Despite heroic efforts to reconceptualize existing paradigms, the dichotomy between ‘brain disease’ and ‘mind disease’ continues to be prevalent. There is growing support, however, for an interactional construct that unifies brain and mind, biologic and psychosocial, based on increasingly sophisticated and complex scientific data and conceptualization. As Eisenberg (1995) has stated, ‘Nature and nurture stand in reciprocity, not opposition. All children inherit, along with their parents’ genes, their parents, their peers, and the places they inhabit’. This idea about reciprocity and interaction of nature and nurture applies to gender differences.

Evidence of gender differences in the nervous system, beginning in fetal life, suggests that from birth boys and girls may not perceive and experience the world in the same way. For example, females are better at language skills such as verbal fluency and grammar, classically left-hemisphere functions, while males, on average, are more facile at spatially related tasks such as picture assembly and block design, typically right-hemisphere processes (Siegel, 1999). Gender differences in neural maturity and organization influence behavior and reactions in infants. These, in turn, can affect caretakers responses, further reinforcing differences. Because experience can modify the structure and function of neurons and neuronal networks, and can even change gene expression, these differences in caretaker responses serve to further alter the growth and development of neuronal pathways (Kandel, 1999).

Another area in which the integration of biological and psychosocial phenomena has relevance has been shown in the data accumulating on the consequences of early abuse. Early childhood physical and sexual abuse is associated with brain dysfunction, primarily of the limbic system (Hull, 2002). Teicher et al. (1993) concluded that their ‘findings are consistent with a complex biopsychosocial hypothesis: namely, that sociological factors leading to early abuse may result in biological alterations in the development of the central nervous system, with these alterations manifesting as persistent behavioral disturbances that are in turn associated with long-term psychiatric sequelae and a proclivity for the intergenerational transfer of abusive and aggressive behavior’. Moreover, some data on the experience of childhood trauma suggest that each sex is affected differently. Women report more problems with self-esteem, relationships, and work, and men are at higher risk to act out the abuse by becoming perpetrators themselves (Glasser et al., 2001).

Studies also demonstrate that brain metabolism and function are affected by psychotherapy. These findings reinforce our understanding of the plasticity of the brain: that it can functionally organize and reorganize, and that it is affected by behavior and experience (Baxter et al., 1992; Schwartz et al., 1996; Thase et al., 1996; Brody et al., 2001; Martin et al., 2001).

These data further underscore that the distinction between the biological and the psychosocial is both artificial and misleading.

Early influences and endowments, both biological and psychosocial, are important in the shaping of personality. In childhood, the presence or absence of continued stable care, styles of child rearing, the responsiveness and nurturance of people in the environment, physical health and illness, loss, and trauma, as well as biological endowment, are all determinants of the ultimate configuration of personality.

The effects of particular cultural practices, including gender differences in child rearing, are also manifested very early in life and affect development. Gender differences in parental behavior, especially related to male and female roles, are powerful developmental forces (Rogers et al., 2002). Ideas about the determinants of gender identity have changed from the early views that the major determinants of gender development were anatomic genital differences, to a view that there are differing developmental experiences and paths. Complex processes take place beginning in the prenatal period, including the hormonal environment, the structure of the family, the presence and roles of other siblings, the mother's past pregnancies, and many aspects of the child's relationship with others.

Gender identity development starts early, with prenatal expectations of parents and others about the child's gender and its meaning. By the second and third year of life, a child's developmental goals include a sense of independence to explore the world and the formation of a stable self-image in the setting of a consistent, predictable, and close relationship with parents and others. Important aspects of this developmental phase are the formation of an internalized image of the parent that remains even when the parent is physically absent, and the ability to sustain a sense of closeness in the face of other conflicting feelings.

The concepts of gender identity and gender role have become important in treatment (Stoller, 1976; Person and Ovesey, 1983). Gender identity is the internalized sense of maleness or femaleness, and the knowledge of one's biological sex, including the associated psychological attributes. It begins to evolve in early childhood and appears to be firmly established by the age of about 18 months. It derives from many influences, including identifications with parents and their attitudes, expectations, and behaviors, as well as biological and cultural factors (Money and Ehrhardt, 1972; Kleeman, 1976; Hines and Green, 1991).

Gender role is a cultural construct referring to the expectations, attitudes, and behaviors that are considered to be appropriate for each gender in that particular culture. There are enormous differences in the roles and expectations of men and women in different societies. Some societies dictate more rigid and fixed roles than others and not all value the same traits or see traits as gender specific in the same ways. For example, despite their smaller size and lesser physical strength, women in some cultures are assigned the heavy work. The role consistently assumed by women across cultures is child-rearing (LeVine, 1991). During early development, in all cultures, the mother remains the primary caregiver of young children. Thus, the earliest bond is more likely to be made with her. She becomes the primary identification figure in early childhood, for both boys and girls. Thus, for girls, the first identification is with the parent of the same sex. For boys, the first identification is with the parent of the opposite sex.

As girls grow up, this same-sex identification does not have to change in order for a feminine gender identity to consolidate. That is, girls learn a maternal identification. In order for a boy to consolidate his masculine identity, however, he must shift his primary identification away from his mother and develop identification with a male figure. In this process he moves away from his early attachment. The complex process of establishing a male identity, and the separation from early attachments that seems necessary to the process of the development of a masculine identity, may be factors accounting for the higher incidence of gender identity disorders in males (American Psychiatric Association, 1987).

Many of these developmental differences have been thought to be important determinants of the personality differences that have been observed between men and women (Chodorow, 1978). For men, the pull toward an early attachment to their mother can feel regressive and create a wish for distance and separation from these early ties. Closeness and intimacy can seem threatening, as if leading inevitably to regression (Chodorow, 1978). Clinically, we often see qualitative differences in intimacy, dependency, and attachment between men and women. Although girls usually function better as students in the primary grades than do boys, and they present fewer behavior problems and less overt psychopathology, these characteristics also represent conformity to social stereotypes. Girls are often expected to be more compliant and conforming, and the later repercussions appear to be that the activity and ambition that lead to a sense of competence and self-esteem can be inhibited (Wellesley College Center for Research on Women, 1992).

For girls, the continuity of attachment to their mothers, or primary caregivers, and the fear of loss of love by manifesting open aggression may make it more difficult to establish autonomy and independence while holding on to important relationships. Aggression, competitiveness, and anger may be difficult to manage because relationships can be threatened (Chodorow, 1978; Miller et al., 1981; Gilligan, 1982). It can be difficult for women to express themselves freely, especially when they experience anger and aggression, and, at the same time, to preserve relationships. This may be seen later in life in a woman's conflict about aggression, manifested in her difficulty in being appropriately assertive and in her inhibited risk- taking behavior (Nadelson et al., 1982).

At times, women may also fail to act in their own best interests because of their desire to preserve relationships, even if these are abusive. For some women this can result in behavior that may continue to put them at risk for victimization (Carmen et al., 1984; Jaffe et al., 1986; van der Kolk, 1989). The threat of loss, then, may motivate behavior that can be interpreted as masochistic. For women, the conflict experienced around aggression can result in turning aggression on themselves, such as occurs in the form of excessive self-criticism, with diminished self-esteem. Culturally supported passivity, with consequent feelings of helplessness can be risk factors for depression.

For girls, problems in the development of self-esteem appear to be intensified in adolescence. Gilligan (1987) found that there are gender differences in self-concept and identity in adolescence. Males generally define themselves in terms of individual achievement and work and females more often in relational terms.

Gilligan found that in mid-adolescence girls experienced a crisis of connection, with conflicts between selfish or individual solutions to relational problems and selflessness or self-sacrifice. This period is also one in which girls become more vulnerable to depression than do boys: by age 15, females are about twice as likely as males to have an episode of depression. It is a time when they begin to assume adult feminine identities and roles. Cyranowski et al. (2000) proposed an explanatory model that links adolescent girls’ changing hormonal milieu, which may biochemically stimulate affiliative needs, with the dramatic role transitions of adolescence and the ‘sensitization’ of some girls to the depressogenic effects of negative life events. In any case, the coalescence of biological and psychosocial factors makes it necessary to integrate and not polarize our conceptualization of development.

As puberty approaches, girls and boys experience their reproductive identities in different ways. For girls, menarche signals a capacity for pregnancy. This change also brings a potential vulnerability for the girl that is not in the boy's experience. It is both a positive experience and a source of risk and anxiety. A girl also develops a new ‘organ’, breasts, transforming her body. This has no parallel in the boy (Notman et al., 1991). Menarche, for a girl, is an organizer of her sense of sexual identity. It is also an undeniable physical experience, and it can be a source of pleasure and conflict about growing up and being feminine. The adolescent girl in Western cultures is bombarded with media images of woman who are loved because of their physical appearance. A specific model of physical attractiveness continues to be more important for women than for men, for whom strength and performance are more valued. For both, however, self-esteem and self-confidence rest heavily on physical attributes and body image, especially during adolescence.

Conflicts around self-image and body image become more prominent during adolescence and can be expressed differently for boys and girls. Discomfort with body image, and fear and ambivalence about mastery, independence, separation from family, and adulthood, including sexuality, are difficult issues that are thought to contribute to the dramatic incidence of eating disorders in adolescent girls, who may literally attempt to starve themselves back into childhood.

Women's life cycles are closely connected to their reproductive potential in a way that differs from most men's life cycles. The acknowledgment of a woman's reproductive capacity is usually an important component of her sense of identity and femininity, regardless of whether or not she actually bears children. The knowledge that there is a finite time period for reproduction also influences her concept of time and her life cycle. She must make decisions about career and family in a way that men do not (Nadelson and Notman, 1982a,b; Notman and Lester, 1988; Notman et al., 1991). This difference can obviously affect her emotional state and her decision to seek treatment, as well as the issues that will be raised in the course of treatment (Nadelson, 1989a). It is rare, for example, for a man in his 30s to seek treatment to resolve a decision about having children; this is not uncommon for women.

Pregnancy as a life event marks a transition to motherhood and raises many issues for a woman, including her relationship and identification with her own mother. This transition may parallel a man's experience of fatherhood, but the life event is not the same. For example, the ante- and postpartum period increases the woman's vulnerability to specific psychiatric disorders, particularly depression (O'Hara, 1995; Janowsky et al., 1996).

Infertility is also a different experience for men and women, and there are different issues to consider in treatment. Historically, and in some cultures today, women have been ‘blamed’ for infertility. A woman's pregnancy has also been viewed as a confirmation of a man's masculinity and potency. Infertility can be as threatening and distressing a problem for a man as for a woman, but in different ways. Social norms have also supported men's resistance to involvement in infertility workups and treatment. Thus, failures occur when couples attempt to conceive and there has been inadequate evaluation or treatment.

Menopause is a marker of the life cycle that does not occur in the same way for men. Stereotyped expectations about women's life cycle and the attribution of midlife symptoms to menopause have resulted in the confusion of the experiences of this time of life, such as concerns about aging, family changes, shifts in expectations, and retirement, with the effects of physiological event of cessation of menses. Menopause has been linked with depression and loss, but there is no evidence supporting that this is an inevitable connection. Those women who become depressed in midlife are generally those who have had depressions at other times in their lives.

The peak incidence of depression in women, in fact, is in early adulthood (Weissman, 1991). Estrogen replacement therapy does not address psychiatric problems, and many women have been referred to menopause clinics for treatment of depression or other symptoms whose problems are not related to the menopause itself. Responses to menopause are also strongly influenced by cultural expectations, and in many cultures, women regard the cessation of menses and childbearing with relief.

Hysterectomy has also been considered a procedure that produces a high risk for depression. Here, too, depression is not linked to the procedure. Most of the data supporting the link have not attended to the woman's age, diagnosis (e.g., cancer), the type of procedure performed (e.g., whether it is accompanied by oophorectomy and thus precipitates an abrupt menopause), or other circumstances, such as other events in a woman's life (McKinlay and McKinlay, 1989).

Personal and societal values affect standards of normality and influence the perception, diagnosis, and treatment of mental disorders and emotional problems (Nadelson and Notman, 1977, 1982b; Person, 1983a). Labeling a behavior as deviant or psychopathological reflects a judgment about normality and affects the way a symptom is understood and whether and how it is treated.

Although there have been changes in how normality, mental illness, and deviancy are conceptualized, evidence suggests that there continue to be differences in what is considered normal for men and women. Broverman et al. (1970) in their classic study, found that when male and female psychotherapists were asked to describe a mentally healthy person, psychological health was more closely associated with descriptions of ‘healthy, mature, socially competent’ men than with concepts of maturity or mental health in women. In both male and female therapists, standards of what was mentally healthy more closely approximated stereotypical description of the normal male than those of the normal female (‘normal’ was thus equated with ‘like a man’).

Although concepts and standards of what is considered ‘normal’ masculine and feminine behavior have shifted somewhat, these changes in expressed values and attitudes are not necessarily integrated into a cohesive view of normality for either men or women. Even if treaters consciously adopt gender-neutral attitudes, their unconscious views about what is ‘normal’ may remain unchanged. Those behaviors and attitudes of the patient that are markedly different from the therapist's may be judged as pathological, and this can affect treatment (Nadelson and Notman, 1977).

In all areas of health, values are communicated to patients in both overt and subtle ways in the process of evaluation and referral as well as during treatment (Nadelson and Notman, 1977; Person, 1983a, b). In psychotherapy, therapists communicate values by their selection of material to question or to comment on, by the timing of their interpretations, and by their affective reaction to the content of what is said by the patient. A patient's life experiences can be viewed differently by male and female therapists, particularly if these experiences are gender specific (Shapiro, 1993). For example, the therapist may emphasize or ignore the patient's references to menstruation, taking drugs, or engaging in risky sexual behavior. On the basis of values a therapist may respond more to the relationship-related problems of women patients and to the work-related concerns of men. By responding this way, the therapist in effect expresses a judgment of what is important and to whom, and consequently may misinterpret the importance of these issues for the patient.

Person (1983a, b) suggested that certain kinds of material are not consciously withheld, but ‘overlooked’. Supervisors report that trainees may ignore certain material or interpret behavior as ‘regressed’ or ‘primitive’ because the trainees fail to understand the critical importance of a particular life event that may have to do with gender. For example, one senior resident, in presenting couples therapy case to a supervisor, discussed the difficulty the husband was having with his wife's ‘regressive’ behavior. The resident described the wife as ‘borderline’. It was only at the end of the supervisory session that the resident casually reported that the wife was scheduled for a hysterectomy the next day. This particular example raises many questions, such as the following: Would the anxious male patient have communicated his anxiety in a way that is more likely to be recognized by a male therapist? If a male patient were to have a similar response to a prostatectomy, would it have been judged to be ‘regressed’? Would a male resident have failed to mention a male patient's surgery in a similar supervisory circumstance?

Gender also affects treatment priorities and approaches. It has been suggested, for example, that concern about some more characteristically male behavior, such as violence related to alcohol abuse, may lead to the development of treatment methods that are more suitable for men. These methods may also be used for women, although there is evidence that they are less effective for women (Reed, 1991; Weisner, 1991). More attention may be paid to treating the adolescent schizophrenic or substance-abusing male, because of the threat of violence, than to treating the seriously handicapped but less-threatening female with posttraumatic stress disorder, depression, or substance abuse.

Women with alcoholism tend to seek specific alcohol-related treatment less often than men, are less likely to seek help from specialized alcohol treatment resources (Greenfield, 2002), and when they do, most treatment approaches are male oriented and do not account for psychological and behavioral factors affecting women that can be barriers to seeking care (Kauffman et al., 1995). For example, treatment programs attempt to dissociate abusers from their drug-using peers, placing women abusers at a disadvantage as they are more likely to live with substance-abusing partners who discourage or prevent them from seeking help, with threats or actual physical and/or sexual abuse. The female partners of male abusers are less likely to be abusers. Most treatment programs also expect total abstinence as part of the treatment plan. This is impossible for most female abusers who continue to live in drug- and alcohol-abusing situations. In addition, treatment approaches use confrontation to get complete disclosure in 12-step programs, a style that is often not comfortable for women. Many groups use aggressive and punitive methods including shouting and verbal assault, which are not as accepted by women who respond better to relational involvement in treatment programs (Comtois and Ries, 1995). Women find women's groups more helpful, and they frequently don't attend mixed sex groups, or they don't participate. As women's substance use occurs more frequently at home and is less public than it is for men, their abuse is often not known by family and friends so they are not encouraged to seek treatment. The fact that women are more likely to be primary caregivers for dependent children and others also makes it less likely that they will come to treatment if they lack childcare or fear losing custody of their children.

Gender also affects diagnosis. If there is a disruption in early life such as a serious illness, a major loss, trauma, or family dysfunction, both sexes may have a greater vulnerability to psychopathology, particularly depression and personality disorders (Adler, 1985; Zanarini et al., 1989). In women, one of the syndromes that has been seen as related to the conflict about autonomy and independence, and the sense of vulnerability to loss, is agoraphobia, which is more commonly diagnosed in women than in men (Symonds, 1971; Bourdon et al., 1988). Although this syndrome may have biological determinants as well, it may represent anxiety about moving out into the world and feeling alone. Depression is more frequently diagnosed in women than in men (Weissman, 1991). In contrast, disturbances involving violent, aggressive behavior, and problems with impulsiveness are more often diagnosed in men (Weissman, 1991), perhaps because of conflicts around intimacy and their socialization toward aggression. These findings raise questions about the factors affecting the process of diagnosis itself, particularly, although not exclusively, with Axis II disorders. Because these disorders more generally reflect clusters of observed personality characteristics rather than specific symptoms, the incidence figures may reflect biases and sex-role stereotypes (Adler et al., 1990; Sprock et al., 1990). It is interesting to note, in this regard, that approximately 75% of those diagnosed with borderline personality disorder are women (Gunderson et al., 1991). Male patients who have the characteristics of borderline personality disorder are often diagnosed as having narcissistic or antisocial personality disorder.

Patients give many reasons for their choice of therapist. These reasons are often based on stereotyped views such as that men tend to perpetuate patriarchal values, or that women are more nurturant. It is also true that some patients have no particular preference regarding the therapist's gender and could work equally well with either gender in therapy.

However, if the patient has a preference, for a woman, the choice to be treated by a woman can represent a wish to restore the relationship with her mother or to have a better mother. A desire to see only a male can be based on the desire to avoid this maternal kind of relationship or the anxiety that these feelings arouse, or may reflect anxiety about the intense attachment that may be evoked by a woman (Nadelson and Notman, 1991).

The search for a role model has also been an important determinant of choice of therapist (Person and Ovesey, 1983). Women frequently feel that a woman therapist would be more responsive to their wishes for achievement, success, and self-actualization or that, because she has faced similar conflicts, she could empathize with them more easily. Women may also request to see a woman because they want permission to succeed in certain goals, particularly those involving their work. Permission, explicit or implicit, can result in improvement and can enable the patient to compete and succeed, even if the issues are not taken up specifically and explicitly (Person and Ovesey, 1983). Although this idea may facilitate the development of an alliance it does not, by itself, resolve the patient's difficulties (Notman et al., 1978). Men may search for a role model in a therapist for different reasons, such as a wish to learn how to be a good father, because for many men there have been more role models for achievement and success outside of the family rather than inside (Pollack et al., 1998).

Identification with a therapist is also important. Although the reasons for the choice may be based on stereotypes, without regard for the characteristics of the specific therapist, the patient's feeling of greater comfort or empathy can facilitate the initial development of a positive therapeutic alliance.

More recently, concerns about sexualization and sexual relationships in treatment have become important factors in requests based on gender. For those patients who have actually been abused in a previous treatment, trust can be severely damaged. It may be particularly difficult for such patients to see anyone who serves as a reminder of the previous experience. Women therapists are often asked to see women patients who have had sexual involvements with male therapists (Person and Ovesey, 1983). Although it does occur, women are less likely to become sexually involved with their patients, either male or female, than are men (Holroyd and Brodsky, 1977; Gartrell et al., 1986; Gabbard, 1989).

Sexual orientation has also become a consideration. Many gay individuals request treatment from gays, who they feel will not only better understand and empathize with them, but be less likely to judge their sexual object choice as pathological (Krajeski, 1984). Although there has been controversy about the appropriateness of this disclosure, some therapists have indicated that disclosure of their sexual orientation to patients may be beneficial in therapy (Gartrell, 1984; Isay, 1989).

Choosing a therapist of a particular gender with the expectation that this will resolve the patient's problems can also be a resistance to therapy. A woman may want to see a woman for treatment because she feels unlovable and unattractive to men and can, in this way, avoid the experience of confronting her feelings (Thompson, 1938). A woman may seek a woman therapist initially because she wants support, and later devalue the therapist or find herself in an angry, competitive interaction, which can be a repetition of her relationship with her mother (Notman et al., 1978). She may be unaware of the origins of her feelings or the reasons for her choice of therapist. Although there are conscious reasons for choices, unconscious factors or needs such as fear of anger or a search for mothering may be important and should be considered in the initial encounter with a patient.

Not only do some patients make gender a priority in choosing a therapist, but some therapists also make gender-based recommendations regarding the choice of a therapist. For example, because some women victims of sexual abuse find it difficult to work with men, some clinicians suggest that they should be treated by women. Others believe that adolescents should be treated by someone of the same sex because sexual issues are so pressing, embarrassing, and intrusive at this life stage that they can interfere with therapeutic progress. Many support the view that women should be treated by women in order to avoid being misunderstood or treated from a male-oriented perspective. This may oversimplify the effects of gender and minimize the necessary working through of ambivalence and conflict in the therapeutic relationship.

Stereotypes and expectations about women affect male patients as well. A man may seek treatment from a woman in order to avoid a competitive or authoritarian relationship with a man, to avoid homosexual feelings, or because he has had poor relationships with women in the past and wants to work these out with a woman. His expectations may be that a woman will provide the cure for his problems with intimacy.

Some women may choose a male therapist who may not focus on or confront certain problems in an effort to avoid being labeled as sexist. These therapists have described feeling intimidated by the successful women who are their patients. They may not feel free to raise questions about the motivation or specific behavior of such a patient, fearing accusations about being sexist or unsympathetic. Some women avoid female therapists who they fear might confront them more directly about this behavior.

Understanding the concept of transference can clarify aspects of the therapist–patient relationship that may otherwise be difficult to comprehend. A patient brings attitudes and feelings to the relationship from past experiences with important figures, such as parents, which may be problematic and need to be addressed in therapy. For example, the patient may bring the need to please or to gain love by acquiescence or seductive behavior into the therapist–patient relationship. If not recognized as transference, the clinician may see this as a genuine reaction to the therapist rather than a pattern of response to someone in authority carried over from past relationships.

The classical conceptualization of transference assumed that both maternal or paternal transference could be developed toward both male and female therapists. Thus, the therapist's gender was not a particularly salient consideration. Freud came to believe that transference responses to a male analyst differed from those to a female analyst (Freud, 1931/1961). Subsequently, Horney emphasized the importance of the competitive transference with the same-sex analyst, and Greenacre stated that strong wishes regarding the choice of analyst with regard to gender should be respected, but also carefully analyzed because prior wishes, expectations, and fantasies could affect not only the choice but the course of the analytic process (Greenacre, 1959; Horney, 1967). Zetzel (1970) indicated that transference repeats the patient's actual identification with the parent of his or her own sex, and the wish for love from the parent of the other sex. Kernberg (1998) indicated that the therapist can ‘collude’ with the culture to reinforce gender stereotypes. For example, a narcissistic male patient with a female analyst may develop an intense erotization of the relationship to avoid feeling dependent and to destroy the analyst's authority, thereby preserving for the patient the conventional relationship of dominant male and subservient female.

One study evaluated the development of transference in 47 cases of same-gender and cross-gender therapist/patient dyads in psychoanalytic psychotherapy. Each therapist was interviewed about two of their cases at 4- and 6-month intervals over a 2-year period. Two judges, a male and a female, rated each of the interviews on the emergence of transference paradigms, such as maternal/paternal relationship themes. The authors found that patients have a strong inclination to develop an initial transference consistent with the therapist's gender, and in opposite-gender dyads, therapists, especially female therapists, have a strong bias against perceiving themselves in the opposite-gender role. In addition, the more experienced therapists were more likely to report opposite-gender transference. The current psychoanalytic view is that the person of the therapist is important and that therapy is affected by real characteristics of the therapist, the patient, and the transference (Gruenthal, 1993).

Therapists often do not attend sufficiently to the transference issues that encourage or inhibit discussion of particular material. This insufficient attention may be based on a number of factors, including gender. It can be seen at any phase in a therapeutic interaction and can occur with any patient or in any treatment modality. Many women feel that it is more difficult for a man to empathize with some issues that are gender specific; this may also be true for women who must empathize with male issues (Horner, 1992).

Women report that they do not tell male therapists details of menstrual-related symptoms or even discuss concerns about hysterectomy or past histories of abortion or miscarriage. These ‘censorships’ create the potential for inappropriate treatment.

The persistence of conventional sex-stereotyped attitudes and behaviors can be seen clinically. A male therapist who accepts the traditional male gender role may experience strong negative countertransference to a male patient who freely expresses emotion (Wisch and Mahlik, 1999). The concerns of a woman who decides to have children late in life or is ambivalent about childbearing, or those of the man, who wants custody of his young children, are still often not appreciated. Therapists treating women may see themselves as advocates for a woman's right to have both family and career and may not fully acknowledge their patients’ conflicts about balancing the two. The woman executive who wants to have a baby but has recently undertaken a very demanding job may need to explore why she chose to make that commitment at the time she did, just as a woman of 40 with an established career who suddenly decides to have a baby and feels she must give up her career would do well to understand this behavior. Both women may be acting defensively as well as making positive choices.

Change or reassignment of a therapist on the basis of gender has been widely discussed and is often recommended. Some have suggested that a change of therapist might mobilize a stalemated situation. Transfers on the basis of the therapist's gender have also been made when there is a therapeutic impasse or failure.

This is an example of a situation where the gender of the therapist made a difference.

Unless there has been a sexual interaction, however, it is rare that gender itself is the significant variable in the majority of cases that are not successful. A transfer based on gender may be a way of avoiding responsibility for failure or dealing with the embarrassment of negative outcome. Because gender affects trust, and even compliance, in other modes of treatment, as well as in psychotherapy, change in the treater based on gender might be helpful in some situations.

As with other forms of therapy, gender may be a consideration in the choice of a therapist for couples or families. This issue is frequently dealt with by having couples and family therapy performed by male–female therapist dyads. In general, as with individual therapy, issues related to gender choice should be clarified and addressed. A couple with marital difficulties may request a female therapist because it is the wife who has made the call and it is her preference, perhaps because she feels intimidated by men or because she fears that she could be left out of the male dyad if the therapist were male. On the other hand, the husband may choose a woman or comply with his wife's choice of a female therapist because he is more comfortable and less threatened by women, because he does not take the therapy seriously, or because he has negative feelings about women. The choice of a male therapist for some couples may re-create, in the transference, a paternal or authoritarian relationship or even the fantasy of possible sexual abuse. This can be a special problem if abuse has actually occurred.

During the course of therapy, attention must be paid to bias regardless of whether the therapist is male or female. Transference issues in couples and family therapy are multiple and more complex because there are more people directly involved in the therapy. For example, each partner, and the couple as a unit, will have different transference reactions to the therapist and to each other. If there are additional family members involved, they, too, will add to the transference complexity.

Changes in family patterns have also presented an increasing array of challenging issues for therapy. For example, the stress and demands of dual-career or commuting families, especially those with two achievement- oriented partners, can create enormous tension. This may be a greater source of conflict if the wife is earning more money, or if there is a job offer for either partner in another city. Because the husband's work has traditionally been the motivating factor in a relocation, a wife's job offer can create tensions, especially involving competition. A wife who achieves success later in life can be on a different timetable than her husband, who may wish to retire earlier.

The therapist can be influenced by his or her attitudes and values about divorce, marriage, and custody. The increasing divorce and remarriage rates have brought a larger number of so-called reconstituted or recombined families. The members of these families often experience divided and conflicted loyalties between their family of origin and their new family. There are also unexpected pressures related to childbearing at different phases of the life cycle with many of these relationships. For example, a woman in her late 30s without children may marry a man in his 50s with grown children, and the couple may be in conflict about having additional children. Although they may have previously agreed that this was not an option, the wife, who is younger, may change her mind, and marital problems ensue.

As men gain permission for expression of their dependent needs and wishes for nurturance, they experience conflicts that are not dissimilar from those that women have traditionally encountered. For instance, a few men now take paternity leave, but risk their careers as most employers see such men as less committed to their careers and therefore less worthy of promotion. The man caught in an unsatisfying and even destructive marriage may find himself torn between a new and gratifying relationship and the potential loss of the intimacy and experience of his children's growth if he leaves his family. The alternatives are to remain in the marriage, leave and attempt to gain custody, or work out joint arrangements.

Feminist critiques of family therapy express concerns about the structural/hierarchical dominant role of males in the family, mother blaming, assumptions about sharing power and responsibility embedded in systemic concepts, and assumptions about therapist neutrality (Nutt, 1992; Stabb et al., 1997). Family therapy has recently been criticized for biased treatment of men—for example, for reinforcing the socialized limitations of male roles (Stabb et al., 1997).

As with couples and family therapy, there are gender issues in group therapy. When group therapy is sought or recommended, the gender of the group therapist is not frequently considered, although the gender composition of the group often becomes an important factor. There are some data suggesting that group behavior both between group members and with the leader is affected by gender (Mayes, 1979; Bass, 1990; Forsyth et al., 1997). McNab (1990) reported that men set themselves apart to a greater extent than women at the start of group therapy and become integrated into the group later.

Women often seek women's groups because in groups of men or even in mixed groups they feel powerless, intimidated, and uncomfortable about speaking up. One need only look at classrooms, professional meetings, and business groups to recognize that women speak less often than men, and when they do speak, their comments are more often ignored or attributed to others. Women report the same experiences, regardless of professional status or income (Nadelson, 1987). They may feel supported and less anxious in same-sex groups, although mixed groups may be helpful in confronting these problems of professional development. Most often single-sex groups have been used for support and consciousness-raising. Both male and female self-help groups often form around a specific focus (e.g., substance abuse, divorce, family violence) and use problem-solving approaches.

Therapy groups with both male and female leaders permit men and women to deal with transference issues, both as peers and as leaders. It is important, however, that the leaders’ relationship with each other, just as with male and female therapists in family therapy, be a facilitating rather than inhibitory factor. Mistrust, competition, and anger that are not addressed in either leader or group members can be unproductive and inhibitory to group process.

There are abundant data indicating that women have a greater incidence of some mental disorders and men of others. A 1991 report from the US Institute of Medicine cited gender differences that have been replicated (Weissmann, 1991; Kessler et al., 1994). A summary of current epidemiology on gender differences can be seen in Table 34.1.

In terms of treatment, most of the early research on treatment outcome did not consider gender as a salient variable. This is beginning to change, particularly in the biological areas of psychiatry.

In the psychotherapy literature, while there is increasing emphasis on outcome, gender has not been well studied. The analysis and interpretation of outcome data considering gender and psychotherapy, as with any outcome data, require consideration of a number of variables, including therapist/patient selection mechanisms and match, type of treatment, treatment goals, therapeutic process, length of treatment, measured and perceived therapeutic outcome, and patient satisfaction.

Most of the data on gender and therapeutic outcome have come from short-term types of treatment. Investigators in these studies have attempted to use easily controllable treatment techniques and protocols and to include patients with specific diagnoses, and they have assessed specific outcomes that are often behavioral, such as a decrease in alcohol intake or impulsive behavior, or measurable with specific objective criteria, such as depression or anxiety scales. Because affective and intrapsychic processes have been less amenable to the kinds of measures traditionally employed, there are many fewer studies of long-term psychotherapy and psychoanalysis.

Cavenar and Werman (1983) in their early critique of studies of psychotherapy outcome emphasized the importance of specifying the treatment approach. They indicated that the gender of the therapist may be more relevant in modalities such as supportive psychotherapy, in which identification with the therapist and restoration of defenses are more critical. With insight-oriented psychotherapy, the goal of self-understanding and the difference in process may change the way interpretations are made and perceptions evolve.

Mogul (1982) suggested that therapist sex matters least in traditional psychoanalysis. The issue, however, may have more to do with the alliance and the transference than the modality or the diagnosis (Gruenthal, 1993; Kernberg, 1993; Shapiro, 1993). Person (1983a) suggested that gender effects are more subtle in psychoanalysis than in psychotherapy but may be just as pervasive.

The popular belief is that women patients do better in therapy with women therapists because women therapists are more relational, empathic, and less likely to disempower women patients. There is empirical evidence on both sides of the efficacy argument for a gender effect in treatment, with most studies concluding that there is none (Zlotnick et al., 1998; Huppert et al., 2001). There are, however, no data from naturalistic studies.

One controlled study (Zlotnick et al., 1996) on the effect of gender on short-term treatment of depressed patients found no effect on level of depression at termination, attrition rates, or patient's perception of the therapists’ degree of empathy early in treatment and at termination. Likewise, patients’ beliefs that a male or female therapist would be more helpful, and their match or mismatch in the study protocol, were not significantly associated with the measures of treatment process or outcome employed. Gender did not interact with therapist level of experience. It is possible that a patient's perception of a specific therapist is influenced not by gender stereotypes but rather by the patient's experience with the specific person.

Studies conducted two decades ago reported little outcome difference by gender of patient or therapist for short-term psychotherapy (Abramowitz et al., 1976; Orlinsky and Howard, 1976; Gurri, 1977; Blas', 1979; Goldenholz, 1979; Malloy, 1979). Kirshner et al. (1978) studied a large number of therapist–patient matches in short-term individual psychotherapy and found that female patients showed greater responsiveness to psychotherapy and that greater patient satisfaction and self-rated improvement occurred with female therapists. More improvement was seen in attitudes toward careers, academic motivation, academic performance, and family relations. At the same time, however, these researchers also reported that the female patients of female therapists were less likely to describe their therapists as competent than were the patients of other gender dyads. When therapist experience and gender were considered, more experienced therapists seemed to have had better therapeutic results and showed fewer gender effects than did less experienced therapists, regardless of sex.

Other controlled studies of short-term psychotherapy have reported that female therapists formed a more effective therapeutic alliance than did male therapists (Jones and Zoppel, 1982) and that patients treated by female therapists reported more symptomatic improvement (Jones et al., 1987). However, these differences may be attributable to methodologic differences and outcome measures. In the study reporting a gender difference in symptoms (Jones et al., 1987), male therapists saw recently bereaved women who had lost a husband or father. Thus, the reported effects may have been related to the specific circumstances in which the symptoms originated or to the effect of seeing a male therapist as a possible replacement for the lost husband or father. Some studies used self-reports; others manualized treatment (Zlotnick et al., 1998). Given the rigid training and protocols used in these studies, naturalistic responses or differences in attitudes and behaviors might not emerge.

Gender also may affect treatment selection. Women, because of life cycle events such as pregnancy, may want to avoid psychopharmacological treatments altogether and yet be in need of acute effective treatment for depression and anxiety. Cognitive-behavioral psychotherapy and interpersonal psychotherapy are both short-term, focused psychotherapies found to be effective in controlled, clinical trials for the treatment of depressive and anxiety disorders and are useful modalities for the pregnant or postpartum patient who wishes to breastfeed (Beck et al., 1979; Klerman et al., 1984; Frank et al., 1993; Stuart and O'Hara, 1995; Spinelli, 2001). A recent study suggests that men and women may benefit from different modalities (Ogrodniczuk et al., 2001). Men responded more to interpretive therapy while women's symptoms responded to supportive psychotherapy. The authors suggest that the two different psychotherapies facilitated trust and a willingness to work: for men, on introspection and the examination of uncomfortable emotions, and for women, on problem solving within a more collaborative and personal relationship.

With regard to referral trends, much of the literature derives from methodologically problematic studies that are now dated. More current work continues to suggest, however, that males are more likely to be referred to a male therapist and that female therapists get fewer referrals of male patients (Mayer and deMarneffe, 1992). This finding implies that gender stereotypes continue to operate.

Other studies of gender differences focus on additional variables. For example, one study (Thase et al., 1994) reported that patients with higher pretreatment levels of depressive symptoms, especially women, had poorer outcomes. Another investigation (Frank et al., 1993) reported that among patients with recurrent depression, men demonstrated a more rapid response to treatment than did women. Still other research indicates that posttreatment outcomes are similar for men and women, that male and female patients suffering from major depression had generally similar outcomes over time-limited courses of cognitive-behavioral therapy (Sotsky et al., 1991; Thase et al., 1996), and that men and women have similar responses to different treatment modalities (Ogrodniczuk et al., 2001). Samstag et al. (1998) reported that the women in their sample were more likely to have either good overall outcome or to drop out of therapy, whereas the men were more likely to remain regardless of outcome. They suggest that this is consistent with reports in the literature indicating that women attend more to relational cues (Gilligan, 1982; Gilligan et al., 1991). A further analysis of their data suggested that the subjective meaning of the alliance seemed to be the most critical factor. These data certainly suggest that more study is needed on gender effects.

Psychotherapy research has more often used female patients, and as noted above, frequently does not consider other salient variables (e.g. age, race). There are also differences of opinion about the importance of therapist experience, with some studies showing that experience is an important variable and that it interacts with gender. Thus, the gender of a less experienced therapist may have a more negative impact on outcome than the gender of a more experienced therapist. There are data suggesting that less experienced female therapists do better with women than less experienced male therapists. The theoretical orientation of a therapist may also be important. For example, some data indicate that therapists who are most effective tend to embrace a psychological orientation and eschew biological treatments but that therapy (especially for depression) is longer with these psychologically oriented therapists (Blatt et al., 1996). Some studies reveal that both men and women prefer therapists of their own gender (Simons and Helms, 1976).

It is apparent that gender is an important treatment variable and that attention to gender effects together with better understanding of the complex interaction of gender and other variables will shed light on the therapeutic process and contribute to greater therapeutic effectiveness.