The Gender Dilemma...

Davies, B., 2015. The Gender Dilemma.... Reformulation, Summer, pp.10-11.

CAT is a developmental model, which describes our experiences of relationships with ourselves, others and the world as being
derived from our early experiences of relationships. The descriptions of reciprocal role procedures allow the nature of these relationships to be clearly defi ned. I think that this way of thinking about personality development might enable us to consider gender in a realistic and open -minded way. We can see our gender identity as developing as part of the wider picture of our personality development. It makes sense that males’ and females’ differing experiences, which it could be argued might be affected by genetic and biological factors as well as how they are treated, will lead to different reciprocal role repertoires. I will look at this in more detail later, but I think that CAT sits well with a post-modern approach, acknowledging the fact that our personalities and identities are constructed by our interpersonal and cultural experiences (our gender is not pre-destined or binary) and able to accept and work with a spectrum of people who may not all fit with traditional expectations.

Gender has a part to play in psychotherapy well before any referral is made. Men and women are found to have different patterns of mental health diffi culties – whilst men have higher instances of ‘personality disorders’ and drug and alcohol problems, women have higher instances of ‘neurotic’ disorders, and whilst women make more suicide attempts, more than twice as many men complete suicide attempts (Department of Health, 2008). At any given time, at least two thirds of my clients are female, and I wonder why this is. We know that fewer men are approaching services, but might it also be a bias in referral for psychotherapy on the part of other clinicians? Are male clients more likely to be assigned to male therapists, or to particular sorts of therapy? I wonder whether men are seen as more logical, and less emotional, and thus more often offered a CBT approach.

Should gender be taken into account when assigning clients to therapists? In peer supervision with a male colleague, he told me that he has had a series of initial assessments with clients who he has subsequently reallocated to a female therapist, as they have said they are uncomfortable working with a man. On some of these occasions my colleague guessed this might be the case and asked “ Certain procedural patterns remain tied to gender stereotypes [which] are still instilled and sustained by cultural and economic pressures. They are also to some degree rooted in... complex evolutionary predispositions... In our culture, patterns of placation and submissive denial are much more commonly found in women... while the avoidance of emotional expression and denial of emotional need remains a largely male characteristic.” (Ryle and Kerr, 2002, p.157) © ACAT Reformulation Summer 2015 12 Reformulation-Summer 2015 v7 amended 26.05.15.indd 12 26/05/2015 12:00:10 about preference. I realised that I never raise gender in this way as part of my assessment, even though I am aware that issues of gender often come up later in therapy. A key issue here is one of abuse in clients’ history, something we often learn about before we even see clients or early on in our assessment. Whilst abuse is more often perpetrated by men, this is of course nowhere near exclusively the case, and furthermore my clients have often had complex and difficult relationships with female caregivers even if they might not be labelled as abusive. However, the picture is even more complex as it is not only the gender of the perpetrator(s) that is an issue, but also the meaning and significance of clients’ own gender in their trauma history. Clients may be very aware, for example, that their parents really wanted a little girl, or that they were targeted for sexual abuse because they were female, or that as a boy they were bullied because they liked dance more than football, or that as the oldest girl they were expected to look after all the other children and were to blame when something went wrong. I think that CAT is very well placed to deal with this complexity; the reformulation letter in particular allows these sorts of narratives to be properly acknowledged – sometimes for the first time.

If, as therapists, we need some understanding of our own psychological make-up to work effectively with clients, then having thought about our relationship with our own gender might be a part of that – this will surely impact on which of our clients’ reciprocal roles we are more likely to identify with or reciprocate. It might also influence the material that comes up in therapy through the questions we ask and our responses to information we are given.

We might also need to consider the assumptions clients make about us. As a woman, might my clients expect me to fit female stereotypes, such as being caring and nurturing (Caring and nurturing to cared for and nurtured)? Might these expectations be influenced by inadequate care from female carers, leading to expectations of either inadequate or perfect care from me? And, how might those assumptions change if I do not meet my clients’ expectations of what a woman should be like? My clients can probably read something about my own relationship to my gender in the way I dress, the way I organise my office, my body language and the way I speak, and I wonder to what extent this facilitates or inhibits the narratives of different clients.

There has been some research into the impact of male vs. female therapists, and it seems that while clients tend to report that they form better alliances with female therapists, there are actually no differences in outcomes for male or female therapists (Jones and Zoppel, 1982). However, whilst this might be the case overall, it might still be important to consider client-therapist match on a case by case basis, not only to make decisions about suitability but also to consider what issues it might raise. It should be possible to do this in a psychologically informed way, and I think that CAT is well placed to help with this.

As an example of the complexity of this issue, a colleague brought a client to my supervision group, who was identifi ed in the referral as a female and used a female name, but who answered the ‘as a man...’ not the ‘as a woman...’ part of the psychotherapy
fi le. Following discussion in supervision, my colleague went on to check out with her client how she saw her gender identity.

This part of the psychotherapy fi le may present these sorts of opportunities for exploring issues of gender early in therapy, and show that the topic is not taboo but can be spoken about candidly. However, I am not convinced that this is always the best way to bring up the topic, and this will only be effective if treated sensitively - this example also brings up a potential issue in working with clients who may not fi t into our binary gender defi nitions. Chess Denman (2004) suggests that “successful psychotherapy with transgendered, transvestite or intersexed clients needs to be conducted from a position that is well informed… and benignly disposed towards the patient”. A good starting point for this is likely to be remaining curious and non-judgemental, and in my opinion this should include, when appropriate, checking out which pronoun (he, she or they) clients prefer to be used, for example, in reports to other professionals.

The corners we are pushed into and the parts we cut off 
As stated earlier, men and women present to different parts of services, and tend to receive different diagnoses. I would like to look at Axis II disorders here, as these by their nature describe enduring personality traits, and furthermore CAT claims to be well placed to understand and treat these ‘disorders’. Women are far more often diagnosed with borderline personality disorder (BPD), whereas men are more often diagnosed with antisocial personality disorder (Ryle, 1997) and narcissistic personality disorder (NPD). Women are more likely to be treated in mental health services, and men in forensic services. Can CAT help us to understand this phenomenon? CAT describes specifi c models for both borderline and narcissistic personality disorders,  lthough there is a recognition that these and other Cluster B disorders often overlap. There is not (to my knowledge) a specifi c CAT model for antisocial personality disorder, however I imagine that similar considerations might be relevant. 

CAT understands BPD as a partial dissociation between different self-states, each of which contains a pattern of reciprocal roles and associated procedures (Ryle, 1997). NPD is understood in CAT as twin, split states of ‘admiring to admired and special’ and ‘contemptuous to contemptible’ (Nehmad, 1997). Elizabeth Howell’s (2005) writing on the relationship between gender, trauma and dissociation, if studied alongside these CAT models, may help us to understand how one’s gender might make one more vulnerable to BPD or NPD.

Howell suggests that gender stereotypes, including males being unemotional, independent and aggressive, and females being passive, caring and dependent, have their roots in trauma and dissociation. She reminds us of the different experiences of trauma suffered by boys and girls – boys more often experiencing physical abuse, outside the home, from extra-familial perpetrators and girls more often experiencing sexual abuse from family members. She proposes that sexual abuse and its
sequalae can lead to mental states that match female stereotypes, such as dependent, masochistic or seductive states, as well as more masculine-linked states such as enraged or violent. It is easy to see the links between these state descriptions, and the CAT BPD model.

Howell (2005) goes on to describe a splitting of two main states – ‘good girl’ and ‘bad sexy girl’. And here culture plays a further part – ‘good girls’ are seen as more acceptable in society, and may in fact help a woman to get on in life – thus the ‘bad girl’ part, with all of the rage that is not seen as appropriate for women, may be disavowed, dissociated from and repressed. The ‘good girl’ is other-oriented, maintaining the woman in a position of object, only existing in relation to a dominant other. In BPD, women may swing between the ‘good girl’ and ‘bad girl’ (perfect care and abusing or rageful) positions, and the extreme of this is Dissociative Identity Disorder, in which abusive, rageful states often have male identities.

Turning to male development, Howell (2005) describes a social and cultural expectation that males do not express any feelings other than anger: feelings of loss, shame and vulnerability are particularly unacceptable. She notes that sexually abused boys, whilst they can exhibit psychological patterns similar to those of girls, including self -abuse, more often behave aggressively towards others. Boys are exposed to higher levels of physical threat and violence than girls, and on top of an expectation not to express emotional vulnerability, this leads to boys and men being forced into aggressive, ‘hypermasculine’ states. Boys are also expected to separate from their mothers more quickly, and to disavow more feminine aspects of them selves (disidentify with the mother fi gure). Howell suggests that this means that achieving a masculine identity comes at a cost of dissociating oneself with everything feminine. Thus emotional bluntness and a denial of vulnerability becomes part of male identity, and this causes problems in an inability to process loss in adult life. Again, this description seems to fi t with the CAT NPD model, and indeed Shannon, Willis and Potter (2006) have adapted the model specifi cally to explain violence in men.

Going back to my criticisms of binary gender assumptions it is important, whilst holding these ideas in mind, to remember that they are generalisations or common patterns, and that in reality every individual grows up in a unique cultural environment, with a different pattern of predispositions, stresses, power and privilege.

Conclusions and implications Gender is a powerful and important part of our identity, and a major area of difference between
people – this is probably one of the reasons that it features so strongly in early psychotherapy theory. The people who come
to see us as therapists are often disempowered and sometimes struggling with aspects of identity – questions like ‘who am I?’ or
‘why did this happen to me?’ often arise. As therapists, we are therefore in a powerful and privileged position, to help people
to work towards resolving those sorts of questions, and I think that CAT can really help in this work.

In this article, I have argued that issues of gender should not either be assumed or ignored. To end on a practical note, I would like to make some suggestions, for how this can be achieved in practice:

• Get to know your own relationship with gender

• Ask about the infl uence of gender, past and present. ‘What was it like being a girl in your family?’ ‘What does being a man mean to you?’

• Remember that gender is not the only infl uence on our power and privilege

• Be aware that people do not always identify as the gender they were assigned at birth, or, if they do, may have complicated  feelings about this - do not be afraid to ask

• Do not be afraid to talk culture and politics. Acknowledge and label distal factors infl uencing psychopathology. We live in a
patriarchy, and I think it is good practice to let clients know that you have noticed this.

About the author
Bethan has written this article from the standpoint of a welleducated western, white, female, queer therapist, working potentially
with people of all genders in a secondary adult mental health service in an urban area. They are a Clinical Psychologist and CAT Practitioner, working for Leeds and York Partnership Foundation NHS Trust.

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Davies, B., 2015. The Gender Dilemma.... Reformulation, Summer, pp.10-11.

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