The assumption that men and women speak different languages can literally be true, says psychologist John Robertson, PhD.
The Lawrence, Kan., independent practitioner and past-president of APA's Div. 51 (Society for the Psychological Study of Men and Masculinity) says he once had a male client who looked like he "just stepped off the ranch." The man sat down for his first session, looked at Robertson and simply said: "Doc, I'm off feed."
After pausing for a puzzled moment, Robertson deduced the diagnosis. "He was saying that he was so depressed, he'd lost his appetite," Robertson recalls. "Here's someone who acknowledged a difficulty that's not easy for him to admit, and he just had a masculine way of doing it."
Robertson's experience is typical for psychologists who frequently work with men in psychotherapy. Many psychologists agree that men, like women, face their own unique challenges in therapy. For example, men might feel cultural pressure to bottle up problems, and many men perceive therapy as a sign of weakness, so opening up in a session might be harder for some men than for women.
Yet for a long time, psychology overlooked such differences and neglected to give men the necessary attention they needed to effectively engage in psychotherapy, psychologists say. It's possible that men's traditional aversion to and difficulty within therapy has had as much to do with psychology as with gender, according to some in the field.
"There isn't an empirically validated way of specifically working with men--it's more of tailoring existing theories of and approaches to therapy to be sensitive to how men work with them," says Matt Englar-Carlson, PhD, a counseling professor at California State University, Fullerton. He notes that when therapists first train, they are often told to ask reflective, feeling-centered questions, but those questions don't necessarily open up men. "Part of it is we are now recognizing some stereotypes in our profession about how psychotherapy is performed and how we see masculinity," he says.
The renewed focus on male psychology has come on the heels of the development of the psychology of women field over the past 30 years, Englar-Carlson notes. "Taking a needed cue from the feminist movement, many gender-aware therapists are becoming interested in helping men out as well. Psychotherapy with men is becoming a legitimately recognizable field in terms of practice," he says.
Indeed, though the psychology of men field started to develop in earnest just 10 to 15 years ago, researchers have developed different men-friendly styles of therapy, such as "action-oriented work," and more practitioners are developing solutions to traditional male struggles in psychotherapy that are now customized for men.
Barriers to therapy breakthroughs
The challenge of getting help for men doesn't end when they come to therapy. Even today, despite changing gender roles, the majority of therapy-seekers are women (see page 57). And even some of the men who actually go to the therapist's office aren't willing to engage in the process.
Why not? "Three words: normative male alexithymia," says APA President Ronald F. Levant, EdD, an expert in the psychology of men and masculinity and former dean and current psychology professor at Nova Southeastern University. According to this theory, many men are socialized to ignore their emotional sides and therefore struggle to express or understand their feelings.
"Some men have difficulty identifying emotional problems because some norms for masculinity require their emotional lives to remain a mystery to them," agrees Michael Addis, PhD, chair of Clark University's psychology department and a researcher in the area of men's mental health. He cites as examples of masculinity norms the widely held notions that men should hide their emotions and soldier on in the face of difficulty without acknowledging their struggles. Norms also dictate that men should always be in control and avoid too much intimacy, particularly with other men--two rules that can run counter to psychotherapy.
"I've seen this type of client again and again--they have difficulty concentrating, are stressed from work or are enduring a break-up," says Christopher Kilmartin, PhD, a professor at the University of Mary Washington. "I'd ask them, 'How do you feel about that break-up?' They'd often reply, 'I feel she shouldn't have done it.' Well, that's not a feeling, that's a thought."
What's more, Kilmartin and others note, men's fathers, families, friends, popular culture and other external sources tell them from early childhood what is appropriate behavior for their gender.
"Men are taught to be tough, emotionally stoic, to go-it-alone, never ask for help," says Gary Brooks, PhD, a psychology professor at Baylor University. "That's contrary to what you want in therapy clients. Therapy is portrayed as something that wusses do--it's the Woody Allens, Charlie Browns and Kelsey Grammers of the world."
As a result, many men who accept these traditional roles are wary of therapy because it runs counter to everything they've learned, Brooks says.
Indeed, in therapy, the standard question, "How does that make you feel?" can draw puzzled looks from even mildly alexithymic male clients, psychologists say.
That means when men do seek therapy, they could be really suffering, Kilmartin adds. "It's hard enough for traditionally gendered men to ask for directions when they are lost in the car, so it's difficult for them to ask for help in any way," he says. "When they actually do get in the room, the typical man has to be in an incredibly deep level of pain."
Making it meaningful for men
So what can psychologists do to leap these hurdles and effectively engage their male clients in psychotherapy? Psychologists who work with men draw from their experiences to offer several suggestions:
First and foremost, do not stereotype. "A lot of men have a perfectly fine time in therapy," Addis says. "The question to keep in mind is: What is it that makes therapy difficult for some men?"
Indeed, each man varies in how ardently he adheres to masculine gender roles, psychologists say. So, they advise, as a client walks into your office for the first time, resist the urge to label and instead spend the first session compiling information about him that indicates how much he follows these roles.
You can do this subtly, says Englar-Carlson. "See how willing they are to talk about the psychological distress they might have and look at their difficulties describing their emotional world," he says, noting the male socialization norm that men aren't supposed to admit weakness and reveal more tender or distressing emotions.
The same rules apply for understanding how gender roles affect people of various ethnicities, say experts.
"When working with men of color, I don't necessarily ask if they identify as, say, Asian American," says William Liu, PhD, a professor at the University of Iowa. "But I will ask questions about who they affiliate with, who they might date or where they grew up, just to get some semblance of how they see themselves."
Be an ear before being a therapist. Making a connection in the first session is critical, Brooks says. "If he believes you listen and know what it's like to be man or that you understand what he's going through, he's hooked. If he feels shamed, he won't come back."
How do you make that connection? By creating an atmosphere in which a client feels respected, Brooks adds.
"Go with what they come in with," he explains. "See what they want to fix in their lives and get an understanding about what's working for them. Guys really want to talk with someone because they are emotionally isolated. So once they sense that there is something in this process for them, you'll have resolved a huge problem."
But ultimately be the therapist. "I've seen men initially respond to, but then tune out, sympathy for its own sake," says Rebekah Smart, PhD, a Los Angeles private practitioner and staff psychologist at the University of Southern California (USC). Many men want to be challenged on their "stuff" but not put down, she says. "As a woman therapist, what helps to engage some men is to be empathically confronting in a way that doesn't demolish their self-esteem," Smart explains. "It's my way of keeping them hooked in."
For example, if a client is seeking therapy to battle depression or a stressful job, Smart says she will acknowledge the situation but also point out patterns of behavior the client engages in where, when threatened, they shut down. Then she will directly ask clients about the point at which they feel they play a part in that destructive loop.
Construct positive vibes in your office environment. Robertson has made his office "masculine congruent"--complete with wood paneling, overstuffed leather chairs and sports-themed wall art. "It looks like it's okay to hang out here," he says.
Therapists with a more gender-balanced client log should consider a gender-neutral environment, says Englar-Carlson. "What magazines are there?" he says. "Do you have Popular Mechanics in addition to Home and Garden?"
Also, look beyond the office interior. "The entrance to my office is private," Robertson says. "No street traffic could know where my client is going when he enters the building." Such anonymity helps reduce a guy's embarrassment, Robertson explains.
One other tip: "I put my credentials up on a wall that's easy for people to walk up to and look at," Robertson adds. "Men actually read my diplomas more frequently than women do. There's a credibility thing that men are looking for, so I make it easy for them."
Be careful with your language. Don't call it psychotherapy, or refer to men as patients, Robertson advises. Instead, he says, call the sessions meetings, conversations or consultations right from the start. Men are likely to feel down about therapy at the outset, so it's important not to exacerbate those feelings up front, he warns.
"For men, the word psychotherapy is evidence of failure," says Robertson, who uses words like strategies, plans, goals, outcomes, measures and experiments when working with male clients. "Those words are familiar to many men," he adds. "Use them rather than treatment or intervention. These words generally describe someone who's failed in some way."
Play to men's communicative strengths. Some men need to talk about actual life events they've experienced to consider their emotions, Kilmartin says. Otherwise, they might experience their feelings as a "nonspecific buzz" in their body.
"Most men are socialized to be storytellers," he says. "So get the guy to tell you a story about something that's happened to him. Start to look for emotional themes in the stories, highlight them and use emotional vocabulary to start a discussion about the themes. This way, therapists can model emotional introspection for clients."
Adjust your therapy style to fit different men's styles of interaction. In initial meetings with younger male clients, Mark Kiselica, PhD, chair of The College of New Jersey's counselor education department, will go for a walk so they can talk side-by-side, grab a bite to eat with the client or toss a ball back and forth in the office as they talk. These techniques help clients open up, he says.
"There are a variety of personality types among men, but across all males there's a tendency for guys to like a counselor who is more active in doing somewhat male-friendly things," he says. "I talk side-by-side, give homework, use films and talk sports. In these situations, I find most men are quite capable of showing emotion."
Educate them up front about the process. Many men don't know how the therapy process works and worry the therapist will be judgmental or discover their weaknesses, says USC psychologist Mark Stevens, PhD.
"I spend a lot of time educating them and clarifying how the process works," he says. "I want to be interactive, so I ask them after a session how they felt about it and ask if they have any questions. Counseling does not need to be a mysterious process."
Help men learn about their emotions. Levant has found men with normative alexithymia don't experience discrete emotions yet still experience their associated physiological sensations, such as butterflies in the stomach. He helps them develop a vocabulary for those emotions by having clients keep a log of every time they feel these sensations and then assessing what's going on that might cause them.
The goal? Teaching men how to identify and discuss their emotional experiences. "Because without that ability," Levant explains, "mildly alexithymic men are likely to feel frustrated by any therapy that relies on dealing with emotions, and they likely will drop out."
Be patient. Some men may take extra time and coaching to sort out their full range of feelings, Stevens says.
"I work with gaining permission," he says. "If I see them struggling with something, I ask, 'Can we play around with this idea a little bit?' If they say yes, then I might do some "coaching," and that develops into a dialogue that many guys feel comfortable having."
APA Psychotherapy Videotape Series IV: Psychotherapy With Men, with Mark A. Stevens, PhD. (2003). Washington, DC: American Psychological Association.
Brooks, G., & Good, G.E. (Eds). (2001). The new handbook of psychotherapy and counseling with men. New York: John Wiley & Sons.
Englar-Carlson, M., & Stevens, M. (in press). In the room with men: A casebook approach to psychotherapy with men. Washington, DC: American Psychological Association.
Andronico, M. (Ed.). (1996). Men in groups: Insights, interventions, and psychoeducational work. Washington, DC: American Psychological Association.
Levant, R., & Kopecky, G. (1995). Masculinity reconstructed: Changing the rules of manhood--at work, in relationships, and in family life. New York: Dutton.
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