  What do they think of the care that they receive?  

Listening to women’s experiences has been key for me, which is why why Out of Her Mind is so full of women’s stories.

Three times more common in women

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Women are three times more likely to be diagnosed with borderline personality disorder (BPD) than men. That fact alone should give you pause for thought. 

Yet when I read the endless academic papers and discussions about the proposed causes of and treatment for BPD, (sometimes still called emotionally unstable personality disorder or EUPD), especially those from the psychoanalytic community in the USA, the question ‘why?’ never seems to arise. It is a ‘complex interplay of genetics, biological factors, trauma, abuse, neglect and pathology of attachment’. But isn’t that true, more or less, for many of us with mental health problems? I say this as someone who has in the past been told I have ‘borderline traits’ (by someone who was reviewing my first book, The Other Side of Silence, on Amazon).  My personality has certainly been influenced by all of these factors, as have those of a great many of us. That doesn’t mean I think we all have personality disorders (which is the direction that ICD-11 has taken us in). Rather like if ‘everything is trauma’ then it follows that nothing probably is, for me the same is true of personality disorder. We are all complex individuals and some of us are far more capable of managing interpersonal relationships than others, depending on many things but particularly the interplay between our early experiences, temperament (which is inherited) and (sometimes traumatic) life events. But that shouldn’t make us ‘disordered’.

Forty years ago when I was training in psychiatry, and hoping to become a psychoanalytic psychotherapist, I was first introduced to the ideas of the great American psychoanalytic thinkers, Heinz Kohut, Otto Kernberg and John Gunderson. I do appreciate their massive contribution to understanding and working with people who have great difficulty in relating functionally to themselves and others. I listened to the legendary British psychotherapist Anthony Ryle in the spring sunshine in garden at a society for psychotherapy research meeting in Ravenscar sometime in the late eighties as he diagrammatically reformulated borderline personality disorder, with his ‘broken egg’ diagram and realised how I had felt many times as though I was stuck between the sharp edges of the egg shell not only as a therapist, but also as a person and a patient. Because I was in therapy too over several years, trying to manage my own difficulties with a persistent depression that was undoubtedly influenced by that complex biopsychosocial morass of factors that both moulded my personality, and resulted in my problems with my mood and my relationships.  For decades I was professionally and personally aware of the overlap between ‘borderline’ symptoms and many other diagnoses, particularly mood disorders. If aspects of our personality contribute to us both experiencing and having difficulty recovering, we need psychotherapy and should be able to get this without being diagnosed with personality disorder. Something I wrote to the NICE guideline committee about with no success.

But, even though later, as a clinical academic general psychiatrist (I decided against becoming a psychotherapist and went into academia) I wrote and taught about personality disorder, I was aware that ‘borderline’ was diagnosis that I almost never personally used. In later years I’ve found the words of George Vaillant the veteran American psychiatrist particularly cogent, ‘The beginning of wisdom is never calling a patient borderline.’ In his paper Vaillant, who followed people up over many years for his research into personality, talks about ways to help those who use problematic defence mechanisms to cope. People who had experienced difficult lives. He calls their defences ‘immature’ but they are very common ways of coping, and I have met them often in my work in mental health, amongst my colleagues as well as my patients. Vaillant says: ‘I believe that almost always the diagnosis “borderline” is a reflection more of therapists’ affective rather than their intellectual response to their personality-disordered patients’, the powerful impact of the countertransference – that the patient has on the therapist. He also talks, as do others such Peter Tyrer, of the considerable symptom overlap with other diagnoses. In British psychiatry “Borderline’ has become an insult applied to many women too often without any adequate assessment of what their problems might be. This now applies to the umbrella term ‘complex emotional needs’ which Hat Porter and their colleagues rightly call a new pseudo-diagnosis that ‘risks further legitimising the personality disorder construct and broadens its scope, therefore widening the prejudice, discrimination and neglect associated with the label.’

I’ve spoken to some who find the diagnosis useful to understand their way of relating to the world, and sadly to obtain therapy (accepting it seems to be required by some therapists). But I have met so many others in the world, during my research for Out of Her Mind, and on Mad Twitter who have not, and have suffered terribly – even been excluded from care altogether.

            But why is it so commonly applied to women? First of all, I’ve no doubt that many women given this label are misdiagnosed and may have PTSD, bipolar disorder, Premenstrual Dysphoric Disorder or be neurodivergent, but have simply not been listened to. Secondly, people who get the label BPD are overwhelming likely to have experienced complex trauma and have experienced childhood adversity which we know is more common in women. How many women who are subject to repeated sexual violence end up with this label? And, as Jay Watts say in her recent paper ‘who gets to be a victim’ determines whether the cPTSD (complex posttraumatic stress disorder) diagnosis is given (which I’ve witnessed in practice), or BPD. Sometimes it’s even both. cPTSD was intended as a kinder label but “Paradoxically, the introduction of cPTSD has reinforced the seeming validity of BPD, as direct comparison often does.” Helping someone doesn’t require acceptance of the label. Therapies researched for BPD do work for cPTSD and perhaps it’s time we took a transdiagnostic approach, working in collaboration with the patient to consider with them what is needed to help them, be it help with emotional dysregulation, mentalisation, processing trauma, or other ways of coming to terms with living in the world. I benefited greatly from psychodynamic therapy so I am biased, but I do know that the sense that my therapist believed in me, and didn’t see me only as a ‘difficult woman’ was crucial.

Yet, mental health professionals seem to find it a label they want to continue to apply especially to ‘difficult’ women, including those who fail to recover from depression or eating disorders as fast as they ‘ought’ to do and especially those who self-harm. I have sympathy with the feminist view that the ‘symptoms’ of BPD are remarkably like the way that women simply cope with extreme emotions. That it is inherently misogynist.  In some ways ‘complex emotional needs’ echoes this – how many women have been told they are ‘too needy?’ I was, many times, in my younger days. 

We must begin to consider in greater depth how women with serious mental health problems which are not ‘psychotic’ (which tends to be the focus of care) are being assessed, diagnosed and helped, or not in mental health systems. Just because ‘this is how we’ve always done it’ or ‘we have specialist units set up for excellence in BPD’ are not good enough reasons to avoid change (except of course for accountants). 

Read about my latest book: Out of Her Mind: How we are failing women’s health and what must change