Out of Her Mind: How We Are Failing Women’s Mental Health and What Must Change

BOOK REVIEW

Out of Her Mind: How We Are Failing Women’s Mental Health and What Must Change

by Linda Gask, Msc, PhD; Cambridge University Press, 2024

312 pages • $25.95 (hardcover)

Reviewed by Awais Aftab, MD

Out of Her Mind by Linda Gask, Msc, PhD, a psychiatrist and a feminist, is a rich and perceptive exploration of social and systemic failures in addressing women’s mental health. Drawing on over 3 decades of clinical and academic experience, Gask weaves together personal anecdotes, historical critique, feminist scholarship, and real women’s stories to expose the biases and inequities in mental health care that continue to harm women.

Gask is attempting a delicate argument, one that puts her in tension not only with the medical profession, given its neglect of women’s mental health issues, but also with those factions within the feminist movement that view psychiatry as the enemy, deserving of nothing but hostility. Part of Gask’s response depends on deflating ideological dichotomies such as “depression vs oppression” and “madness vs sane reaction to an insane life.” Things are, as she argues, a lot more complicated than that. Women can be both depressed and oppressed; there is no contradiction or mutual exclusivity here. As Gask notes, “To deny that a woman is experiencing a mental illness, and to suggest that this is simply a ‘normal’ reaction to what is happening to her, is also a way of denying her reality. But calling this illness doesn’t mean her stressful and traumatic life experiences don’t matter. Of course, they do, very much, as they can act as the trigger for her becoming ill and prevent her from recovering,” (pg 33).

The book takes a life-course perspective, examining mental health challenges unique to various stages of women’s lives—from the psychological pressures of adolescence and the stigma of eating disorders to the often-dismissed struggles of perinatal and menopausal mental health. The basic premise that injustice and illness are both real plays out in almost every case. For example, discussing the critics of the premenstrual dysphoric disorder diagnosis, Gask writes, “I know where these writers are coming from. Women are dismissed as hormonal just as much as they are called hysterical. But is it fair to suggest we should just cope with it and stop complaining? Those who experience severe symptoms and are desperate for help might beg to disagree,” (pg 73).

Gask is unflinching in her critique of how many women seeking help for mental health problems are treated in the health care systems. “They aren’t seen as asking for help in the right way and not behaving like patients, and especially women patients, ought to behave,” she writes. “Doctors and nurses tend to reject people who expose their inadequacies. They feel challenged by people they don’t understand and whom they are unsure how to help. They hope women will just shut up and go away, but it isn’t clear how women have to behave to be taken more seriously,” (pg 14). Her frustration is palpable, and it serves to strengthen her resolve as an advocate for change.

A valuable feature of the book is its practical focus. Every chapter ends with a section, “What Must Change?” that offers useful clinical, social, and policy guidance on how to address the relevant issues. This structure ensures that Gask’s critiques are not just diagnostic but solution oriented. Her feminist perspective seeks to challenge the entrenched male centered norms in research and practice, prioritize fair representation, and create care environments that minimize harm and foster trust.

Out of Her Mind goes beyond exposing systemic shortcomings; it is a thoughtful and urgent appeal to clinicians, researchers, and policymakers to rethink how mental health care is delivered. Gask’s recommendations—such as expanding access to psychotherapy and integrating more nuanced, gender informed research—are ambitious, but essential. By sharing her own story, Gask infuses the book with an authenticity that bridges personal experience and structural critique.

Gask’s discussion of borderline personality disorder (BPD) will be particularly provocative for psychiatrists and mental health professionals. Gask is of the view that “Borderline is an insulting label we can surely manage without. I agree with feminist psychologists that it is inherently misogynist… It certainly pathologises a way that women behave in extremis when they are powerless and traumatized,” (pg 206). This is also the chapter when I personally have the most qualified disagreements. Gask makes a persuasive case that women who receive the BPD diagnostic label are often misdiagnosed and treated horribly (Gask focuses on the British health care system, especially the NHS), many are more traumatized by the care they receive by professionals than by what they have experienced in life elsewhere, and that few receive the kind of meaningful and empathetic psychotherapy that focuses on building long term trust, containing painful emotions, and examining attachment patterns that they really need. The diagnosis instead becomes an excuse to deny care to a “difficult woman.” 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. The maladaptive patterns of relating to self and others that have historically been characterized using the “borderline” construct are as real as anything else in psychiatry, regardless of what we call it. In a context where the term is shrouded by such stigma that it becomes a hindrance to providing compassionate, effective care, I would agree that it is best avoided by the wise clinician. Nonetheless, I am of the view that what seems inherent to a diagnosis may instead be the consequences of a failure of healthcare systems to adequately care for so-called “difficult” patients.

Throughout the book, Gask grapples with the tension between feminist skepticism of psychiatry and the reality that women’s mental health issues demand medical recognition. Reflecting on the feminist rejection of medical explanations for conditions like anorexia, Gask acknowledges, “The feminism of my youth vehemently rejected medical explanations for anorexia, believing the cause to lie only in society’s attitudes to women,” (pg 69). She underscores that rejecting medical diagnoses entirely can be just as harmful as ignoring societal factors: “Some therapists still sadly search around for trauma in a woman’s past history that may not exist, telling her that ‘mental illness’ isn’t real, or that if she accepts medical or psychiatric care she is bowing to the medical patriarchy… It’s just another kind of gaslighting,” (pg 90).

A feminist psychiatry has the responsibility to not only recognize the myriad ways in which women are subjected to marginalization and how this negatively affects their wellbeing, but also to advocate for clinical recognition of distress and disability that women experience along with access to compassionate clinical care that respects their rights. Denying the reality of women’s mental health problem fails women. Gask is demonstrating that a feminist psychiatry is not only possible, but is a necessity if feminism and psychiatry are to live up to their missions.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He writes online on his blog Psychiatry at the Margins.