Cover Story

Try to imagine the Marlboro man in therapy. The image just doesn't compute, does it? The Marlboro man wouldn't admit to needing help. The Marlboro man wouldn't talk about his emotions. For that matter, the Marlboro man might not even recognize that he has emotions.

That, in a nutshell, is the problem with convincing men to seek help of any kind, including therapy, according to Jill Berger, PhD, a recent psychology graduate of Nova Southeastern University who studies the psychology of masculinity. Traditionally, she says, society demands that men emulate a Marlboro man ideal--tough, independent and unemotional--that just isn't compatible with therapy.

Indeed, dozens of studies and surveys over the past several decades have shown that men of all ages and ethnicities are less likely than women to seek help for all sorts of problems--including depression, substance abuse and stressful life events--even though they encounter those problems at the same or greater rates as women. In a 1993 study published in Psychotherapy (Vol. 30, No. 4, pages 546-553), for example, psychologist John Vessey, PhD, reviewed several epidemiologic surveys and found that a full two-thirds of mental health outpatient visits were made by women. This inability, reluctance or straight-up unwillingness to get help can harm men's own mental and physical health, and can make life more difficult for their friends and families, says Berger.

Of course, not all men are the same. And recently, some researchers have begun to delve more deeply into men's help-seeking behavior, to try to parse the societal and personal factors that make some men, in some situations, more likely to reach out to a psychologist or other source of aid.

"I don't think that it's biologically determined that men will seek less help than women," says University of Missouri Counseling Psychology Professor Glenn Good, PhD, who studies men and masculinity and also has a private practice that focuses on men. "So if that's true, then it must mean that it's socialization and upbringing: Men learn to seek less help."

He and other researchers hope that by understanding what drives men toward or away from therapy and other types of help, they'll be able to encourage more men to get help when needed, and to make that help more effective. Their research so far suggests two key solutions: Make men understand that many other men face mental health issues like depression, and adjust the description of therapy itself to make it more appealing to men.

Why men don't seek help

The first hurdle some men face is that they may be so out of touch with their emotions that they do not even realize that they are, for example, depressed. APA President and Nova Southeastern University psychologist Ronald F. Levant, EdD, has coined the term "normative male alexithymia"--literally "without words for emotions" (see page 60)--to describe this phenomenon.

Many boys, he says, learn from their parents and from other children that they are not supposed to express vulnerability or caring. They learn to suppress their emotional responses--like crying or even sad facial expressions--so much that, by the time they are adults, they are genuinely unaware of their emotions and how to describe them in words.

In his book "New Psychotherapies for Men" (Wiley, 1997), Levant gives the example of a father stood up by his son for a father-son hockey game. When asked his feelings on the subject, the father said "He shouldn't have done it!" It wasn't until the therapist prompted him again that he managed to say he was upset.

Even when men do realize that they are depressed, abusing alcohol or have some other problem, they are still less likely than women to see a psychologist or other mental health professional, says psychologist and masculinity researcher James Mahalik, PhD, of Boston College, who gives a thorough overview of the evidence in a 2003 article in the American Psychologist (Vol. 58, No. 1, pages 5-14). In the article, he and co-author Michael Addis, PhD, also outline some of the factors underlying men's reluctance:

  • Masculine role socialization. To benefit from counseling, a man must admit that he needs help, must rely on the counselor and must openly discuss and express emotion. These requirements, says Mahalik, conflict with traditional ideals of what it means to be male: toughness, independence and emotional control.

"What we're finding is that the more men 'do their gender' and define themselves by traditional roles in our society, the less they tend to get help," Mahalik says.

In a study published this January in the Psychology of Men and Masculinity (Vol. 6, No. 1, pages 73-78), for example, Berger, Levant and their colleagues found that men with higher levels of traditional masculinity ideology also tended to have a more negative opinion of seeking psychological help.

And in a 1995 study in the Journal of Counseling and Development (Vol. 74, No. 1, pages 70-75), Good found that men who scored higher on a test of male gender role conflict--a conflict between rigid learned gender roles and the healthy expression of emotion--were more likely to be depressed and more likely to have a negative opinion of psychological counseling.

  • Social Norms. Some men may also worry that society will look down on a man who can't "tough it out" on his own, and that seeking--or even needing--help is not "normal" male behavior. Even men who do seek counseling may worry about what others think of their choice, including Tim (a pseudonym), a client of Good's in his 50s who began therapy after he ended an extramarital affair.

"I was not afraid of counseling," he says, "maybe because I'm not a very typical male--I tend to be pretty open with my emotions."

He did, however, have one concern--telling his boss why he needed to take time off work. Although his boss ended up being relatively understanding, Tim says, he's not sure that would be the case with everyone.

"I have to be very careful with whom I discuss the issue of being in therapy--I think there is a stigma," he says. "People expect men to be 'strong.'"

And indeed, Mahalik notes, a man who is surrounded by a supportive group of other men--say, a church group that encouraged members to share problems and seek support--might be more likely to seek help than a man whose only social network discouraged such sharing.

In general, Mahalik says, men are more likely to seek help for problems that they think are normative--that is, problems that many other men share.

"If men perceive that being depressed is not 'normal,' then if they do try to get help they may feel dysfunctional and aberrant," Mahalik explains. "So instead they might try to keep the depression quiet, and maybe self-medicate with drugs or alcohol."

What can be done?

One way to convince more men to seek help, then, is to convince them that the things they need help with are "normal." In this regard, Mahalik says, psychology could take a cue from the erectile dysfunction drug industry.

"Men are going in to see their doctors much more about erectile dysfunction now, after the ads for Viagra and other drugs, because there's so much more awareness," he explains.

And in fact, psychology is beginning to do just that. In 2003, for example, the National Institute of Mental Health launched a national media campaign called "Real Men. Real Depression." to raise awareness that depression affects more than 6 million men annually (see page 66). And the National Football League's "Tackling Men's Health" campaign--which aims to convince men to visit their doctors and proactively manage their health--includes a Web site section on mental health, with a link to a depression self-screening test (see www.nfl.com/tacklingmenshealth).

Psychologists can also work to make the terminology they use to describe therapy more palatable to men, says John Robertson, PhD, an emeritus professor at Kansas State University. In a 1992 study in the Journal of Counseling Psychology (Vol. 39, No. 2, pages 240-246), for example, he created two brochures for a campus counseling center and distributed them to community college students in auto mechanics, welding and other mostly male areas. One of the brochures described the center's counseling services in traditional terms, the other used terms like "consultations" rather than "therapy" and emphasized self-help and achievement. He found that the men who received the second brochure were more likely to say they'd seek assistance at the center than men who received the traditional one.

Robertson also has a private practice that focuses almost entirely on men, and he says that in his advertising he emphasizes skills--like parenting skills or anger control skills--much more than, say, personal development.

"It's not a particularly surprising or brilliant notion," he says, "that you want to match the client to the service."

And as psychologists continue to study men and help-seeking, they'll be better able to do just that.

"What are the contexts that may influence men to seek help, and why?" asks Mahalik. "That's the challenge for us to figure out, in terms of both clinical research and outreach. Right now we have some beginnings of the answers."

Further Reading

Visit Div. 51 on the Web

Check out the Web site of APA's Div. 51 (Society for the Psychological Study of Men and Masculinity) to read its newsletter and for division activities, convention programming, journal information and more.