Learning Objectives

This is an introductory to intermediate level course. After taking this course, mental health professionals will be able to:

• Discuss one presenting problem of male clients from a male-sensitive framework that takes into account male socialization and cultural norms.
• Describe the four masculine conflict zones used in the assessment of men who come for psychotherapy.
• Explain three ways in which male depression might be expressed differently than the DSM IV criteria.
• List two practical interventions which can enhance the depth and quality of psychotherapy with men.
• Provide one example each of the transference and countertransference issues that emerge in psychotherapeutic work with men.
• Discuss two interventions to engage men in couples therapy.

Introduction

Male clients present a unique challenge to the psychotherapist. Men are socialized to fear core components of the therapeutic process: the language of feelings, the disclosure of vulnerability, and the admission of dependency needs. Male clients’ discomfort with the developing intimacy of a therapy relationship can manifest as early termination, anger at the therapist, unproductive intellectualizing, and other forms of resistance. Yet, cutting edge theory and research, emanating from what has been termed, “The New Psychology of Men,” suggests that men can benefit from psychotherapy approaches that incorporate empathy and sensitivity to a man’s unique personal and socialized experiences.

Male psychic pain is not always obvious. Many men do suffer from depression and anxiety-related disorders, but often it is manifested in the forms of addiction, violence, interpersonal conflict, and general irritability. Many mental health professionals see men as reluctant visitors to the consulting room, coerced by family or legal pressures to attend. Initial resistance to psychological intervention might lead to the conclusion that men are not good candidates for therapy. This course will help therapists understand the damaging impact of male socialization, the problems men are likely to present in therapeutic environments, and the special skills and treatment modalities most effective in making progress with male clients. It will also address the personal and countertransference issues that often emerge for both male and female clinicians in their clinical work with men.

Course Outline

1. Understanding men
   1. Psychodynamic formulation of male development
   2. Impact of socialization on men
   3. Diversity among men
2. Creating a male friendly environment
3. Assessing men’s conflict zones in therapy
   1. Ambivalence about relational dependence in boys and men
   2. Prohibitions against sadness, grief, and mourning
   3. Problematic masculine specific self structures
   4. Preferences for “doing” versus “being”
   5. The wound as a portal to understanding a man’s depth
   6. Utilizing the conflict zones as a framework for clinical assessment
4. Working with the problems men bring to therapy
   1. Relational problems
   2. Male survivors of abuse
   3. Male survivors of trauma
   4. Violence and antisocial behavior
   5. Addiction
   6. Depression
   7. Sexual orientation
5. Engaging men in couples therapy
   1. Heterosexual couples
   2. Gay couples
6. Treating men in groups
7. Conclusion

Understanding Men

Despite the fact that we live in a society that appears to be dominated by men in powerful positions, the reality is that many individual men do not feel empowered in their lives. Painful and often traumatic early experiences of loss and separation overlaid by society’s expectations of achievement, strength, and toughness can lead a man to feel conflict, anxiety, and confusion. Because the traditional male role requires men to hide more vulnerable emotions, they often have few outlets for emotional expression. In comparison to women, higher rates of alcoholism, drug addiction, violence, and successful suicide suggest that many men act out rather than verbally share their emotional pain. It is imperative that clinicians who work with men in therapeutic settings understand the “new psychology of men” conceptualizations and research that account for internal emotional dynamics as well as cultural gender role socialization (Levant & Pollack, 1995).

Some may argue that all of psychology is the psychology of men. However, a gender specific approach to understanding human behavior was proposed by feminist scholars in the 1970’s as a way to study women’s psychological development. Men’s studies researchers in the 1980’s also began to use a gender specific approach to look at masculinity as a complex and multi-layered construct. Given the enormous changes in the empowering roles of women in North American society, traditional male behaviors could no longer be accepted as a normative standard. When studied from more sophisticated psychological and sociological approaches, male behavior seems to be guided by socially constructed rules that encourage men to take charge in their relationships, at work, and in their roles as fathers and husbands. At the same time, situations that call for cooperation, interdependence, or just “being” can create internal conflict for men. The crossfire of interpersonal and intrapersonal demands that require response flexibility may result in frustration and confusion in many men who have been shaped by traditional cultural expectations of how a man is supposed to act.

A psychodynamic formulation of early male development

Western culture values autonomy as an essential aspect of masculinity. Dependency, on the other hand, is to be avoided because it exposes neediness and vulnerability. Psychoanalytic theorists postulate that individual identity—that “sense of self” that is comprised of a gendered component—is forged out of the complex interplay between the developing child and those other significant persons who comprise the child’s interpersonal milieu. In the context of ongoing, intimate, and emotional relationships, a coherent, stable sense of self and other is developed (Kohut, 1977).

The development of a gendered self occurs within the context of close interpersonal relationships with first the mother and father, and later with other important persons in the child's interpersonal milieu. These deeply personal, unique, and emotionally charged relationships provide the basis for the development of the boy's conception of what it means to be a boy and later inform his notions of what it means to be a man (Rabinowitz & Cochran, 2002). The mother, father, or primary caretaker who has developed his or her own idiosyncratic notions about the meaning of gender, conveys this through interactions with the developing child.

Chodorow (1978) states that gender is communicated interpersonally from the mother when she writes, “The different length and quality of the pre-oedipal period in boys and girls are rooted in women's mothering, specifically in the fact that a mother is of the same gender as her daughter and of a different gender from her son. This leads to her experiencing and treating them differently.” (Chodorow, 1978, p. 98) What Chodorow argues is that little boys experience a gender-specific “relational discontinuity” in their developmental progression from attachment through separation within the mother-child dyad. In contrast to little girls, who experience a connective sameness with the maternal figure that results in a joining of identity and relationship, little boys experience a sense of separateness as a part of their identity (Rabinowitz & Cochran, 2002).

While Chodorow's analysis acknowledges the complex interplay between cultural values, attachment, and gender identity in early life, Pollack (1995) postulates that perhaps little boys are pushed from connection to their mothers at an early age in conformity with our cultural values related to masculine independence. It is possible that little boys experience this push from the maternal orbit as a deep loss. Such an abrupt, often premature, separation experience is viewed as a “traumatic abrogation of the early holding environment, an impingement in boy's development – a normative life-cycle loss – that may, later in life, leave many adult men at risk for fears of intimate connection. This traumatic experience of abandonment occurs so early in the life course that the shameful memory of the loss is likely to be deeply repressed.” (Pollack, 1995, p. 41)

Little boys’ experience of the loss of maternal “holding” is thought to result in a self-protective, defensive firming of ego boundaries as well as internalized conflicts related to relationships and dependency (Rabinowitz & Cochran, 2002). The emotional aspect to this earliest inner experience of little boys' sense of self and other is “a normative male, gender-linked loss, a trauma of abandonment for boys which may show itself, later, as an adult through symptomatic behavior, characterological defense, and vulnerability to depression.” (Pollack, 1998, p.154)

This relatively common developmental trauma will have a significant influence on the boy's evolving sense of self if it occurs early in the boy's life. It is likely to result in a breakdown of empathic holding and a vulnerability to developing narcissistic-like compensating self-structures (Cochran & Rabinowitz, 1996; Pollack, 2001). To the extent that such developmental trauma is “normative” for boys, they are as a group more likely to have character structures distinguished by a firming of self-other boundaries, conflicts around dependency and relatedness, and an overvaluing of autonomy in service of preserving these structures (Rabinowitz & Cochran, 2002).

The psychodynamic model offers an interesting explanation for what is commonly perceived as men's unique psychological characteristics—a tendency to prefer autonomy to relatedness and a deep-seated, if not unconscious, discomfort in response to demands for interpersonal connection. Although these characteristics have often been called forth in service of criticizing men, psychotherapists must recognize their normative developmental origins and be prepared to work with them within the context of an empathic, supportive therapeutic relationship.

The impact of socialization on boys and men

The most popular explanation for why boys and men are the way they are comes from the impact of socialization. Gender role socialization affects both males and females. A culture’s influence on how boys and girls are raised permeates everything from choices of colors for clothes to what kinds of emotional expression are allowed. Historically, our culture has encouraged women to be more relationship-oriented and men to be more self-reliant (Rabinowitz & Cochran, 1994).

David and Brannon (1976) coined the four preeminent values of western culture’s version of masculinity: “the big wheel,” “the sturdy oak,” “give ’em hell,” and “no sissy stuff.” The value of being a “big wheel” is embodied in the importance of being successful, important, and in charge. The importance of being a “sturdy oak” is portrayed in the masculine ideals of being tough, self-reliant, and confident. “Give 'em hell' means to be aggressive, competitive, and powerful both on the playing field and off. And “no sissy stuff” requires restraining from showing affection, emotion, or any behavior that might be construed as feminine.

Underlying much of the male ideal has been an anti-feminine stance. “You throw/you look like/you act like…a girl” is one of the shame oriented put downs that seems to have inhibited many boys from being more emotionally expressive. This has also translated into sanctioned homophobia that creates fear in men to touch or be verbally intimate with each other for fear of being identified as “gay.” Even sensitive men are expected to publicly adhere to norms that reflect a male warrior culture that values power, control, aggression, and assertive heterosexual desire (Mahalik, Good, & Englar-Carlson, 2003).

In response to the civil rights, women’s, and anti-war movements of the 1960’s and 70’s, traditional rules and values of what was considered feminine and masculine came under attack. Our culture was changing and men were challenged to respond to the contradictions of current and historical versions of masculinity. On one hand, men were still being raised to be tough, strong, and powerful by our social institutions. On the other hand, men were being asked to be more relational and sensitive by the women in their lives.

Goldberg (1976) was one of the first to describe the “impossible binds” that our culture imposes upon men. These include the expectations to be strong and in control but to also be sensitive and responsive (the gender bind), to be physical and active but also savvy and in command of oneself (the kinetic bind), and to take risks and challenge oneself but also care and nurture oneself (the hero bind). Fasteau (1974) and Farrell (1975) noted that the power dynamics of men’s relationships with women had shifted, leaving many men feeling lost, confused, and disempowered.

O'Neil (1981) proposed six types of strain men feel in their roles, which he called “gender role conflict or strain.” These included restrictive emotionality; socialized control, competition, and power; homophobia; restrictive sexual and affectionate behavior; obsession with achievement and success; and health care problems. Later research (see O'Neil, Good, & Holmes, 1995) verified the existence of four discreet elements of male gender role strain: conflicts between work and family relations; restrictive emotionality; restrictive sexual and affectionate behavior between men; and success, power, and competition issues. Continued research has shown that the endorsement of items that reflect a high degree of gender role strain are correlated to higher levels of psychological distress (Good et al., 1995), depression (Good & Mintz, 1990; Good & Wood, 1995), and avoidance of mental and physical health care venues (Good, Dell, & Mintz, 1989).

While today there appears to be some tolerance for variations in the masculine ideal in many subgroups of western culture, many boys still grow up believing that they must follow what Pollack (1999) calls the “boy code.” They must be tough on the playground, keep their vulnerable emotions in check, restrict impulses toward expressing affection, and laugh or keep quiet when another boy is being victimized. This early restriction on emotion and self-expression leaves many men in adulthood with problematic communication skills and normative alexithymia. Alexithymia is defined as an inability to put words on emotions (Levant, 1995).

Diversity Among Men

Ethnic and cultural identity interacts powerfully with gender role influences to shape masculine expectations. For many men of color who grow up outside mainstream European-American, heterosexual, middle class culture, they are reminded by their experiences of prejudice and oppression on a personal and institutional level that although they are men, they are less privileged and more vulnerable to forces outside of their control (Caldwell & White, 2001).

Although many men try to maintain a colorblind perspective, America is still racially divided. It is difficult for white men to comprehend the subtle harassment that men of color experience on a daily basis. Questionable stares, increased scrutiny, and automatic suspicion by peers, strangers, and police are regular occurrences for these men who work and live in the mainstream culture (Majors, 1994). Not only are they subject to the stresses of traditional masculinity, they must also cope with the overlay of subtle and not so subtle racism. A layer of anger related to this cultural predicament common in many men of color, even those who are trying to live by the rules of mainstream society (Franklin, 1998).

Men of African, Hispanic, and Asian descent face unique challenges because of racial stereotypes that hardly reflect the realities of most men. Despite wide variance within ethnic identity groups, limited experience often leaves more privileged members of society with only a superficial understanding of these groups’ worldviews. Therapists are encouraged to not only study the macro-level of cultures not their own, but also attend to the many variations that occur within groups. When considering how to counsel men from racial groups other than their own, clinicians need to pay attention to how masculinity intersects with an individual’s culture, family, and unique psychological make-up. Particularly important is the level of acculturation of the client. Those less integrated into the dominant culture often need more of an advisor and advocate than a traditional psychotherapist (Casas, Turner, & Ruiz de Esperaza, 2001).

While not as obvious as skin color, there are varieties of “white” identity as well that leave men vulnerable to feelings of alienation. Men who are unemployed or who work in the blue-collar work sector may feel alienated from those in white-collar jobs. In many places in America, gay men are fearful of expressing aspects of their sexual orientation in the presence of their straight counterparts. Jews, Muslims, Christians, and men from other religious backgrounds also feel ambivalence about how public they should be in acknowledging their religious identities. Men with physical and psychological disabilities can be subject to unwanted scrutiny and judgment from other men. Clinicians should be sensitive to the predicaments of men who do not fit the middle-class, Caucasian, heterosexist norms.

Creating a Male Friendly Therapeutic Environment

Due to male socialization and the psychodynamics of relational intimacy, many men are uncomfortable with a therapeutic process that asks them to be open and vulnerable about themselves. As difficult as it was to get to the office, it is still a huge obstacle to make the most of the therapeutic situation. Many men are anxious about what they should disclose. Often the reason a man is there is shameful to him. Talking personally about an emotional experience is not a usual part of his repertoire. To disarm oneself and share information that might be used to one’s disadvantage goes against everything a man has been culturally taught. It should come as no surprise that many men share only the surface of what is going on with them. Often it is framed intellectually with little emotional expression. Sometimes it is minimized or discussed in brief. If the therapist is a man, he may feel a need to present himself in a strong light. A man who is used to being in competitive environments with other men may find himself trying to show the male therapist that he is strong and competent, and has most of his life together. With a woman therapist, a man may try to display behavior that might make him feel attractive and important. Underlying the initial display of bravado is an insecurity and feeling of shame about having to admit to failing in some aspect of being a man.

Clinical Illustration (The names and identifying information in all the clinical illustrations in this course have been changed to protect the identities of clients.) The following is an exchange between a male client, Jake, and his male therapist in the first session. Jake is coming to therapy at the request of his wife who told him he needed to work on himself, or else the relationship would be over. J: So where do I start? T: Start anywhere you like. J: So you want to know something about me? T: Sure. J: Well, let’s see. I’m 43. I work in the insurance business. I do pretty well. I have two kids that I love with all my heart. I just have a little problem I need some advice on. T: Okay. Do you want to talk about the problem? J: Not really, but I guess I should since I’m here. Like I told you on the phone, I’m having some problems with my wife. She says I need help because I can’t be intimate with her. T: What do you mean by intimate? J: I’m not really sure. It’s not like I can’t get it up. I feel like I could have sex anytime. She hardly ever wants to though. T: Is it about sex? J: No. I told you. I don’t need Viagra or anything like that. She says I don’t tell her enough about myself, like I’m hiding something. T: Are you? J: Not that I know of. You know, I don’t tell her every detail of what happens to me but I don’t know too many guys who do. T: Must be hard to be here talking to me about this. J: Yea, I guess, but I want to show her I’m serious about the marriage. If coming here makes her feel like she can be with me, I’m for it. Note in the initial exchange how cautious Jake is about revealing much about himself. His disclosures remain on the surface. The therapist is patient and follows Jake’s lead. The competitive dynamic of having to open up to a male therapist seems to encourage Jake to show his strength as a worker, father, and sexual being. Among adult men, it is not uncommon for identity to be based on “keeping score” about how one measures up to the standards of physical prowess, high achievement, and financial power (Vodde & Randall, 1994). Jake does not want to be in a one down position in this relationship, yet he feels like he is and must compensate. The therapist’s intervention of “must be hard to be talking about this” shows some empathy for the client’s predicament and is likely to lead to more productive sharing by Jake. Having empathy for the difficulty of sharing personal information in a strange environment is likely to go a long way toward helping Jake feel more like he is understood and less like he is being judged. Later in the first session J: So how does this work? Do I talk and you give me advice? T: I don’t necessarily give you advice, but I listen and try to help you come up with ways you might approach things. J: Is it okay for me to ask you a few questions? T: Sure. I am open to questions you might have. J: So, are you married? Do you know what I’m talking about? T: Currently, I’m not married but I’ve worked a lot with men and relationship issues. J: So you were married? T: Yea. I was married for awhile. J: It didn’t work out? T: No. We had differences and decided not to stay together. How about you, Jake? You worried about splitting up? J: Yea. I’m not sure I’d be going through all this if it wasn’t for my kids. I think it is good for them to have two parents living at home. I wish we were getting along better. It’s probably not good for them to see us fighting. While it looks like Jake has turned the tables on the therapist, the self-disclosure by the therapist is helpful in getting Jake to feel more comfortable talking about himself. The therapist has disclosed some of his vulnerability, leaving Jake to feel a little less like he is in the weaker position. The therapist does a nice job of modeling disclosure and masterfully turns the question about being married around so that Jake is talking again about his situation. Even though he is not talking with emotional depth about his concerns, the first session is really a testing of the relationship. “Am I going to be able to be myself?” “Am I going to be judged?” “Is this therapist someone I can confide in?” “Do I like the therapist?” “Does he seem to have it together?” “Does he speak my language?”

 

Clinical Illustration Steven, a 44-year-old man, has come to the office of a female therapist in her mid-fifties. Steven has recently split up with his partner of 15 years. He has been feeling depressed and using marijuana to soothe his emotional pain. S: I’ve been feeling really sorry for myself lately. I shouldn’t be so upset by this. I knew it was coming. We hadn’t been getting along for the past year. T: You sound like you are blaming yourself for this break up. S: I think I caused it. T: What do you mean? S: Well, I didn’t keep up my end of the deal. T: What was your deal? S: That I would make her a priority in my life no matter what. T: And something happened? S: You could put it that way. I’m embarrassed to talk about it. T: It’s okay. Just share what you feel comfortable sharing. S: Well, it’s hard. T: Is it because I’m a woman?” S: Kind of. It has to do with some sexual stuff. T: And you are not sure how I will react? S: Yea. I don’t want to make you uncomfortable. T: Try me out. I work a lot with men, and hopefully I won’t be blown away by what you say. Because the therapist is a woman, a different transference dynamic has emerged with this male client. Whereas Jake was a bit competitive with his male therapist, Steven is hesitating about sharing something that he thinks a woman wouldn’t understand. Since he is ostensibly coming to therapy because of rejection by his female partner, talking about something that he thinks destroyed the relationship feels a bit unsafe. “What if she reacts the same way that my partner did?” is probably going through his mind. Therapy is feeling uncomfortable for Steven, yet the therapist does a nice job of being non-judgmental and understanding. The therapist understands that because she is a woman, this might be interfering and she brings it to Steven’s attention. It allows for an important exchange that lets him know that the therapist has experience and will likely react differently than his partner. Later in the first session S: It surprises me that you were able to listen to me talk about the affair. Most women would be angry and upset at me. T: You seem relieved that I didn’t act like your partner. S: I just assumed that you would think it was sleazy to have someone on the side just for sex. I mean I know other guys that do it, but they tell me it’s no big deal. T: But it is a big deal to you. S: I’m pretty sensitive and I thought I could keep the sex and love separate. I really love Georgia. Elaine and I just see each other in a physical way. There aren’t any strings attached. I don’t have a larger relationship with her. It’s just sex. That’s all she wants, too. T: Seems like you got your needs met but it broke the rules that you and Georgia had set up for your relationship. S: I feel bad about that. I think she misunderstood my intentions. T: In what way? S: I appreciate that she doesn’t have the same sexual appetite that I do, and I thought by getting those needs met with someone else, it would take pressure off her. I was wrong about that. She feels I cheated on her. T: But it didn’t feel like cheating to you. S: I’m not sure. Like I said, I was getting my needs met and I thought I was giving her a break on my sexual demands. The therapist empathizes with Steven’s fears about opening up to another woman, especially when his partner had judged him harshly. The therapist’s nonjudgmental attitude allowed Steven to continue to process the “disconnect” between his perceptions and those of his partner. At the start of therapy, Steven wants to talk rationally about his perspective. It is important for the therapist not to push too hard for the feeling level too soon. In this case, Steve is stating his perspective, and going further in verbalizing and looking at his own actions because he is not feeling judged.

Sweet (2002) reminds women therapists who are working with men to be aware of their own countertransference reactions to men in the session. She asks women clinicians to look honestly at their own feelings about men. “Do I like men?” “How do I expect men to be?” “What are my experiences with significant men in my life?” “How have these relationships impacted my ability to have empathy for men and their psychological issues?” If the therapist is not aware of her own issues around men, including male sexuality, experiences of infidelity, and relationship insensitivity or miscommunication, it is likely that her own reactions might come across as judgmental and may push the client away. In this clinical example, the therapist shows empathy and awareness for the male client’s view of the dynamics of his relationship with his partner.

Assessing men’s conflict zones in therapy

Regardless of the issue that brings men to therapy, clinicians can organize their approach by assessing male-specific conflict zones that are the result of cultural attitudes toward masculinity (Rabinowitz & Cochran, 2002). These conflict zones include ambivalence about relational dependence; prohibition against sadness, grief, and mourning; problematic masculine-specific self-structures; preferences for doing instead of being; and the emotional wounding that has brought a man to therapy and is exposing his emotional depth and vulnerability.

Ambivalence about relational dependence in boys and men

Masculinity in contemporary American culture emphasizes independence, the capacity to “stand on your own two feet,” and all that is associated with this particular psychological value. How does the developing little boy, who is initially unaware of the way his culture devalues his dependence, negotiate this experience? How does our culture's ambivalence about, and disavowal of, dependency in males become integrated into boys' and men's psychological lives?

The little boy is dependent on his early caretakers for feeding, holding, and shelter as well as love and support. This is a universal human developmental experience, yet in our American culture, dependence and its psychological meaning are often seen as contraindicated with masculinity. This early relationship with a caretaker, characterized by dependence, longing, and (hopefully) gratification, forms the basis for expectations in boys' and men's relationships with their own mothers, and later with both men and women in their lives (Rabinowitz & Cochran, 2002).

Often, the longing and gratification that the little boy experiences is culturally devalued as he grows into manhood. Males are confronted by cultural messages that they are unmanly and abnormal if they experience gratification from their dependency needs. Boys are prone to internalize contradictory, mixed interpretations of their experience because of their underlying ambivalence about dependency. On the one hand, they experience affirmation and gratification of dependency in their early relations with mother and other important adults. On the other hand, they learn that such an experience is to be disavowed if they are to be accepted. Other powerful forces in the social landscape that may also reinforce this learning include parents, teachers, coaches, and especially same- sex peers.

Disapproval and shame become associated with the presence and enactment of dependency needs. To disavow the most basic of psychological needs—the need to depend on another person for love, support, and nurturance—results in a boy or man who must “stand on his own two feet” and not ask for help or support, even under the most disturbing circumstances. It also may result in a distancing in interpersonal relationships so as not to appear needy or dependent. Pollack (1998) called this “defensive autonomy.” In intimate relationships, it might manifest as an avoidance of emotional intensity or an unwillingness to commit out of fear of being engulfed.

In the therapeutic relationship, the conflict about dependence manifests itself in several ways. The fact that few men even make it to a therapist reflects the avoidance of men in our culture of involving themselves in a potentially dependent relationship, even if it is for their own good. Another demonstration of this conflict results in the devaluing of the therapeutic relationship, particularly early in the process. Men in the initial stages of therapy often perceive it more as an impersonal psychological “tune up” rather than an intimate relational process. The dependence conflict may also be manifest as a perceived lack of commitment by the male client to the therapeutic endeavor (Rabinowitz & Cochran, 2002).

Sometimes therapists misinterpret a man’s closed posture, simple and gruff language, hesitancy to share, and lack of emotional expression as resistance that needs to be overcome rather than an expression of the conflicting nature of dependent urges toward the therapist and therapy.

Clinical Illustration Bill was a thirty-year-old single man who requested therapy after being asked to move out of his cohabiting relationship with his female partner, Anne. After a ten-month courtship, they had decided to live together, and had been sharing a house for the past two years. They held many common values, and Bill described to his therapist how he perceived them to be very happy together. Bill and Anne each had professional jobs and they enjoyed a comfortable living. As Bill's sessions unfolded, though, he described a “dance” he and Anne would perform that would begin with Ann making a request for a deeper commitment to the relationship. This was often in the form of planning more “quality time” together or, ultimately, asking for a promise to marry. In response to these bids for greater commitment, Bill would either avoid comment altogether or would “buy time” by saying he would “have to think about it.” Finally, Anne's frustration outweighed her own investment in the relationship, and she asked him to move out of their home. In therapy, Bill had a hard time explaining his behavior from a rational framework, as illustrated by this short exchange with the therapist. B: I don’t know why I couldn’t commit. She was everything I wanted in a woman. I don't get it. T: You feel regret now about how you pulled away. B: I feel terrible. I wish I could have made the commitment. It was like something in me felt repelled, like I was going to suffocate if I let her get any closer. I didn’t know how to tell her how I felt because I didn’t understand it myself. It scared me. (Rabinowitz & Cochran, 2002, p. 18) Bill's situation is a common one for many men seen by psychotherapists for help with relationship problems. When asked for greater involvement, commitment, or a demonstration of their love or caring, some men simply “draw a blank.” They are at a loss as to how to respond to such a basic, elemental relational situation. Frequently, a man’s loss of voice in this situation is felt as withholding or rejecting by his partner. This then leads to increased frustration and disappointment with the relationship for both partners. Out of frustration, a man may thus be referred for therapeutic consultation.

The roots of this dilemma lie deep for many men. Basic ambivalence around dependence and intimacy played out in a relational context recapitulates the earliest experiences of dependency and relational “holding” with the mother and father. Adult intimacy is often associated with vulnerability and, ultimately, with disconnection; the man unconsciously remembers his connection—then disconnection—with his earliest love object. The “blank” that many men draw when asked for deeper commitment may be the present-day enactment of this early relational conundrum.

Prohibitions against sadness, grief, and mourning

From an early age, little boys are presented with both overt and covert messages suggesting they suppress their emotional experience and their expression of feelings. ”Cry baby,” ”keep a stiff upper lip,' and “gut it out” are but a few of the admonitions given to little boys to deny, disavow, and suppress outward expression of their sad or vulnerable emotions. Such values expressed by parents and other caretakers profoundly shape the growing boy's interpretation of his experience of loss and grief, and have a long-lasting impact on the manner by which he eventually learns to mourn his losses. This is particularly problematic in light of the fact that both boys and girls experience disappointments, betrayals, and losses from birth onward. Just as girls and women are often perceived to be more comfortable with these emotions, boys and men seem alarmed by them. As a result, boys and men frequently dissociate themselves from these feelings and repress them deep into the hidden realms of their inner lives.

Dissociation, as a defensive psychological process, compromises natural mourning that occurs as a result of the making and breaking of intimate emotional attachments to others throughout the lifespan. When this normal process of grieving is truncated and thrown off course, anger, shame, and control-oriented defenses often arise as a means of self-protection. This also creates conditions that invite self-medication and acting out to relieve the discomfort caused when these emotions threaten to break through into consciousness. Perhaps it is through this dynamic that we can understand why so many men suffer from alcohol and substance abuse problems, and tend to ”distract” or act out many of their emotions in benign as well as destructive ways (Cochran & Rabinowitz, 2000).

In the therapeutic relationship, issues of grief and loss and the accompanying emotional experience of sadness may be elusive or difficult to acknowledge. A male client may describe a loss experience and take a “what can I do about it now” attitude instead of moving toward the emotional level of experiencing the loss. Similarly, a male client may minimize the impact of a loss experience, saying, “It’s no big deal, I can handle this.” Often, when a therapist openly addresses loss and grief issues, many men find a new and rich level of emotional experience (Cochran & Rabinowitz, 1996). Therapy that encourages male clients to talk about loss experiences can facilitate the unclogging of the emotional ice jam that has been maintained by shame and the fear of losing control.

Clinical Illustration John sought therapy to address his feelings of boredom and lack of motivation for his work. He had been employed as an assistant professor for two years, and was experiencing serious work inhibitions. He felt “uninspired” and “bored” in his classroom teaching, his writing, and his work with students. As he described his situation to his therapist, he began talking about his childhood and his experience as a boy growing up in his family. John's father was a practicing alcoholic who was away from the home for much of the time when John was a boy. His mother was a grade-school teacher who over-functioned in this role as well as in the role of homemaker. He had a sister who was two years younger. John recalled a great deal of conflict in his relationships with his sister and his mother. He recalled being the brunt of many “man jokes” and being criticized in most of his activities by his mother and sister. Adding insult to injury, he felt little support from his father who was rarely home. As a result of this family of origin experience, John felt he had never developed a healthy, positive sense of himself in general and as a man in particular. He “longed” for a more positive childhood, and at the same time would chide himself for “crying over spilt milk.” In discussing these feelings with his therapist, he would simply dismiss his longing by saying it was “in the past” and that he should "just get over it." J: I feel like a big whiner. Plenty of people have had rougher childhoods. No one hit me or abused me. T: Maybe no one hit you, but you feel like you missed out on something important when you were younger. J: What do you mean I missed out? What am I missing? You mean like my father? T: Does that fit for you? J: I sure wish he had been more there for me. Living with my mom and my sister was pretty brutal at times. I guess those are the breaks. (Pause) T: You are doing it again. J: Doing what again? T: Trying to rationalize your way out of the feelings you have of missing your dad. You're pulling away from looking at your sadness about this. J: I know. I just don’t like to admit it to myself. I keep thinking I can redefine myself and get on with my life without acknowledging his absence. T: That doesn’t seem to be working very well. You still get down on yourself. J: I wish I could just let out all this damn emotion and be done with it. I want to feel free. I want to move on. (Rabinowitz & Cochran, 2002, p.20) John’s experience is not unusual. For many fathers (and mothers), being a good provider often means being away from the home for much of the time. John’s situation was complicated by experiences with the women in his family who did not support him emotionally and who were highly critical of him. As a result, John left home with a poorly defined sense of self, highly negative associations about his masculinity, and a pattern of negative interactions with women.

John’s emotional life during these years was stifled, dissociated, and repressed. His longings for connection with his father, his needs for support of his own growing interests, and his poor interpersonal experiences with women left him deeply wounded and sad. As he made his way through secondary school and then college, he began to be acknowledged for his sharp intellect and his biting wit. This carried him until he was faced with the self-activation required of him as an assistant professor. As a result of this activation, his repressed sadness and longing for more intimate and meaningful connection broke through into consciousness, overwhelming him with grief that he was unaccustomed to managing.

Problematic masculine specific self structures

As a result of contemporary child rearing practices and the influence of relationships with siblings, peers, teachers, and the popular media, a boy’s psychological development is intimately intertwined with conscious and unconscious transmission of cultural values around masculinity and femininity. Little boys are given mixed and incongruous messages about how important others view their masculinity. Such messages often conflict with their inner experiences of emotional need and desire. The development of a coherent sense of self with a positively valued facet of masculinity is therefore a significant challenge for many boys. As many boys venture into puberty, problematic aspects of their masculinity have been well-learned and suppressed, resulting in a flattening of the emotional expression of sadness, anguish, fear, and tenderness. At the same time, many male adolescents tend toward acting out emotional conflict through risk-taking and aggressiveness (Rabinowitz & Cochran, 1994).

As boys begin to construct masculine-specific self-structures, they must balance how peers, family, and the cultural influences of school and the media view certain aspects of masculinity with their own acquisition of masculine traits. Often, these outer definitions of masculinity conflict with inner needs, wishes, and values. The boy who is hurt and needs emotional support, or even a hug, is sometimes admonished to “stop crying” and “take it like a man.” Over time, such contradictory and mixed admonitions result in the creation of a facade of problematic masculine-specific self-structures designed to hide vulnerability and apparent weakness. Such self-structures include a tendency to restrict emotional awareness and expression, a propensity to distance or withdraw from interpersonal connection, a discomfort with depressive feelings and the corresponding expression through tears, and a penchant to show force or action when encountering a personal problem (Rabinowitz & Cochran, 2002).

Conflicting masculine self-structures are often one of the reasons a man may come to therapy. The denial of sadness and loss, the retreat from intimacy in relationships, compulsive competitiveness, the neglect of physical and emotional health, and other “traditional” masculine ways of being often have detrimental consequences to the man as well as his relationships with those he loves. Understanding the conditions under which these self-structures have been created and working on dismantling the dysfunctional elements is an important therapeutic focus of gender-sensitive psychotherapy for men.

Clinical Illustration Craig came to therapy to discuss a number of problems he felt he was having both at work in his career and at home in his relationship with his partner, Jim. He was referred by his company’s Employee Assistance Program (EAP) after he had sought advice on how to deal with an apparent ongoing conflict with his supervisor. Craig described his approach to things as ‘straight ahead.’ “I see what I want and I go get it,” he explained to his therapist. After exploring the elements of his problem, it became apparent that Craig was oblivious to the impact of his aggressive style on his coworkers and his supervisor, that latter of which was a woman who approached her supervisory duties through teamwork and collaboration. The immediate incident that brought Craig to the EAP was a situation where he had given some valuable team information to a potential customer who had then used it to negotiate a better purchase price with a competitor in the industry. Craig’s supervisor had confronted him with the negative consequences of his indiscretion, and she told him that she expected him to either change his ways of doing things or apply to join another team in the firm. Craig's partner, Jim, while sympathetic, could see the supervisor's point of view since Jim often felt that Craig was impulsive and self-serving in their relationship. C: I am tired of hearing all this bullshit about me not being sensitive to other people’s needs. I work hard and do what I think is right. I may have screwed up but at least I was trying my best. I was taught that you take a stance and follow through. I’m not going to back down when things get rough. T: You sound angry. C: My dad taught me to be strong and trust my instincts. All this corporate sensitivity to how others feel really runs against my upbringing. T: Your instincts seem to have gotten you into some hot water at work. C: Yeah. It happens at home, too. Jim tells me I come on too strong sometimes. I don't take his needs into consideration. That’s not good. I’m not sure what I can do. The rules I learned don’t seem to be working these days. (Rabinowitz & Cochran, 2002, p.22) Craig’s dilemma is a common one for a man who has adopted the “take charge” and “get results” elements of our culture’s definition of masculinity. He was confused and angry. He noted the similarity between his supervisor’s complaint and his partner's feedback to him about his tendency to just “take charge” and not include him when making plans. He was genuinely stumped by the consequences of his actions. It was apparent that an exploration of his masculine self-structure, composed of his gender role history and the messages he incorporated in his development as a man, would be a relevant element of his therapy.

Preferences for “doing” versus “being”

In observing a typical school playground, it might be noticed that boys are often involved in competitive, active play within larger groups. Girls are frequently involved in smaller groups of more relational, cooperative play. These sex differences appear to persist into adulthood and are thought to reflect externalizing defense styles (Gjerde, Block, & Block, 1988), distracting response styles (Nolen-Hoeksema, 1990), or externalizing ego defenses (Levit, 1991).

Winnicott (1988) believed that “being” was a universal developmental milestone accomplished by the union of a “good enough” environmental (maternal/paternal) adaptation with the infant’s physical and emotional needs. It is out of this elementary experience of being held and nurtured that the capacity for true “doing” arises. Doing corresponds to the spontaneous, joyful emergence of the “real self” and the actions taken to activate and outwardly express this self. But such behavior is based on, or evolves out of, the basic capacity for simply being that is characterized by an absence of restlessness and contentment with one’s emotional self. Despite believing that both men and women can experience both states, Winnicott noted that girls and women seemed to be more comfortable with being, and boys and men more at home with doing.

Boys’ preference for doing over being can be observed in a number of ways. As noted, the little boy may prefer active, physical play on the playground with his friends at an early age. In addition, boys and men, appear to prefer more action-oriented means of problem solving that may have adaptive as well as maladaptive consequences. Adaptive doing is seen in active problem solving, a willingness to take risks to protect others, and a capacity for hard work that characterize many men. Maladaptive doing is observed in unseemly risk-taking, difficulty relaxing, and/or overt and destructive acting out behaviors that often serve as distractions from unpleasant emotional states. Aggression and problems with various kinds of addictions from substance abuse to compulsive gambling to sexual promiscuity to workaholism are also forms of maladaptive doing. (Rabinowitz & Cochran, 2002)

Men’s tendency for doing, and a discomfort for being, can be seen as a relevant component of many men’s emotional and relational difficulties. As the unpleasant and destructive consequences of a life that is based on an over-reliance on doing accrue, therapists can help men recognize the value in cultivating their capacity for being, and strive to strike a balance between doing and being. Relational bonds that have occurred through productive doing can be strengthened by a therapeutic approach that intertwines activity in the therapy relationship along with a focus on being with the feelings that emerge. The familiar doing approach can often act as an entryway to the being world. With an appreciation of the meaning of both of these elements for men, a sensitive psychotherapist may be better able to facilitate the attainment of this balance.

Clinical Illustration Dave sought therapy after his third arrest for operating a motor vehicle while intoxicated. He had been pulled over while driving home from a party at a friend's house. Dave relished his reputation as the “life of the party.” He had many friends and engaged in many sporting activities. Some of his sporting activities, like motocross racing or white water rafting, were considered dangerous or risky. As Dave told his story to his therapist, he described how he enjoyed “pushing himself to the limit” and how he got a thrill out of mastering dangerous situations. Although he had many friends, Dave disclosed his frustration at not having a more permanent or serious significant relationship. He had dated a few women in college, but now, fifteen years after graduation and with several failed relationships behind him, he was unhappy and worried. He began to notice the double-edged nature of his preference for doing. Namely, while he was active and busy, racing his bicycle and going on camping excursions, he avoided close interpersonal connections with any potential partners. D: I’ve noticed that a lot of my old friends don’t want to hang out with me much anymore. T: What do you think that might be about? D: You’re the therapist. You tell me. (Pause) Only kidding. T: Seriously, this is your life Dave. What do you think is going on? D: I probably have scared them off. I’m still doing the crazy stuff we used to do when we were younger. These days it seems like everyone’s married or settled down. T: How does that feel? D: It feels kind of lonely, to tell you the truth. I really do miss my friends. T: It feels lonely. Do you think your need to do the crazy stuff, as you put it, is worth this lonely feeling? D: I'm beginning to wonder. I really feel lonely a lot of the time. I just don't have the same connections I had when I was younger. (Rabinowitz & Cochran, 2002, p.24) Like many men, Dave had been socialized to be active, outgoing, and fun-loving. He did not immediately perceive any particular costs to this lifestyle. However, as his sessions unfolded, it became clear to both Dave and his therapist that his high intensity, risk-taking lifestyle left him devoid of intimate interpersonal contact. He simply moved “too fast” for anyone to ever get close to him. This downside of his lifestyle became more and more apparent as he began to recognize how most of his old friends had “settled down” and were beginning to establish their own families of choice. Dave was still the fun-loving, fast-moving guy. He was, however, beginning to recognize the limitations that his lifestyle imposed on the fulfillment of his emotional needs.

The wound as a portal to understanding a man’s depth

Most, if not all problems that men present to a psychotherapist, have an element of wounding. Wounding refers here to the nature of the experience that has precipitated a visit to the therapist. Interpersonal conflict and rejection, failure experiences, and frustrations with not meeting expectations of life all can be construed as wounding experiences for many men. Deaths of family and friends, the inevitable confrontation with aging and physical decline, or the reconciliation of one’s life dreams with reality’s limitations are often felt as wounds to men.

Wounds challenge a man’s basic sense of self. They bring to awareness a man’s shortcomings, or his perceived failure to live up to his culture’s masculine ideals. Such perceptions are felt as failure and are, as such, experienced as a “narcissistic wound” to the ego (Kohut, 1977).

A rejection in an intimate relationship has an obvious element of wounding. The man who is rejected often enters therapy feeling confused, hurt, angry, and unable to understand completely what may have “gone wrong.” The man’s sense of adequacy as a partner, both sexual and social, has been challenged. His view of himself must be reconciled with his partner’s view of himself. The realignment of self-perception and another’s perception is frequently a painful one for many men.

Failure at work is a similar wounding. A man who is laid off from his job or who is fired experiences a sense of failure and inadequacy. A process of realignment, similar to that which occurs with rejection in an intimate relationship, takes place wherein the man must reconcile his own perceptions with others’ perceptions. In addition, his identity as a provider is challenged.

Utilizing the conflict zones as a framework for clinical assessment

The clinical use of conflict zones involves combining them in a synergistic manner that merges the male client’s psychological history, formative experiences, cultural upbringing, and current functioning. The wound portal focuses client and therapist on those elements of the man's life that will serve as the window into deeper, more integrative levels of the male client’s psychological functioning. Together, they provide a framework for conceptualizing the male’s psychological difficulties and intervening from a deepening perspective.

Clinical Illustration Gerald sought consultation with a therapist after he and his spouse had decided to discontinue marital counseling. Gerald, his spouse, and their couple’s therapist had concluded that, until Gerald made some decisions about his level of commitment to the marriage and his willingness to work on joint issues, couple’s counseling would be of limited benefit. As he met with a new therapist for an initial consultation, Gerald outlined the problem areas that he perceived in his relationship with his spouse. G: We don’t seem to agree on much at all, especially when it comes to how we spend our time together. T: What do you mean? G: Well, she wants to just sit at home on the couch and rent a movie and make some popcorn. I just get real edgy and feel claustrophobic when we do that. I can’t stand it, really. I would prefer to do something. T: You get edgy and claustrophobic? G: Yeah. Edgy. I don’t know. I can’t explain it very well, but I just get real uncomfortable. And Anne can pick right up on it, then she gets frustrated and hurt, and then we usually just get into a fight. T: You said you get real uncomfortable? G: Yeah, it’s just an anxious feeling. Like I want to sit down and have a nice evening, but then like I don’t. I feel like I just want to leave and go drive around in my car or something. T: What do you think would happen if you were to sit down with your wife, eat some popcorn, and watch a movie? G: I don’t know, but I just haven’t felt like being close or intimate with her lately. I just don’t feel very warm. I guess I would have to level with her about how I’m having so many second thoughts about our marriage and how I don’t really want to be with her. Ugh. This makes me feel uneasy just talking about it. T: Uneasy? What do you feel the uneasiness is telling you? G: I feel like I’ll get pinned down, like I’ll have to say what I really feel and own up to it. And the fact is that I just don’t know if I’m in love with Anne any more. And I think that would just devastate her. I don’t know if she could take it. (Rabinowitz & Cochran, 2002, p. 29)

Note how the conflict zones are illustrated in this case example. We might view a major element of Gerald’s presenting conflict to be associated with the first psychological dimension—ambivalence around dependence. Gerald is straightforward about his hesitation and second thoughts regarding his marriage and his relationship with Anne. We might expect that this conflict would have significant emotional and historical underpinnings that could be further explored. Still, Gerald is stuck in a position of not having brought his feelings out in the open with Anne, for fear of how she might react and his concern that she would not be able to “take it.” This reveals the projection of his own dependency conflicts onto Anne. Further exploration might help Gerald to integrate these emotions, examine his own dependence on Anne, and take a look at his own fears of what would happen if he were honest with her about his feelings.

The second psychological dimension—prohibitions against emotion in general and grief and sadness in particular—is illustrated by Gerald’s avoidance of honesty with Anne and his holding back of his real emotional experience with her. At this point, we do not know the origins of this particular conflict, but wonder how they might be rooted in Gerald’s own gender-based restrictions on emotional expression in the context of an intimate relationship.

The third psychological dimension—a problematic masculine-specific self-structure—may be reflected in Gerald’s overall inhibition of emotional expression with his spouse, Anne, and with his tendency to escape intimacy through involvement in a solitary activity. Restrictive emotionality in men and avoidance of intimacy and emotional expression are common themes of male psychological conflict.

The final psychological dimension—comfort with doing and discomfort with being— is clearly illustrated by Gerald’s anxiety and discomfort with the possibility of “just sitting” with Anne on the couch and enjoying a movie together. His fantasy of escape involves going and driving around in his car, clearly a doing mode as opposed to a being mode. The therapist might wonder what the threat is that is associated with “just being” for Gerald. The escape into an apparently solitary doing activity might be the result of gender-based learning.

A portal to Gerald’s inner life may be found in one of several possible locations. First, the anxious feeling that Gerald gets when he thinks about sitting down with his spouse on the couch and watching a movie represents a bodily manifestation of what appears to be a core conflict with a likely history of wounding. Further exploration of this feeling on both the cognitive as well as emotional and physical levels may reveal the portal to Gerald’s deeper ambivalence about intimacy and connection. Another portal entry might be discovered by following the feeling of being “pinned down” and how Gerald fears he might have to be honest with Anne about his true feelings. Through either of these portals, Gerald and his therapist will discover his authentic, true feelings about himself and his life.

Working with the Problems Men Bring to Therapy

When men are faced with crises in their lives, the motto, “I can figure it out myself,” seems to be the predominant response. Even when the crisis is as major as sexual abuse, family violence, traumatic victimization, and major interpersonal loss, many men are hesitant to consult a therapist to deal with the emotional pain. Only one-third of voluntary psychotherapy clients are men (Vessey & Howard, 1993). In contrast, a much greater number of men than women are seen in alcohol and substance abuse treatment centers and in incarceration settings (Hanna & Grant, 1997). Epidemiological surveys report that the lifetime prevalence for alcohol and drug dependency is approximately 30% in men. Major depression occurs in men at about a 10-15% lifetime prevalence, social phobia at 10%, and antisocial personality at 5-8% lifetime prevalence (Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993). It has been suggested that drug abuse, depression, difficulties in social relationships, and antisocial behavior form a composite profile of a male tendency to externalize psychological distress through action, distraction, and compulsive acting out (Cochran & Rabinowitz, 2000).

Relational Problems

Interpersonal conflict is one of the major complaints of males seeking treatment (Brooks & Silverstein, 1995). Experiences of rejection and shame, confusion, and seemingly avoidable relational tension may become a pattern in a man’s life that might lead him to seek psychotherapy. Poor intimacy skills in the form of shyness, isolation, and limited emotional expression may also lead to disturbances in relationships for men.

Depending on the stage of relational disturbance, a therapist must identify the form of therapy that would be most likely to be beneficial. For instance, an individual who is a part of a couple in which problems are beginning to emerge may best be treated in couple’s therapy (to be discussed in a later section). Often, a clinician will see a man who is in the final stages of a deteriorating relationship or one that has recently resulted in separation. In this circumstance, a therapist is more likely to work with the man individually to deal with unresolved emotional issues.

While individuals grieve in distinct ways, Worden (1991) has suggested that those going through relationship separation or divorce have the following psychological tasks to manage: accepting the reality of the loss, experiencing the emotional pain of grief, adjusting to a life without the partner, and detaching from the ex-partner in order to be psychologically open to new relationships.

Male socialization issues often keep a man from fully acknowledging the impact of relationship loss. A façade of self-reliance and strength often belies the anxiety, uncertainty, and depression that have brought him to therapy. It is more likely that his emotional response is being acted out in other venues. Substance abuse, overeating, irritability, over- or under-involvement in usual activities, sleep disturbance, unexplained anxiety, and/or impulsive decision-making may let him know that something is not right, despite little psychological awareness (Cochran & Rabinowitz, 2000).

The clinician needs to take a slow approach to uncovering grief in men. For many men, it is much easier to access anger than it is to access sadness, especially in interpersonal relationships (Brooks, 1998a). Talking to a man about what is “pissing him off” might be a better opening that discussing what is making him feel sad. Utilizing a “doing” approach may also be more comfortable for a man (Rabinowitz & Cochran, 2002). This might involve asking what he is doing in response to the relationship issue. Later, it might mean discussing actions that he might take in a more cognitive way.

Clinical Illustration Rich, 27, had recently found out that his wife of three years had been having an affair after noticing her withdraw from him over the past six months. Early in their relationship, they had talked of having children. At that time, Rich had been hesitant since he was just beginning his career as an accountant with a big firm. He knew he would be working long hours. His wife, Judy, who had been disappointed by Rich’s desire not to have children right away, had enrolled in a master’s program in counseling, and had recently graduated. Rich, who often worked six days a week and 10-hour days, was shocked when he came home unexpectedly and found his wife in bed with another man. Without saying a word, Rich had left the house and driven his car five hours to Las Vegas, where he spent the weekend drinking, gambling, and going to strip clubs, things in which he had never allowed himself to indulge. When he returned, Judy had moved all of her belongings out of the house with a note that she was not in love with him anymore. This is dialogue from the third session R: I still can’t believe what a bitch she is. How could I be so fooled? T: You still seem incredibly angry at her. R: The bitch betrayed me big time. I was working my ass off for both of us and then she has to go fucking around. T: It seems like you have really been able to feel your anger, but you lost someone you really cared about. R: I can’t go there. I am still so friggin’ angry. The way she did it, too… screwing some guy in my bed. Wow. Can’t get that image out of my head. T: Would you do anything in your anger to get her back? You know something physical? R: No. It’s not worth messing up my career for a little revenge. I never touched her in a violent way ever. T: How is this affecting the rest of your life? R: The rest of my life? I’m just going through the motions. Work seems boring. The house is empty. I’m watching a lot of television. T: When you talk about Judy, you seem to get energized, like your anger lights you up. R: Shit, yea. Bitch has what she wants. Why didn’t I see it coming? T: Maybe you did. You told me she had been withdrawing from you. R: I just figured we were working too much. She always said she was tired. I thought that made sense. I was certainly tired. But she lied to me. I trusted her. Bitch. T: I’m struck by how alive you are with your anger. I wonder where you would be without that feeling? R: Probably under the covers. T: What do you mean? R: I got to keep going to work. If I start feeling sorry for myself, I could end up living under a friggin’ bridge. I can’t let this get to me. I’m not going to ruin my life because of her shit. I’m a survivor, not a loser. At this point in therapy, Rich makes it clear that he does not want to deal with his grief. Fueled by his anger, he is determined to keep up the façade that everything is okay. His denial of the loss keeps him from feeling as if he is going to fall into the abyss of pain. In this early stage of therapy, the therapist acknowledges Rich’s anger and only gently approaches the denied emotional experience. His socialized sense of self includes denying his dependence, avoiding grief, adopting a tough guy identity, and keeping himself busy for fear of approaching the depth of his wounding. From the 12th session R: I was looking forward to talking to you today. I didn’t get to work out the last couple of days because I pulled some muscles in my back. I was really distracted at work. Couldn’t get much done. T: So you had to be with your feelings a bit more. R: I guess you could put it that way. Usually I can work out and feel better. I’ve been thinking about Judy again but I’m not angry. T: Can you describe what it’s like for you? R: I feel like I’m always hungry but then I really don’t want to eat anything. It just doesn’t go away. T: Empty? R: Good word. Yea. I feel like I want to fill myself up but I don’t know how. T: Do you feel it right now? R: Yea. I also feel pressure in my eyes. T: What do you think the emptiness and pressure in your eyes means? R: Sad? Like I’m sad? T: Does that fit for you? R: Yes. My life feels empty right now. I can’t ignore that. T: It’s okay to feel it. Being a man doesn’t mean you have to ignore your sadness. You lost a lot. R: I didn’t just lose Judy. I lost my whole dream. Having a family with her. Growing old together. I can’t deny how much I have lost. In this later session, Rich is no longer dominated by his anger. He is beginning to feel the loss and looks forward to being able to talk about his feelings with a therapist he has come to trust. In the safety of the therapeutic relationship, Rich has the opportunity to differentiate his bodily sensations and learn the vocabulary of his emotional being. Levant (1997) suggests that using a psychoeducational approach to discuss male socialization and the physiology of emotion are important elements of helping men in therapy come to accept their reactions to life events. For Rich, the next stage of therapy will involve looking at his own contributions to the deterioration of the relationship instead of seeing himself as a victim of his wife’s choices.

Male Survivors of Abuse

Men who have been have been verbally, physically, and sexually abused as children are more likely to have higher rates of all types of mental illness, including affective disorders, substance abuse, are certain personality disorders. They are also more likely to come to the attention of clinicians (Lisak, 2001; Weeks & Wisdom, 1998). Multiple experiences of childhood trauma appear to change the neurobiology of the brain, leading to impulsivity and higher levels of anger (Stien & Kendall, 2003). Violence is also higher among men who have been abused or witnessed abuse in childhood (Rosenbaum & Leisring, 2003). Episodes of depression and higher rates of suicide are also more likely among this population of men (Lisak, 1994).

Because of traditional masculine gender role prohibitions on acknowledging victimization, many men do not willingly reveal the extent of their abuse to others. Therapists need to approach childhood abuse issues patiently and with empathy for the shame that many men feel in revealing these episodes in their lives. It is not unusual for a man to downplay the psychological damage done by childhood abuse and to not reveal the extent of the abuse until later in treatment. Even when abuse is disclosed, therapists must be sensitive and supportive to the sense of foreignness or strangeness that may be experienced in the revelation. In autobiographical interviews of male survivors of sexual abuse, researchers found consistent themes about anger, betrayal, fear, helplessness, isolation, loss, shame, humiliation, self-blame, guilt, questions about one’s sexuality, questions about the legitimacy of one’s abuse experience, negative interpersonal relationships, and negative schemas about oneself and others (Dhaliwal, Gauzas, Antonowicz, & Ross, 1996; Lisak, 1994).

Clinical Illustration Jason, an overweight 27-year-old married man, had been referred for therapy by his family physician, who had been treating him for depression and anxiety. Jason, who had been taking buproprion for the past six months, complained to his physician that he was still having trouble sleeping and that he often had intrusive thoughts that were interfering with his relationship with this wife. These thoughts also affected his relationships with his coworkers at the manufacturing company where he was employed as a shipping clerk. The following is from the third session T: Can you describe what you have been experiencing this past week? J: Sometimes I feel spacey. Sometimes I miss periods of time, like I have been somewhere else. It’s like I come out of a dream. T: Has this happened before? In childhood? J: I can’t remember that well. T: Anything that stands out for you emotionally from childhood? J: My mother had a lot of boyfriends when I was growing up and… T: And, did something happen during this time? J: When I was ten, one of my mother’s boyfriends did something. The bad thing is that I really liked this guy. He listened to me. He seemed to genuinely take an active interest in who I was. He would be really friendly. T: What do you mean he did something? J: He’d find a way to touch my penis, like after a bath or shower. He told me he was making sure it was clean or dried off. T: You perceived this as uncomfortable? J: Sure. It was weird. I felt kind of creepy and dirty when he did this. Sometimes, my penis would get hard and it felt good. I didn’t know what to think. I think it scared me really. T: So on one hand it felt great to get some attention from a father figure, but there was something disturbing and scary about it. J: During those times, I just blanked out. I pretended like it hadn’t happened so I could still enjoy what this guy had to offer me. I wasn’t used to having a receptive older guy around the house. T: Did you ever tell anyone about it? J: No, I didn’t want to worry my mom. She had enough to worry about. Like I said, I just erased it from my mind so I didn’t have to deal with it. I rationalized that he just was being helpful to me at bath time. T: Jason, do you think that your intrusive thoughts are at all related to these incidents? J: Maybe. The images come and go, and when I become aware of where I am, it’s like a dream that I can’t remember. This whole memory thing is pretty overwhelming to me right now. T: That’s understandable. You look afraid. J: I know it happened. But it seems unreal. I’ve never told anyone about it before today. I don’t really know what to make of it or what to do with it. I can feel myself shaking. T: It’s okay to let yourself feel here. You’ve put a lot of energy into trying to fight off those feelings. J: I feel uncomfortable, like I’m some sort of freak. T: You’ve had your trust violated. Your reaction is normal for what happened. I hope that this will be a place where you don’t have to hide it. It can be out in the open here. (Cochran & Rabinowitz, 2000, p. 60-62) In this session, the client has revealed sexual abuse for the first time. The therapist listens and validates his dissociated feelings. Rather than being judged, Jason is allowed to talk about the disturbing images from his past. By connecting his current symptoms to the sexual abuse, the client is able to make some emotional sense of experiences he has had to repress. While it appears to be overwhelming, the therapist reassures the client that this will be a safe environment in which to explore what might be bothering him. Although it is difficult for any client to reveal childhood abuse, it is especially difficult for men who have grown up with the code to keep painful and shameful experiences to themselves. There are some reports that suggest that a mixed therapy group of men and women who have been abused in childhood might be a facilitative modality to get at the expression of pain, loss, and anger for both sexes (Knight, 1993).

Male Survivors of Trauma

Trauma that occurs after childhood also has the potential to be debilitating for men. Victims of violent crime and destructive accidents; individuals who serve to help others in traumatic situations such as police officers, fire fighters, emergency medical technicians, and emergency room personnel; and soldiers involved in combat situations are susceptible to post-traumatic stress disorder. Not only are men directly affected by the trauma, but many are also guided by their traditional male gender role socialization that tells them to keep the fear, disturbing mental imagery, and emotional pain to themselves.

Typically for a man to be diagnosed with this disorder, there has had to be a direct encounter with a situation that was perceived as life threatening resulting in a reaction of intense fear and/or helplessness. Because of socialization, a man may initially deny this reaction since it might be perceived as “unmanly.” Despite the denial of the impact of the trauma, it is not uncommon for disturbing images, memories and flashbacks to occur without predictability after the event. Often stimuli in the environment that remind a man of the traumatic situation can trigger intense physiological reactions and send an individual into a dissociative-like state of re-experiencing the trauma (American Psychiatric Association, 2000).

Many men work hard to avoid talking about or participating in activities or relationships that may bring the trauma into consciousness. Relationships toward family and friends are often marked by a tendency to withdraw from intimacy, general irritability, and outbursts of anger. Many with PTSD have difficulty falling and staying asleep at night, a hard time concentrating, and are prone to excessive vigilance of the environment for threats to their well-being. The reader is referred to the DSM IV-TR (American Psychiatric Association, 2000) for a more detailed description of the criteria for post-traumatic stress disorder.

Men who have experienced trauma not only battle the aftereffects of the traumatic situation in which they have been involved, but also the normative male socialization that has told them to keep their emotional reactions to themselves. When symptoms do emerge, not only does a man feel the impact of the trauma itself but also the shame for not being able to contain his reaction. Therapy with men who have been traumatized is fraught with a push-pull dynamic of self-protective defensiveness along with a desire to be free of intrusive thoughts, hyper-arousal, and pessimism (Egendorf, 1978).

Brooks (2001) describes a model for working with combat veterans that requires therapists to be empathic to the underlying emotional pain and the shame that covers it. He believes that men need to reevaluate their gender role and make life changes that counter the destructive messages they have learned about masculinity. He warns therapists to be patient and reinforcing of small steps of progress while also expecting resistance to change. Successful therapy with combat veterans involves being compassionate about the sacrifices these individuals have made and the emotional wounds that may not be visible (Brooks, 2001).

Clinical Illustration Clay, 41, came to the Veteran’s Administration several years after seeing combat in the first Gulf War. He was addicted to speed and alcohol, and had served some time in jail for assault. Clay was initially admitted to the substance abuse ward. Once detoxed, he went to inpatient group and individual therapy. The following is from an individual session in the working phase of his treatment. C: I used to think that being a man meant being the toughest son of a bitch I could be. A lot of good that did me. It got me some jail time and a life as a drug addict. I sure hope this therapy can help me. I’m not sure what else I can do. T: How is it going for you so far? C: To be honest, it is pretty painful. I hate that I have to be honest about my emotions but the guys in here won’t have it any other way. T: What are you working on right now? C: The source of my rage. I can fly off the handle so easily. I guess I used alcohol to deal with my pent up anger. Now I have nothing to save me. Just acknowledging what I’m feeling and trying to use words. T: Did you have the rage before your tour in the Gulf? C: Yea. I was a hothead. I actually thought that enlisting would give me a job that let me go crazy on people but... T: But? C: It wasn’t like that. I was actually more constricted. All the damn discipline just kept it pent up. When I let go, it was worse than I could imagine. T: Are you remembering something right now, as you talk to me? C: Yea. T: Can you talk about it? C: I don’t want to go there. I feel like I will lose control. T: Here and now? C: Yea. It was horrible. T: You having a flashback? C: Yea. (Shuts his eyes and grimaces) T: It’s safe here. You know that. C: Yea. I’m just not up for this right now. Can we back off? Go over it another day? T: No problem. You got closer to talking today than you did last week. I want you to know that we’ll go at your speed with this. C: Appreciate that. Thanks. The realization that traditional masculinity has had negative consequences is an important insight for Clay, who must change how he defines himself. He acknowledges that he is uncomfortable without his usual coping methods of using alcohol and drugs. He wants to trust the process but isn’t sure. The therapist is able to stay with Clay as he experiences the flashback without pressuring him. In previous sessions, Clay would avoid speaking of anything having to do with his combat experience. Not only is the flashback frightening, it is also shameful to be so exposed in the presence of another man.

In general, therapists working with men who have experienced severe trauma will have to deal with denial and anger in the early stages of their work. Pushing too hard for resolution at this phase will likely result in more resistance. A testing phase is also likely to occur to ensure that the therapist can handle the depth of his emotional pain. This may take the form of confrontation or cynicism about the therapeutic process. Once a man feels trusting of the therapist, he is more likely to take the risk to reveal his inner emotional cauldron. Therapists are encouraged to stay patient, emotionally neutral, and accepting during the process. In environments where the work is with those who have been traumatized, it is important for clinicians to have their own support systems in the form of supervision, personal therapy, and outlets for emotional expression.

Violence and Antisocial Behavior

It is common in warrior cultures for there to be a sanctioned masculine ideology that encourages toughness, independence, fearlessness, and aggressiveness toward others (Lisak, 2001a). This cultural encouragement may have its advantages when fighting wars, but has a steep price for men who engage in this type of behavior under more civilized circumstances. While men may have a biological predisposition to act aggressively, it is our culture that encourages men to act this out more often (Lisak, 2001a). Men are more likely than women to commit acts of violence. Higher rates of substance and alcohol abuse among men are also linked to increased rates in violent crime (National Crime Victimization Survey, 1994). While each man’s history with anger and violence is different, research suggests that men who use violence in their interpersonal relationships are more likely to have come from homes characterized by interparental aggression, exposing them to violence as a means to resolve conflict (Rosenbaum & Leisring, 2003).

The impact of acting out violence against others affects not only the victims of these actions, but also places the perpetrator in danger of losing employment, family relationships, and future success in life. Often, those who commit violence against others are incarcerated. Initial encounters with the legal system sometimes offer men the opportunity to remain out of the prison system. The ability to remain employed or maintain status in school will often be contingent upon receiving treatment for anger management, domestic violence, or violent behavior. Many treatment programs for men utilize group interventions to address these issues. Both highly structured cognitive oriented groups (e.g., Beninati, 1989) and more emotionally integrative groups (e.g., Nosko, 1988) have shown success in dealing with male violence issues.

Cognitive-behavioral interventions are often used in individual therapy with men who have anger or violence problems. Many men who come to counseling or therapy for anger and violence concerns may initially deny the severity of their actions. They may seem to lack intrinsic motivation to change. There is still an opportunity for clinicians to have an impact by gently reminding the client about the consequences of his actions on others and himself. Through empathy and respect, and a focus on changing damaging thoughts and behaviors, many men will respond favorably to treatment.

The essence of the cognitive-behavioral approach is that violence as a response to anger is a learned behavior that can also be unlearned (Hollenhorst, 1998). The cognitive approach encourages the therapist to help the client to first become aware of the underlying thoughts and cues in the environment that lead to an escalation of anger, verbal abuse, and physical acting out. By gently challenging distorted and misguided thoughts in a collaborative therapeutic relationship, the client is able to become aware of the consequences of his perceptions, thinking, and emotional reactions. In the process, a man learns that he is responsible for his actions even when he is in provocative situations. Other issues that are bound to emerge will relate to childhood experiences with violence, recognizing triggers that are based on past experience, identifying alternative ways of handling conflict, learning relaxation techniques, implementing time-out methods, and anticipating and eliminating some of the sources of one’s frustration and anger (Beck, 1976; Ellis & Tafrate, 1997).

Clinical Illustration Dom, 33 came to therapy with his partner, Stacy, to deal with Dom’s temper and occasional violent outbursts. Stacy made it clear that she didn’t feel that she had anything to work on for herself but she was concerned about Dom. It was determined that doing couple’s work at this juncture was secondary to dealing with Dom’s angry outbursts. Dom agreed to see the therapist alone if it would save his relationship. The following occurred in the first individual session. D: So where do we start? I’m still not sure I am that bad. You must see guys in here who are a lot worse than me, who beat their wives. I’ve never done that. T: I’m here to help you, not accuse you. I’m on your side. I know you don’t want to lose control of your anger but it has happened. Tell me what circumstances bring it on. D: You know it doesn’t happen that often. Stacy knows how to push my buttons. She’ll get on my case about something, and then she keeps going. I try to blow it off but she keeps harping on me and then sometimes I lose it. T: What do you mean when you say you lose it? D: I yell. I hit the wall. I lose it. T: You hit her? D: I’ve pushed her with an open hand, but I never hit her with my fist. I feel really bad saying this out loud. We get along most of the time. T: I’m not here to scold you, just to help. Let’s try to break down the sequence of events and look at what your thoughts are that lead up to you losing it. D: Okay. T: Start with what your reaction is to Stacy’s criticism. D: I don’t know. I feel like I did something wrong. T: What do you say to yourself when you feel this way? D: I feel like a bad person. Like I am no good. I wish she would stop. She doesn’t realize how easily I get down on myself. I feel so bad. T: It really hurts. D: Yea, but I’ve learned not to let anyone know. T: Sounds like her criticism reminds you of being scolded as a child. D: Yea. My dad used to vent at me a lot. He was an asshole. Always made me feel like I was doing something wrong. I guess I internalized that. In this session, the therapist takes a strong, but nonjudgmental, approach to Dom’s minimizing of his problem. By reminding Dom that he is not accusing him, but rather trying to help him, the therapist makes some headway in getting the client to acknowledge his actions and begin to take responsibility. A cognitive approach encourages Dom to reflect on the steps that escalate his anger and opens him to talking about the feelings that he is trying to avoid. Many men react with anger to cover feelings of vulnerability and hurt. In this case, the early experiences he had in his family have made him sensitive to his partner’s criticism.

Addiction

It is not uncommon for men to enter the therapeutic environment because of a problem with addiction. This might include difficulties with alcohol and other mood-altering substances. In addition to these substance-based addictions, some men will experience “addictions” to work, gambling, computer games, sexual activity, sports, television, or any number of outlets that ultimately serve to deflect a man’s attention away from the content and quality of his inner, emotional life. It is believed that addictive behavior may be a way for men to avoid experiencing depression. The data suggests that women are diagnosed with depression at double the rate of men while men are diagnosed at double the rate of women for alcohol and drug addiction (Cochran & Rabinowitz, 2000).

Addiction may have its roots in both neurochemical predisposition and traumatization. The numbing of painful experience and the conversion of a negative mood state to one that is pleasurable are often the motivators and reinforcers of addictive behavior. Because our culture makes it difficult for men to express vulnerable emotions, outlets are often limited to legal and illegal addictive substances and activities. Research suggests that men with higher scores on masculine gender role stress have greater problems with the use of alcohol, and drink alcohol to improve their social, emotional, cognitive, and interpersonal functioning (Isenhart, 1993; McCreary, Newcomb, & Sadava, 1999). The use of drugs is also an option used by men more often than by women, and seems to reflect a reluctance for men to seek help for underlying distress (Cochran & Rabinowitz, 2000).

Clinical Illustration Brad came to counseling following a two-week crack cocaine binge. He used most of his savings to pay for the drugs. His wife and children left him a note that they had gone to live with his wife’s family 500 miles away. Brad had been through two 30-day stints in a drug rehabilitation center in the past three years. He had been clean for over six months before his recent binge. Brad is employed in a family business owned by his uncle, who has let him return to work after each of his treatments. This exchange is from the fourth session B: I am so damn stupid. And I am so friggin' selfish. I’m not sure I even deserve what I have been given. I’ve blown everything I have ever had. On top of that, I still haven’t stopped shaking. I’m still craving the coke. How stupid is that? T: You are really beating yourself up right now. What if we separate out the part of you that is feeling really angry with yourself from the other parts? B: What do you mean? T: I’m thinking that we aren’t going to get very far talking if all you do is be super critical of yourself. I was thinking you could identify the various parts of yourself that exist inside. Obviously, there is a part of you that went on that binge who didn’t listen to the critical self. B: Oh. Like separating myself into different people? T: Yea. I was thinking that you could have a dialogue with yourself. All the different parts talking to each other so we know where each is coming from. How might you describe the different aspects of yourself? B: Well, I definitely have this addict side to me who cannot control himself. T: Say more about what he is like. B: He never has enough. All he wants to do is escape into pleasure. He wants to be high, to have sex, to indulge himself with reckless abandon. T: You know him well. B: He’s the one who gets me into all kinds of trouble. T: You described a critical self. B: Man. I would call him the hanging judge. He’s harsh. He hates that part that’s an addict. T: So the addict gets punished but it doesn’t seem to help. B: Yea. The addict is sneaky. T: Maybe the addict is trying to escape the harshness. B: You know, a lot of times I am trying to get away from those messages. T: What kind of messages? B: Like “you’re no good,” “you are such a phony,” “you don’t know what you are doing,” “you’re just a selfish idiot,” “you are wimp.” Stuff like that. T: Wow. Those are intensely negative self-statements. What is it like to just say them here? B: I can feel myself getting uptight and ready to run. Like I could run out the door right now and not come back. I’m not going to do it but I feel like I could. T: Which part of you is wanting to run? B: I don’t know. It’s the part that doesn’t want to deal with this stuff. I guess that is the addict. T: Is there a part of you that sits on the side of the conflict? Not the addict or the judge? B: Yea. The part that is coming for help. I just want some help in this war. Maybe if I can learn some techniques for catching myself before I act out, I might have a chance. T: That does seem like something we can work on here. The therapist uses a gestalt technique to get the client to differentiate various elements of his personality. By separating the parts of self, the client is able to speak freely from each perspective. In this session, Brad has identified in his own words three aspects of himself that can be addressed in his quest to live a more moderate existence. The therapist will be able to refer to these aspects of the client when he notices their appearance. By increasing awareness of these parts, the client already is beginning the process of gaining some cognitive control over his behavior.

Twelve step support groups like Alcoholic’s Anonymous, Narcotics Anonymous, and Sexaholic’s Anonymous might help with ongoing behavior and emotional control for some individuals, especially middle-class Caucasian men. The emphasis on giving up some of their control to a higher power seems to resonate with this group of men who tend to be more control-oriented (Isenhart, 2001).The results are mixed for women and for men from ethnic minority populations.

Cognitive methods that emphasize moderation and personal control also show efficacy in combating addiction. Motivational interviewing, for instance, focuses on the client discussing the benefits and costs of making changes in a permissive and open atmosphere. This also seems to fit a more traditional masculine model of weighing alternatives and having choices. Motivational interviewing embodies the therapeutic principles of expressing empathy for the client’s concerns; dealing with discrepancies considering motivation for change; avoiding putting the client on the defensive; rolling with resistance by using it as a part of treatment; and supporting an individual’s ability to deal with the problem behavior by focusing on past success in other areas of his life (Miller & Rollnick, 1991).

It is recommended that clinicians not trained in working with addiction be careful in treating men who report addictive behavior. Individual differences in the severity, scope, and nature of the addiction must be assessed to ensure that outpatient treatment is the best route. For some, inpatient treatment is necessary to remove the individual from the environment so he can detox and be engaged in daily intensive treatment. An individual’s belief system about his addiction must also be considered. Forcing a 12-step model on an individual who doesn’t “buy” its underlying principles might create resistance and early termination. It is possible to support an individual who is motivated by this model even if it is not a clinician’s preferred mode of treatment. On the other hand, therapists who themselves have difficulty with accepting the tenets of the 12 step model should be up front with clients who are seeking this kind of treatment.

Depression

A significant concern for men detailed in recent clinical reports is depression (Cochran, 2001; Cochran & Rabinowitz, 2000). Many men, after experiencing interpersonal or traumatic loss, react by plunging into a depressive episode (Cochran & Rabinowitz, 1996). In fact, a number of recent popular, as well as professional, reports draw attention to the problem of undiagnosed and untreated depression in men (e.g., Pollack, 1998; Real, 1997). Since many men use alcohol or other mood-altering substances or activities to self-medicate, the problem of an underlying depression for those who seek the services of a psychotherapist must be addressed. Winokur (1997) suggests that alcoholism and antisocial behavior disorders are likely masculine expressions of underlying depression with a genetic basis.

At the extremes of depression lie difficulties associated with suicide and homicide. Given their tendency toward action and externalization, men are much more prone to aggressive acting out of their depressed mood. This predilection may lie, in part, at the root of findings indicating that suicide is a significant mortality risk for depressed men (Mosciki, 1997). Despite reporting half the depression than women acknowledge in epidemiological surveys, men commit suicide three to four times more frequently than women do (Cochran & Rabinowitz, 2000). This risk rises even higher with increasing age (Kennedy, Metz, & Lowinger, 1995). In addition to suicide, homicide is associated more frequently with men. This, too, often occurs in conjunction with a depressive episode. Careful assessment of the risk of both suicide and homicide is warranted when working with depression in men.

Cochran (2001) suggests that clinicians assess depression from a masculine-sensitive approach. The traditional symptoms described by the DSM IV-TR (American Psychiatric Association, 2000) such as dysphoria, thoughts of death, appetite change, sleep change, fatigue, diminished concentration, guilt, psychomotor changes, and loss of interest in previous activities should also be supplemented by the following criteria (Cochran, 2001, p. 236):

Identification of important comorbid conditions

• Alcohol abuse and dependence
• Substance abuse and dependence
• Related personality features (antisocial, compulsive, narcissistic traits)

Masculinity related symptom expression

• Somatic or physical complaints
• Increases in interpersonal conflict
• Work-related difficulties and conflict
• Wounds to self-esteem (job loss or relationship loss)

Culturally influenced manifestations of emotional distress

• Class and race considerations regarding emotional expressivity
• Level of awareness and acceptance of traditional male gender roles
• Family of origin role models and norms regarding emotional expressivity

Suicide and homicide risk assessment

• Ideation, plan, means, access, and intent
• Alcohol or drug intoxication
• Psychotic or delusional features
• Capacity for cooperation with clinician

Clinical Illustration John entered psychotherapy after dropping out of his second year of medical school. He had been succeeding at his academic work, but had not been enjoying the classes and was becoming increasingly unhappy with his choice of a career in medicine. He explained that he had become gradually withdrawn from his classmates, and finally had stopped attending classes all together. A phone conversation with his parents had convinced him to take a leave of absence from his studies and spend some time clarifying his purpose and direction in life. He described his situation in an early interview with the therapist. J: Everything just gradually became empty this year. The classes. My friendships. It was as if the color just faded from everything. Nothing gave me pleasure or interested me much. Nothing was any fun. Oh, I could still make the grades. But there has to be more to life than making good grades and getting a good Dean’s letter. T: That a really vivid way to put it, John. The color faded from everything. Have you ever had this kind of experience before? J: Well, my junior year in college things were pretty gray. I had broken up with my girlfriend. Or I should say she had broken up with me. I didn’t really have any direction or plan or anything at that point. I decided then to take the MCATs and go to medical school. It gave me some purpose. A direction, I suppose. But things were pretty gray during that time. Like now. I feel really alone and hurt by getting dumped by her. T: So the decision to go to medical school was made on the heels of being dumped by your girlfriend? J: Well, now that we are talking about it, I guess it was. I never really thought about it that way before. I just figured it was something to do, go to medical school. I always got good grades, and I thought helping people would be a good way to use my talents. But I remember thinking I have to have something to do. I have to have somewhere to go. T: Well, I would agree with you on the helping people with your talents part. But then we have to figure out why medical school lost so much of its appeal all of sudden. I wonder if the original motivation for going was to take your mind off the ending of your relationship. What do you think? J: This is really interesting. I remember now that when I was in high school, I got dumped by my very first serious girlfriend when I was a senior. I was devastated and just didn’t know what to do. This was right after a disastrous spring break for us. Then, all the college acceptance letters started coming. It was a great way for me to keep my mind off my relationship with Michelle. The same thing. Somewhere to go. Something to do. But thinking back on it now, I was pretty miserable during that spring. T: Yea. That is interesting. I wonder what is worse for you. Making a major decision about your future or being jilted in a relationship. J: I’ve never really thought about it this way before. Making these decisions about my future this way just keeps me away from the pain. I’m focused on the future, something to do, and don’t have to feel what I’m feeling at the time. But I can’t run forever. I think what all this means is that I need to look at this rejection and pain and see what is so difficult about it for me. That fits for me. I can feel sadness just sitting here thinking about this stuff. (Cochran & Rabinowitz, 2000, p. 118-120) This session illustrates the importance of focusing on loss in men’s lives when doing therapy for depression. The client realized that his actions were geared toward the avoidance of relational loss and that this was having an impact on his life in the present. The combination of psychological losses of relational discontinuity along with the failure to live up to masculine ideals of being in control and strong may lead men to experience an unidentifiable sadness and loss of interest in their lives. The optimal outcome of working with men in therapy is a blend of sadness and acceptance of the inevitable losses and limitations of life. The affective acceptance allows a man to be more internally driven and focused on finding meaning in the life he is living. It can also be the impetus for a change in behavior and life direction (Rabinowitz & Cochran, 2002).

Sexual Orientation

Gay and bisexual men are more likely than heterosexual men are to seek counseling and psychotherapy (Haldeman, 2001). The life development of gay and bisexual men often has been marked by harassment, discrimination, and even violence. Unfortunately, a large segment of society does not embrace homosexuality, leaving many gay men feeling marginalized and stigmatized. While men in the early phase of their acceptance of their sexual orientation might seek therapy, many gay and bisexual men come to counseling for issues other than their sexual orientation. Issues around relationships, self-esteem, work, and emotional conflict are more often the focus (Haldeman, 2001).

Boys and men who are struggling with their sexual orientation may come to a therapist to deal with the complex array of feelings and consequences that come with acknowledging their circumstance. In our heterosexist culture, many of these boys and men must work through their feelings about their sexual orientation on their own without the support of family and friends.

The watershed event for most gay men is “coming out” and acknowledging one’s identity as a gay person (Bepko & Johnson, 2000). “Coming out of the closet,” whether it is to oneself or to one’s family and friends, is one of the most difficult actions a man can take, as he knows that he will face discrimination and rejection by many who find out. Therapists need to provide support and empathic understanding as a man struggles with shame, internalized homophobia, and the reality that his life isn’t matching up with the dominant heterosexual male cultural ideals.

Clinical Illustration Mark, a 46-year male, came to therapy to deal with the aftermath of the break up of a 15-year gay relationship. Mark had been married to a woman when he was 19, even though he had felt homoerotic attraction since his early teen-age years. He had believed at the time that he could overcome his feelings and become heterosexual. During the three-year marriage, he found himself having fantasies about men and eventually could no longer be honest in marriage. He and his wife parted amiably after Mark told her he thought he was gay. During the early years of his experimentation, Mark sought counseling with a gay-affirmative therapist, who gave him support as he came out to friends and, eventually, his family. Mark met Steven in his early thirties. They settled into a committed relationship, sharing a house and a life together. Recently Steven, who is four years younger, announced that he no longer wanted to be in the relationship. Mark asked Steven to come to counseling, but Steven said it wouldn’t do any good. He was in love with someone else. Mark was devastated and sought out the therapist he had worked with earlier. The following is from the second session M: I still find it hard to believe he would do this. We had an agreement that we would talk to each other before acting on our attraction. I mean we would go together to parties and had given each other permission to have sex with other people but it was understood it wasn’t to be emotional. T: You feel really betrayed. M: You bet I do. I’ve had my chances, too. I’ve been real attracted to guys over the years but I have always put our relationship first. I never wanted to mess that up. I still can’t believe it. I know it’s real when I go home and his stuff isn’t there. T: Feels empty? M: Oh yea. I have a hard time getting out of bed to go to work. My friends have been supportive but it’s just not the same as knowing Steven is there. We had our issues like any couple would. We were having sex a lot less and now looking back on it, we should have talked about that more. I have put on a little weight. Maybe he wasn’t as attracted to me. This hurts. T: Yea. I can see that. You invested a lot in this relationship. M: To make things worse, my dad just went into the hospital with heart problems. He collapsed when he was on vacation with my mom. When it rains, it pours. I feel like things are really out of control. At least I have my health, I hope. T: What do you mean? M: Well, if Steven was out cheating on me and I didn’t know who he was with, who knows what kind of disease he might have picked up. He told me he engaged in safe sex but can I trust anything he says at this point? T: Losing trust is big on all levels. M: I still can’t believe it. I thought I knew him so well. T: I see you’re hurt. Have you gotten angry? M: You know me. It’s hard for me to express anger. I don’t react like that. You know in my job in sales I have to be personable and up all the time. I’m afraid I might not be able to keep it up. I’m afraid my real feelings might break through. T: What would be so bad about your real feelings breaking through? M: In here, I can tell you but out in the world I need to show that I am still in control and have it together. I don’t want my clients to know. T: You don’t feel like they would understand. M: You know, it’s hard enough to live a gay life. I don’t want to be the stereotype of the queen who is emotional and upset all the time. I have to be strong out there. T: I understand you feel like you need to be confident at work. In this case, anyone who has gone through a breakup like this would be upset. It’s human, not a gay thing. M: Easy for you to say. You deal with emotional people all day. My world is way more formal and uptight. T: Sounds like you are buying into the traditional male stereotype of having to remain strong and stoic. M: Yea, I guess I am. It feels like those are the rules. In this session, the therapist shows empathy for Mark’s pain and loss but also is willing to challenge him about holding back. The themes that the client brings to the session have to do with relationship loss, but they are influenced by the context of being a gay man. Mark feels like he shouldn’t act too gay at work, suggesting that despite his comfort with his sexual orientation, he has also internalized some homophobia.

Even sensitive clinicians need to be aware of how their own biases, including heterocentrism, support the notion that heterosexuality is the norm for behavior (Haldeman, 2001). Surveys suggest that about ten percent of social work clinicians are outwardly homophobic and that a majority are heterosexist in their worldviews (Berkman & Zinberg, 1997). When dealing with a gay or bisexual man, the therapist must assume his or her client’s life is neither so different nor so similar to their own. Men who are comfortable with their sexual identity are likely to be in therapy about an issue that is not related to their sexuality. Yet, it is important to be sensitive to the cultural environment from which the client comes, and the degree to which he can be open about his lifestyle. While a gay therapist may more readily serve as a role model, a heterosexual therapist with sensitivity, imagination, empathy, and experience can be very effective with gay male clients (Lebolt, 1999).

Engaging men in couple’s therapy

Heterosexual couples

While men are highly ambivalent about the individual therapy process, it is even truer for couple’s therapy. Men are likely to be cautious entering an arena in which they feel they are out of their element. Because therapy already feels like a feminine activity, couple’s work involves two individuals who speak a different language from the man, his female partner and the therapist. To protect himself in this environment, a man may present himself as highly masculine and a bit detached from the flow and language of the therapy process (Englar-Carlson & Shepard, 2005).

At the onset of therapy, it is important for the couple’s therapist to anticipate the defensive posture that masks the male partner’s concerns about help-seeking and the process with which he is about to engage himself. These include his fears about being seen as mentally unstable, about being coerced against his will, of not being understood, and confusion about how therapy actually works (Englar-Carlson & Shepard, 2005). It is best to acknowledge these issues at the beginning of therapy, and to encourage the male partner to feel free to ask questions if anything feels weird or doesn’t make sense to him.

Since the language and milieu of therapy seems more congruent with the feminine world than the masculine one, a major task of therapy is to “engage men in therapy by speaking a language they can understand so that their own unhappiness and that of their partner can be addressed.” (Shay & Maltas, 1998, p.99) Unlike individual therapy in which the therapeutic alliance is being formed one on one, there is the added dynamic in couples work of building an alliance with two individuals who have different gender socialization histories.

Generally, when speaking with women, it is normal to ask, “How does that make you feel?” and to receive a rich, detailed and engaged response. For men raised with traditional male norms, the therapist must show a respect for the unique way a man expresses himself and use an appropriate vocabulary in communication with him. For instance, if a man mainly interacts in the business world, follows sports, or does problem-solving in his work life, a therapist might use the words, images, and metaphors of this type of discourse to make a connection (Shay & Maltas, 1998). For example, he or she might say, “It seems like the two of you are coming in here with two strikes and two outs in the bottom of the ninth,” “It appears to me that the foundation of your marriage may need to be repaired,” or “I wonder how you analyze the benefits and costs of continuing with the same patterns in the relationship?”

Clinical Illustration Joseph, age 37, and Marie, 38, came to couple’s counseling because Marie was fed up with Joseph’s being both physically and emotionally absent for much of their six-year marriage. It was tax time, and Joseph was an accountant. His long hours at the office had provoked a marital crisis, manifested in arguments in which Marie would demand Joseph pay her more attention and Joseph would retreat to his home computer. Marie was the first to speak about her concerns and her desire to be in couple’s counseling. She noted that Joseph did not want to come to counseling and that it took an ultimatum to get him to agree. As she spoke, it appeared to the male counselor that Joseph was uncomfortable physically (shifting in his chair) and emotionally (he looked somewhat anxious as Marie spoke about relationship problems and made dismissive expressions in response to Marie’s categorization of why they were in counseling). The following is from the initial session T: I sense that Marie was the driving force that brought both of you here. It has been my experience that most couples are not pleased to be in counseling. For many men, it seems especially challenging, as if being in counseling is a reflection of a personal failure as a man. Joseph, I am wondering about some of your thoughts about being in counseling, in particular I wonder about your expectations of what you thought would happen here. J: I just don’t see this as helping us. I’m a believer that people can solve their own problems. My impression of counseling is that we’ll be talking about “feelings,” and I don’t think that will get us anywhere. Anyway, Marie just doesn’t get it that I am who I am. I’m frankly not interested in being changed by Marie or by you. Don’t get me wrong. I do want our relationship to improve, but I don’t see why Marie and I can’t just sit down at the kitchen table and work this out ourselves. T: I hear some concern that you will not be heard or that I might value Marie’s ideas or perceptions over yours. Also, it seems that you have an expectation that I might try to force you to see things in a different way. J: Yeah, that is what I think. T: Okay, I’m guessing there’s some way you could get some benefit from speaking with me, but let’s figure that out together. We could start by talking more about some of the expectations that you might have about being in counseling and what could be helpful to you. (Englar-Carlson & Shepard, 2005, p. 386)

Therapists must be able to make an assessment of how entrenched in traditional gender roles the couple is in order to know how to respond to each partner. For men, it might be an observation of how competitive he seems, how much he needs to be in control, and how much psychological distress he is willing to acknowledge. Couple’s therapists should have a thorough knowledge of gender issues, including how men and women are socialized (Philpot, Brooks, Lusterman, & Nutt, 1997). It is in the couple’s best interest to explore openly how their current relationship predicament might be framed by historical and cultural norms. The idea is that both partners can explore how their adherence to gender role norms is actually inhibiting them from making better choices with each other. By understanding what rules each partner is often unconsciously following, each will gain empathy for the other’s experience. In this way, neither partner is seen as the villain, but rather the system is seen as the origin for many dysfunctional behaviors (Philpot, et. al., 1997).

For example, therapists can invite their clients to link the process of therapy with their socialization experiences. For a male client having difficulty expressing his emotions, it might be a perfect time to ask him to talk about where he learned about what was acceptable to share in the emotional realm. This might turn into a discussion about male gender roles, experiences he had in his family of origin, and what he learned from his peers. These questions might also offer some different kinds of answers as to why he has such a hard time responding to his partner (Englar-Carlson & Shepard, 2005).

Perhaps the most difficult task of the therapist is how to get the less expressive male partner to share his more vulnerable emotions like fear, sadness, helplessness, and discomfort. Rather than make assumptions about why a man might do this, it is important for the therapist to explore the following possibilities—unconscious repression of emotion, difficulty with putting words on the emotion, withholding because of past associations with vulnerability and weakness, and the appraisal of the social situation as being unsafe for talking about emotions (Wong & Rochlen, 2005).

If a man seems to be repressing emotion and is unable to identify and verbalize feelings, he might be considered to be alexithymic (Levant, 1997). If this is the case, a man may need a slower and more psychoeducational approach to therapy. The therapist might help the female partner to be more empathic to the male partner’s lack of ability in this area of his life by creating homework assignments that encourage her to help him develop skills by reflecting back to him what she senses he is feeling. Eventually this practical approach will not only help the man better identify his emotions but will also create more intimacy and less frustration between the partners (Englar-Carlson & Shepard, 2005).

Other men may be able to identify their vulnerable feelings but they have internalized prohibitions on sharing them because of learned gender role socialization. Bergman (1995) suggests that some men fear exposing their internal discomfort with the language of emotion. He terms this “relational dread.” Rather than confront the client, it is more important to show empathy for his dread of sharing. Saying, “It is hard to talk about these feelings when your whole life you have kept this to yourself,” may be a way to normalize the fear. A male therapist might say, “I know I had to work real hard to trust that my words wouldn’t be used against me, especially feeling words that are so ephemeral.”

When the male partner is having a hard time expressing himself, a powerful intervention might be for the therapist to “stand in” for him using an intuitive sense of the client’s non-verbals and what is not being said. For example, the therapist might say, “Let me try to act as if I am Stan right now. Margaret, I am a little intimidated by you since you so easily share your feelings. I am a bit afraid that you aren’t going to be there for me if I decide to leave my job.” This intervention helps to facilitate the client’s awareness of his feelings, allows him to internalize the voice of the therapist, helps the client learn to articulate delicate emotions, and gives the female partner a chance to respond empathically to the emotional message rather than his inarticulateness (Englar-Carlson & Shepard, 2005).

Gay couples

Gay men typically view their committed relationships as seriously as heterosexual couples, despite their marginalization by society. One of the most powerful differences in gay relationships is dealing with the homophobic and heterosexist biases of a culture that does not recognize their union or their rights to be parents (Bepko & Johnson, 2000, O’Dell, 2000). This leads to a stressful everyday existence, especially for male couples living in non-gay enclaves. It is not unusual for men to have to pretend to be roommates for acquaintances, work colleagues, and unsuspecting family members. This lack of social support can add to tension in the relationship, especially if each partner has different ideas about how visible the couple should be to the outside world. One man’s desire to keep a low profile might run counter to his partner’s need to have some public validation for their union.

Gay men are raised in the same masculine society as heterosexual individuals, leading many to incorporate the same healthy and unhealthy behaviors and roles. It is not unusual for men in struggling relationships to be dealing with issues of power, control, and emotional commitment. Who makes more money, who has a more prestigious job, and who is more emotionally expressive are all relevant dynamics often explored in couple’s therapy (Bepko & Johnson, 2000). On the other hand, therapists need to not project heterosexual roles onto gay couples. Most gay men define their relationship roles outside the prescribed norms of heterosexual society. In this sense, they are freer than many heterosexual men are to pick, choose, and negotiate their relational scripts (Scrivner & Eldridge, 1995).

Clinical Illustration Peter, 44, and James, 45, came to therapy to deal with dissatisfaction in their relationship of 17 years. Peter worked in a white-collar executive position with a large company. His companion, James, worked for the telephone company in a primarily blue-collar position. Peter was not out to his colleagues at work while James was out with his coworkers. Peter tended to have a more traditional masculine style to his manner. He was low key, quiet, and hardworking. James was gregarious and more emotionally expressive. James was the one who had called the therapist. He had gotten extremely upset when he found emails and phone messages suggesting that Peter was having an extra-relationship affair. This exchange occurred in the second session J: I still can’t trust you, Peter. After all this time, you knew that we had rules about sex outside the relationship. I know I was bad at the beginning but I have been faithful to you since that time. P: (Quiet in response) J: Aren’t you going to say something? I mean, don’t I deserve that? P: What do you want me to say? I’m sorry. It won’t happen again. J: How do I know that? You would have never told me if I hadn’t found out. I can’t believe you would do this! Is there something wrong with me? T: Sounds like you are really hurt, James. What were the rules that you and Peter had about sex outside the relationship? J: Why don’t you tell him, Peter? Maybe I didn’t understand. P: You are really overreacting to this. I didn’t do anything. I flirted a bit. J: Oh, yea. One of the things we didn’t tell you was that Peter has lost like 50 pounds in the past year. He is really getting a lot more attention. I mean he looks great. I tell you that but it doesn’t seem to have the same meaning coming from me as it does coming from some other guy. P: It is true I’ve lost weight and feel better about myself. Just so you know, we do date other people but the rule is that we both know who the other person is and it’s not emotional. It’s purely physical. T: So you go out and hook up but you have definite rules about that? J: Yea. We go together and leave together, and we engage in safe sex. What worries me is that we haven’t been very physical with each other lately. It’s like the only sex happening is with other people. I have a strong need to be affectionate and even that is not very frequent. T: Is that an issue for you too Peter? P: I guess. I work really hard, get home late, and go to the gym and work out; to tell you the truth, I’m tired. I love James. We’ve been together all these years. It’s never going to be the way it was when we first started seeing each other. J: How come none of our stuff is in both of our names? I don’t really care about the material part, but it seems symbolic. P: You know I’m not comfortable with being legal about all this stuff. Nobody at work knows I’m gay and I’d rather keep it that way. J: Well, that’s another thing. I feel like we have to hide and pretend to make sure you don’t get outed. I’m tired of that. T: Sounds like there are a lot of levels to what’s going on with the two of you that haven’t been fully communicated like the sex, work pressures, what each of you needs from each other, and how you want to be perceived as a couple. Where do you want to start? In this session, Peter and James are revealing the rifts in the relationship through the content and process of their interaction. The therapist remains nonjudgmental as he encourages each man to talk about his side of the conflict. James is much more emotionally expressive and could dominate the session if the therapist does not periodically make sure that Peter’s voice is also heard. At this point, the therapist must be thinking that therapy will involve having each partner express his dissatisfaction, his hopes, his needs, and what each might want to renegotiate in terms of their expectations of each other and their rules of engagement.

A significant issue that brings couples to therapy is a change in sexual desire or a breach of relationship rules (LaSala, 2001). It is not uncommon for monogamous male partners to have negotiated rules about extra-relational sex and its place in the relationship. In a study comparing monogamous and nonexclusive gay relationships, it was found that while men in the open relationships reported a higher desire for sexual excitement and diversity, the two groups were no different on measures of love, liking, commitment, and relationship satisfaction (Blasland & Peplau, 1985). In light of these findings, it is not unusual for the therapist to encounter couples when there has been a violation of one of the rules that the couple had set up around sex. Often the change in relationship dynamics around sex will reveal other fissures including power issues, money conflicts, role discomfort, communication problems, and personality differences that can be productively explored in the therapeutic environment.

Treating Men in Groups

Men’s groups are able to deepen a man’s experience in several ways. Just as a man was thrust into the world of men from mother’s orbit, the men’s group recapitulates this trajectory. But instead of entering a hardened and competitive male world, he enters one that is interpersonally receptive. The men’s group is supportive of feeling rather than rejecting of it. The men of the group nurture each other in a uniquely male way through verbal and nonverbal gestures (Rabinowitz & Cochran, 2002).

The men’s group can help a man confront his disappointments and losses. Instead of denying past hurt, shame, and wounding, the men’s group asks its members to bring this out into the open where it can be healed by the supportive actions of the group. It is safe to get angry, to cry, or to express one’s frustrations and grief.

The men’s group challenges the gender role norms of culture (Stein, 1983). Instead of maintaining rigid patterns of behavior that result in the avoidance of intimacy, addiction, and privately experienced distress, the group encourages warmth, support, and trust so that conflict can be dealt with in a straightforward fashion. Men are free to engage in confrontation because they trust that they will gain personally from the interaction. Affection, rather than being avoided, can be used to show caring among men.

Men learn also how to take their doing orientation to life’s problems into the being world with each other. Rather than try to solve problems, men are given a chance to express feelings, empathize and support each other, and learn to stay with uncomfortable emotions. Although “fixing” is not a part of the men’s group, using the male tendency toward action is. Through exercises and activities, men learn to “be” with their inner experience.

Finally, the men’s group encourages men to approach and enter the emotional “portal” of depth. Men are asked to give up some of their control and vulnerability in order to explore beneath their social roles and facades. Men support each other in taking on this challenge.

The attractiveness and success of group therapy for men is built on the premise that the group situation is often a better fit for many men, especially those with traditional gender role orientations, than individual psychotherapy (Brooks, 1998, 1998a). Even though many men who participate in a men’s group have also been in individual therapy, they freely acknowledge that the multiple relationships that are developed in a well-run group are often better able to push them to deal with conflict, emotion, and interpersonal connection than an individual therapy approach that involves only the one relationship between therapist and client (Rabinowitz, 2001).

Men's therapy groups build on the support that men can uniquely give each other. Sharing similar physical bodies, similar socialization, and similar relational perspectives, men often feel a different kind of support than what they receive from the women in their lives. One man in a weekly therapy men's group said it this way, “I have always gone to women for emotional support to my tender and expressive side. With my male friends, I tended to relate about sports, school, and work and not burden them with the stuff I would tell my mother or girl friend. I felt like I couldn't be completely real with either women or men. In the men's group, I have found out that most men feel this way. It has been such a feeling of a burden lifted to realize I can be totally myself here; gentle, aggressive, compassionate, wild, or competitive and still be accepted by these guys, who I initially thought were going to judge and reject me.” (Rabinowitz & Cochran, 2002, p. 158)

Men's groups help men trust other men again. In our competitive culture, men are often pitted against each other at work or even at play. The buddies one might have had growing up are more difficult to find in the adult world. Many men find the pressures of work and family take most of their energy and time. It is easy to lose touch with one's emotional self by trying to obey the social rules in each aspect of life. In a men's group, it is expected that each man will talk about who he really is, not just his work or social persona. Through the rules of confidentiality and through honest sharing, men learn they are not alone and, in the process, build trust with each other at a personal level.

Men's groups give hope and rebuild confidence in members. In very few settings, do men actually verbalize and show each other support, respect, and care. The men who initially come to group are often emotionally isolated and discouraged, receiving very little positive support from relationships or work (Rabinowitz, 2001). Often they are in the midst of a personal crisis, such as divorce or other significant loss, or they are in a situation in which they must change in order to avoid family dissolution or incarceration. Some are recovering from addictions to drugs, sex, gambling, or work. Self-disclosure of impotent feelings, as well as the expression of anger, frustration, and sadness, is usually met by supportive comments, sharing of similar experiences, and even supportive physical touch (Rabinowitz, 1991). A man may begin to feel less alone and find hope from the camaraderie found in the group.

Many men who are dependent on women for initiating interpersonal conversation and giving them social validation find the all male group challenging. While some men's groups have female leaders, the group situation brings up a different set of dynamics for men than a group made up of both men and women. Competition centers not on the need to posture for female attention as is common in mixed groups, but more around personal insecurity and inadequacy. Without women, men are forced to deal with their discomfort with each other, including learned homophobia (Rabinowitz, 2001). Introjected anger toward other men may also be a source of discomfort, stemming from unexpressed resentment toward the father and socialized distrust of other men. The men's group can potentially provide a corrective emotional experience for men who have been culturally alienated from each other (Brooks, 1996).

Men's groups challenge men to constructively deal with interpersonal conflict. Many men have been socialized to avoid conflict through distracting activities, intellectual rationalization, rage, or silence. Heated exchanges sometimes arise in a men's group. Depending on the stage of the group, men will respond to these interpersonal challenges with varying effectiveness. In the early stages of a group, conflict is typically ignored in order to focus on commonality between members. While this allows for early trust building, it also sets the stage for conflict later in the group process (Sternberg, 2001).

Once initial trust has been established through mutual sharing and self-disclosure, group members will begin to tire of being "nice" to each other. If allowed to go on for too long, "niceness" will become a group norm that supports safety but no challenge. In order for a men's group to work, it must provide a challenging psychological atmosphere (Brooks, 1998). Group leaders must encourage and model interpersonal confrontation as well as support for the men. Learning to deal with confrontation can help participants acknowledge their own feelings, value interpersonal feedback, and understand the projective nature of many confrontational remarks. These interpersonal skills can be used in relationships in the world outside of the group to facilitate intimacy and connection.

Men's groups allow for the safe expression and containment of strong emotion (Brooks, 1996). Many men have been taught that to express strong feeling exposes too much personal vulnerability. For men who are detached, unassertive or depressed, anger releasing exercises may encourage openness to feeling in the body, leading to more emotional honesty. In domestic violence groups, men learn strategies to control their anger and identify other emotions such as fear, sadness, and hurt that often have been overridden by expressions of rage. Successful groups for men who have been physically abusive utilize self-awareness of body oriented emotional cues and the situational factors that trigger anger and hostility (Levin-Rozalis, Bar-On, & Hartaf, 2005). Being able to transfer the learning from group to home life is perhaps the most challenging task for men who lose control of their emotions (Pandya & Gingerich, 2002).

Men's groups also encourage men to re-explore their family of origin roots. Through the processes of story telling, interpersonal encounters, and strong emotional expression, the story of one's earlier life often emerges. Memories about mother, father, siblings, friends, and others who had significant impact in the man’s life are often rekindled. It is not unusual for a man to recall something his father said or did when he was a boy, or to reflect on the interactions with siblings that helped shape views on trust, masculinity, or his sense of self. The past unlocks some of the mystery of current interpersonal problems and allows for a reframing of current emotions, reactions, and behaviors (Rabinowitz, 2001).

Men’s groups also address the existential predicaments of life. In the presence of his peers, a man can face his fears of the unknown. Often group discussion centers on the willingness to take risks. Ultimately, this is based on the assumption that life is finite and that if a man is to make the most of his time here, he must be willing to risk leaving the safety of the familiar and move toward the potential unknown (Yalom, 1980). Men may come to grow intellectually ready to leave a job or let go of a dysfunctional relationship, but are often deeply frightened of risking life change. The men’s group uniquely encourages men to take the risk. The voices from a well-functioning group often counterbalance the internalized society, family, and work messages that say "don't change" or "just be a man and suck it up." The group not only encourages each man to take a risk in his life, but also provide the support necessary to absorb the consequences of his actions.

Conclusion

Doing therapy with men can be extremely rewarding. While there are many approaches to therapy, it is important for therapists to utilize their strengths as clinicians to make an interpersonal connection with the men who come to their offices. Therapists must remember that for most males in American society, just making an appearance in the consulting room is an act of courage.

Because society tells men that to admit weakness or vulnerability is the antithesis of masculinity, most attend therapy with ambivalence. Many men experience “relational dread” and must be reassured that they are doing “all right” as they struggle to tell their stories in session. Therapists who speak a man’s language, who recognize the strengths that men have, who are willing to appropriately self-disclose to enhance the interpersonal connection, and who possess empathy for the difficulty many men have in seeking words for their emotions will find responsive male clients. Once they trust the process, most men will actually look forward to their therapy sessions to actively reflect and consider changes that will enhance their lives.

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