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Crossing the No Cry Zone: Psychotherapy With Men
by Fredric E. Rabinowitz, Ph.D.

4 CE Hours - $59

Last revised: 10/11/2016

Course content © copyright 2006-2016 by Fredric E. Rabinowitz, Ph.D. All rights reserved.

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Learning Objectives

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

The materials in this course are based on the most accurate information available to the author at the time of writing. The field of men and psychotherapy continues to grow. New information may emerge that supersedes these course materials. This course will equip clinicians to have a basic understanding of how to approach a variety of men, but cannot address all men or all issues they may present. It is also possible that the content may bring painful feelings to the surface.


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,” suggest 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. Special Focus: Depression and Suicide in Men
    2. Relational Problems
    3. Male Survivors of Abuse
    4. Male Survivors of Trauma
    5. Domestic Violence
    6. Addiction
    7. Sexual Orientation
    8. Transgender Men
  5. Engaging Men in Couple’s 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 recent conceptualizations and research that account for internal emotional dynamics as well as cultural gender role socialization (Addis, 2011; Englar-Carlson, Evans, & Duffey, 2014; Levant & Pollack, 1995; Robertson, 2012).

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 many 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. Newer understandings of gay men and transgender men, along with the intersecting influence of culture and ethnicity make the study of male psychology a rich and diverse field (e.g., American Psychological Association, 2012, 2015).

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 [a] 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 of 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, 2005). 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. Much of male culture around the world has encouraged women to be more relationship-oriented and men to be more self-reliant (Kilmartin, 2009; Rabinowitz & Cochran, 1994).

It has been suggested that the historical origins of masculine socialization are based on the training of boys and men to be hunters and warriors (Lisak, 2005a).  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. Recent cross-cultural research studying the gender role socialization of Japanese men verifies adherence to the norms described by David and Brannon (Chan & Hayashi, 2010).

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 antiwar 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, 2015; 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, 2005).

Although many men try to maintain a colorblind perspective, America is still racially divided. Even with the recent incidents of shootings of black men and the protests generated by Black Lives Matter, it is still 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 (Barry, Kovaleski, Robertson, & Alvarez, 2012; Majors, 1994; Winter & Vallano, 2016). 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 is 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 Esparza, 2005; Liu, Iwamoto, & Chae, 2010).

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. Transgender men are especially vulnerable to prejudice and misunderstanding, but also susceptible to mental health distress that few clinicians are trained to address (APA, 2015). 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. Men struggling with issues of under or unemployment may present with defensiveness that belies underlying fears of being judged for not living up to perceived masculine ideals. Clinicians should be sensitive to the predicaments of men who do not fit the middle-class, Caucasian, heterosexist norms.

Therapists should consider addressing salient cultural aspects of a male client’s presenting concerns in early sessions. In particular, it is important to note that different cultural heritages can have very different gendered norms relating to male emotional expressiveness, self-disclosure, and initial trust of the therapist.

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 (Vogel & Wester, 2003). 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, the client 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.

A Male Client’s Readiness for Therapy

Brooks (2010) has a matrix for male clients who come to therapy based on their readiness to engage in treatment.  By utilizing the precontemplation and action stages of change model (Prochaska & Norcross, 2003), as well as the coercive pressure being applied by outside forces, Brooks differentiates the goals of therapy, the tasks to be accomplished, and the nature of the therapeutic relationship.

The male client most resistant to change is the individual who has not questioned his own behavior and has little outside pressure to do so.  Only occasionally do these men come to therapy.  It has been my experience that a respected close friend, partner, or family member has made the suggestion to attend, but the individual is really in a pre-contemplative stage where he doesn’t quite know what to work on or why he really needs to be there.  A therapist engaging this type of man needs to be more of an educator about how male gender role pressures may keep him from doing everything he might.  Ideally, the male client might get hooked by the therapist talking about masculinity and it’s potential impact on one’s life.  It is not expected that the client will stay in treatment very long from this position, but by having an experience of therapy as a non-threatening situation, this man might return in the future.

A rare, but significant male client is the one who is ready to change, but has very little environmental support to do so (Brooks, 2010).  In this case, the individual is feeling internal pressure to make a change, but fears that in doing so he will upset the equilibrium of his support system.  Joe, a police officer for the past ten years, came to therapy because of his extreme sensitivity to the emotions of those in his environment. Joe grew up in a low socioeconomic neighborhood, excelled at school, and became a policeman when it was suggested by a respected teacher.  Joe enjoyed the interpersonal aspects of the job, but had grown increasingly troubled by the pain he could read on those with whom he had to interact, especially troubled teen-agers. He was bothered by the cavalier and prejudicial attitudes of his colleagues.  At home, Joe was also troubled by his wife’s drinking and the disturbing interactions he had with his divorced parents.  He felt that he had to be “the rock” for everyone and it was getting to him.  In this situation, the therapist validated Joe’s concerns and emotional reactions.  Joe appreciated having a place to talk about feeling overwhelmed, since his outside life left him few opportunities to be authentic.  Joe was eventually referred to a men’s therapy group where his feelings could be expressed and understood without having to worry about it jeopardizing his job.  It also gave him a chance to work on changing the dynamics of his family relationships.

The most common male client is one who is in the pre-contemplative stage of change, but who is being highly pressured to come to therapy by the environment (Brooks, 2010).  Brooks (1998a) suggests a “soft-sell” approach to engagement.  This involves the therapist acknowledging the resistance a man might have to being in treatment, while building a strong therapeutic alliance.  Brooks (2010, p. 78) writes, “In the common situation in which a male client has been more or less coerced into therapy, a therapist is prudent to maximize the strategic benefits of the triangulated position…For example, useful questions might be as follows: ‘What is it that your wife (boss, doctor, judge) is so worked up about?’ ‘What do we need to do to get them off of your back?’ From this position, the therapist can mediate the benevolently between the troubled factions without losing credibility with either.” In many ways, the therapist can thus ally him or herself with the pre-contemplative male client, and get him to begin to take ownership for the problems that others are noting without triggering resistance.

The male client who is ready to make changes and has the environmental support to do so is likely to require the least amount of direction from the therapist.  Brooks (2010) suggests that the therapist act as an empathic, collaborative facilitator who encourages the male client to pursue his goals.  The therapist in this scenario is more likely to be able to confront a male client when he is falling back into old patterns or is internally fearful of how change will affect his life.

Practical Considerations

By cultivating a repertoire of male-friendly attitudes and interventions, therapists can play a part in increasing the likelihood that men who need treatment will come to treatment and will stay in treatment (Rochlen & Rabinowitz, 2014). One important task for clinicians is to become educated on the ways in which the traditional male gender role both inhibits and complicates the expression of male distress, and how some aspects of the traditional male gender role may actually be called on in service of treatment. For example, the traditional male wish to “take control” of a problem and solve it for himself can actually augment the therapeutic alliance with men, especially in the early stages of treatment. A therapist’s support for the male client’s desire to take an active, problem solving approach to dealing with whatever may be contributing to his psychological distress will give him an impression that the clinician trusts the male client, sees and values his strengths, and does not hold a view that the male client must dwell on his negative, sad, or depressed emotions in order to get better.

In addition to cultivating male-friendly attitudes and a comfort with addressing male gender role socialization issues directly with male clients, psychotherapists may also become sensitive to the actual physical décor and layout of their offices. Décor that may be intended to make some clients comfortable, such as pillows, stuffed animals, candles, or other physical objects that may be perceived as feminine by a male client should be employed judiciously. A more casual arrangement of furniture that encourages the male client to situate the seating to reflect his level of emotional comfort with the clinician can help set the male client at ease, especially in early sessions where close quarters, face-to-face interaction may be felt as too intrusive for the male client.

The therapist may cultivate a “language” to employ with her or his male clients that reflects the male client’s choice of words and vocabulary usage. For example, beginning a session by inquiring, “What would you like to work on today,” may convey an action orientation that is calling upon the male client’s value of “fixing” something that has broken or gone wrong. Metaphors often resonate more than abstract concepts with men (McKelly, 2014). Other male clients may have limited emotional vocabularies and may benefit from the psychotherapist prompting the expression of emotions simply by suggesting or offering feeling words. For example, after a long disclosure about being stood up on a date, a counselor could simply reply, “That must have really hurt,” instead of the usual, “How did that make you feel?” Over time, the male client will begin to choose words that convey emotions.

Clinical Illustration

(The following is an exchange between a male client Jake and his male therapist. 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: Yeah, 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: Yeah. I was married for a while.

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: Yeah. 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: Yeah. 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 nonjudgmental 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 (2012) 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.


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.


Clinical Illustration

Jose 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, Jose. 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: Yeah. 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, especially in relationship to presenting depressive symptomology. 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).

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 transmissions 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 (Cochran & Rabinowitz, 2000).

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. 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 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 (Rabinowitz & Cochran, 2002).

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 fired or laid off from his job 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 on to 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, difficulties in social relationships, antisocial behavior, and under-diagnosed male depression form a composite profile of a male tendency to externalize psychological distress through action, distraction, and compulsive acting out (Cochran & Rabinowitz, 2000).

Special Focus: Depression and Suicide in Men

This section will address the issue of depression and suicide in men. Beginning with a brief summary of the literature on depression, this section will contrast the typical DSM-5 criteria with a proposed male-specific perspective on depression. In addition, clinicians will be given some tools for assessing male-specific depression and suicide, as well as strategies for treatment.

Brief Overview of Depression

Depression is a psychiatric disorder with several different forms and variations. Major depression, at its extreme, is characterized by a subjective sense of several of the following: depressed mood, diminished interest in most activities that previously provided pleasure, insomnia or hypersomnia, feelings of worthlessness, tearful and sad demeanor, diminished ability to think and concentrate, periods of emotional upset, guilt, and recurrent thoughts of death and suicide that cause impairment in social and occupational functioning for a minimum of two straight weeks (American Psychiatric Association, 2013).

Dysthymia, which often includes low energy, low self-esteem, poor concentration, insomnia or hypersomnia, poor appetite or overeating, and subjective feelings of hopelessness, is a less intensive and debilitating form of depression that is present for two years or more (American Psychiatric Association, 2013).

Bipolar disorder is another variant of depression that involves the symptoms of major depression punctuated by shorter periods of manic-like symptoms, including high energy level, inflated self-esteem, racing thoughts, distractibility, little if any sleep, and engagement in high pleasure activities without regard for consequences (American Psychiatric Association, 2013).

When there has been an obvious psychological stressor such as a major relationship loss, job loss, or death, a person may have the symptoms of major depression and/or dysthymia, but psychiatric professionals consider this to be a normal grief reaction and tend to label it as “uncomplicated bereavement” or “adjustment disorder with depressed mood” (American Psychiatric Association, 2013). Seasonal Affective Disorder, a recently distinguished disorder, involves depressive symptoms manifested during the winter months, when there is less sunlight and more indoor confinement.

Research suggests that major depression and bipolar depression are disorders with a strong genetic component, with higher than expected rates for children of a depressed parent and increased levels of concordance in monozygotic twins (McGuffin, Katz, Watkins, & Rutherford, 1996; Weissman, Gammon, John, Merikangas, Warner, Prusoff, & Sholomskas, 1987). Those with genetic predispositions may be most susceptible to depression when faced with adverse life conditions, interpersonal problems, or a particularly strong environmental stressor (Blackmore, Stansfield, Weller, Munce, Zagorski, & Stewart, 2007).

The heterogeneity of depressive symptomology makes it difficult to identify the exact mechanisms in the brain that are responsible for the disorder. Since the 1950’s, one of the most researched areas in the field has been the monoamine neurotransmitters, which regulate emotion and motivation in the limbic system in the brain (Schildkraut, 1965). Neurotransmitters are chemical messengers that connect the various areas of the brain through electrical and chemical processes. The neurotransmitters serotonin and norepinephrine have been implicated in understanding depression, with lower levels associated with depressive symptomology (Hammen, 1997). The effectiveness of antidepressant medication has made the case for this relationship, with drugs that increase serotonin and norepinephrine resulting in the amelioration of depressive symptoms over time. However, the relationship is complex, since many antidepressant medications that increase amounts of these neurotransmitters in the limbic system do not result in immediate mood shifting and work effectively in only 50-60 % of those who take them (Schatzberg & Kraemer, 2000).

The brain’s endocrine system, which includes the hypothalamus, pituitary, and adrenal glands, is also implicated in the physiological manifestation of depression. The release of hormones from these glands is triggered by the actions of the neurotransmitters norepinephrine and serotonin, which are first responders to perceived stress (Lewis, Amini, & Lannon, 2000). During stressful situations, the release of the hormone, cortisol, into the bloodstream mobilizes the body to cope with danger. In a short-term stress event, cortisol levels return to normal relatively quickly. Cortisol can have damaging effects if the stressor is long lasting, or of high magnitude (LeDoux, 2002). It is believed that excessive cortisol can destroy portions of the hippocampus, the brain center responsible for integrating new experiences into more long-term memory, leading to problems with new memory formation. This is often experienced as a loss of interest in previously engaging activities, dulled perception, and an agitated, negative mood state. The stress reaction theory is bolstered by the robust findings that depressed individuals often have higher levels of cortisol in their bloodstream than nondepressed individuals do (LeDoux, 2002).

Male Specific Depression

What is perhaps one of the more dramatic scientific findings related to the prevalence of depression is that in many epidemiological studies, women are typically found to have a higher rate of depression than men (Martin, Neighbor, & Griffith, 2013; Nolen-Hoeksema, 1990). While early data was derived from studying admission rates to psychiatric hospitals, later findings have come from large population-based studies. One such study, sponsored by the National Institute of Mental Health, examined samples from five population areas in the United States. Interviewers trained to detect the signs and symptoms of mental illness had in-depth interviews with 19,182 persons in New Haven, Connecticut; Baltimore, Maryland; Raleigh-Durham, North Carolina; St. Louis, Missouri; and Los Angeles, California (Robins & Reiger, 1991). The findings, replicated in another large epidemiological survey, found women to have a 30% lifetime prevalence rate of major depressive disorder/dysthymia and men to have a 17.5% lifetime prevalence rate.

Some researchers have suggested that because of sexism in the culture, discrepancies in earning power compared to men, and women’s more relationship-oriented social roles, women are under more stress than men and more susceptible to depression (Bifulco, Brown, Moran, Ball, & Campbell, 1998; Daley, Hammen & Rao, 2000). Others have proposed that women are more emotionally reactive to stimuli in the environment (Kendler, Thornton, & Prescott, 2001). Nolen-Hoeksema’s (1990) research has attributed higher depression rates among women because of their tendencies toward rumination about life events as compared to men, who tend to use more distractive strategies.

Perhaps the most powerful evidence for the expression of male-specific depression is the high suicide rate for men when compared to women. For example, suicide rates of men between the ages of 15 and 24 and for men over 80 are seven to fifteen times the rate of women of the same age. For all age groups, men kill themselves at four times the rate of women (Buda & Tsuang, 1990). This data supports the hypothesis that because fewer men seek treatment for underlying depression, they are at a higher risk for a worsening of their mental condition with the result of self-inflicted death (Cochran, 2001). Men are also overrepresented in the categories of alcohol and drug abuse and dependence by a margin of 35% to 17% for women. Lastly, they are more likely than women to be involved in antisocial acts including fighting, stealing, and homicide (Cochran & Rabinowitz, 2000).

Recent evidence supports the hypothesis that men may indeed experience depression differently than women.  A study of a large, nationally representative sample of U.S. adults utilized a gender inclusive depression scale that incorporated non-DSM symptoms. When the researchers asked about anger/aggression, irritability, and substance abuse, as well as traditional depression symptoms, men were diagnosed at comparable rates to women (Martin, Neighbors, & Griffith, 2013).

This supports theories that men may be masking the symptoms of their depression by self-medicating with alcohol and mood altering substances (Addis, 2008; Cochran & Rabinowitz, 2000; Pollack, 1998). Additional support for this interpretation comes from studies of cultural groups in which alcohol and illicit drug use is minimal, and in which there are no significant differences in the rates of depression between men and women (Cochran & Rabinowitz, 2000). This was true in a study of the Amish in Lancaster County, Pennsylvania (Egeland & Hostetter, 1983) and in a study of an Orthodox Jewish community in London, England (Lowenthal, Goldblatt, Gorton, Lubitsch, Bickness, Fellowes, and Sowden, 1995). Non-acculturated Chinese Americans living in Los Angeles were found to have no gender differences in rates of depression, but those who were higher on indices of acculturation showed the normal 2:1 female to male prevalence rate of depression (Takeuchi, Chung, Lin, Shen, Kurasake, Chun, & Sue, 1998).

Finally, in two studies of elderly populations, it was found that depression rates were actually slightly greater for men than women (Bebbington, Dunn, Jenkins, Lewis, Brigha, Farrell, & Leltzer, 1998; Girling, Barkley, Paykel, Gehlhaar, Brayne, Gill, Mathewson, & Huppert, 1995). Even when taking antidepressant medication, elderly men identified as having major depression had significantly higher mortality rates than elderly women on medication (Ryan, Carriere, Ritchie, Stewart, Toulemonde, Dartigues, Tzourio, & Ancelin, 2008). These findings taken together suggest that cultural practices, as well as developmental stage of life, may have an impact on the gender normative way that depressive symptoms are expressed or suppressed.

Traditional Western culture gender role norms encourage a diminutive emotional response to many life events for men. Men are taught to suppress impulses to cry, to be strong in the face of adversity, and to solve problems independently. Showing emotional pain is thought to signify weakness and vulnerability. Taking control, maintaining one’s cool, and demonstrating one’s dominance through flashes of anger are more accepted social norms when facing difficult life circumstances (Robertson, 2012).

It is not surprising that when most men are asked how they are feeling, they often reply with a single word, “Fine,” regardless of their inner emotional states. Implied in this response is that, as a man, “I don’t need any help.” It is shameful to feel needy, overwhelmed, unsure, or not in control of one’s life (Cochran & Rabinowitz, 2008). The consequences of not asking for help are often dire. Men are less likely to seek timely healthcare for medical and emotional problems, are less likely to share important information about their physical and mental health when they do make contact with a health care professional, have higher death rates than women for all 15 leading causes of death, and will die nearly seven years younger than women will (Courtney, 2011).

Men raised in a culture that values the suppression of distressing emotion may express depressive symptoms in a way that varies from traditional diagnostic observations. Termed masculine-specific depression, these symptoms are often mistaken as normative male behaviors (Cochran, 2005; Pollack, 1998). While some of the traditional DSM symptoms of depression might be present, masculine-specific symptoms can include irritability, increased interpersonal conflict, increased alcohol, food, or drug (illicit or legal) intake, somatic complaints, a desire to be alone, work-related complaints, and difficulty with concentration and motivation (Cochran & Rabinowitz, 2000). Shame has also been implicated as a key component in men experiencing depression, both as a potential cause, and also as a self-judgment for not being able to overcome its symptoms (Shepard & Rabinowitz, 2013).

Since many men have been trained to avoid negative feelings by distracting themselves with mood altering activities, and because women have been reinforced for ruminating about distressing moods, it is not surprising to find that men are less likely to report depressive symptoms. While effective in the short term, it still leaves open the question about whether this is a good long-term strategy. The high male suicide rate suggests that unsuccessful attempts at distraction and avoidance may result in a worsening of the underlying depressive conditions for some men (Rabinowitz & Cochran, 2007).

Assessment of Male Specific Depression

Cochran and Rabinowitz (2003) have outlined a gender-sensitive protocol for approaching the assessment task with depressed men that incorporates research findings that are derived from gender-specific findings and clinical case reports of therapists working with depressed male clients. This protocol recommends first assessing for the more traditional symptoms of depression noted above, then covering the symptoms more likely to be manifested by men, addressing any culturally salient aspects of the presenting situation, and finally, assessing for suicide risk since men are at increased risk for committing suicide in the throes of a depressive episode.

Some men will simply present themselves as depressed and show the traditional DSM-5 symptoms such as sad or depressed mood, loss of interest or withdrawal from typical activities, sleep difficulties, trouble with concentration and thinking, thoughts of death and suicide, and so forth. For most clinicians, these types of presentations will be relatively straightforward and present minimal difficulties with assessment. The main task for the psychotherapist in meeting men who present in this fashion is to create a welcoming and positive space for the male client to feel comfortable expressing these symptoms since they will most likely be uncomfortable for him to admit. Once the therapist creates this welcoming environment, typical follow up inquiry into the duration and severity of symptoms, family history of mood disorder, and evaluation of risk factors such as suicide can be accomplished in a straightforward fashion.

However, a sizable portion of male clients will present more oblique and difficult to decipher clusters of symptoms related to depression. These include, but may not be limited to, complaints regarding work and productivity, anger management difficulties, alcohol or substance abuse, other addictive or obsessive behaviors, and difficulties in intimate relationships with family and partners (Cochran & Rabinowitz, 2003). Men who are experiencing chronic physical pain are also likely to show irritability and interpersonal distress indicative of underlying depression (Linton, 2000). Often, these men may be referred by a third party or coerced into a visit with a therapist in order to stay in a relationship or to be retained in an employment situation. Obviously, these men present more challenging assessment tasks. They will often have difficulty with self-disclosure, preferring at first to respond to questions with minimal replies.

Several researchers suggest that clinicians assess depression from a masculine-sensitive approach in order to get a more accurate read on male symptomology (Addis, 2008; Cochran, 2001; Martin,, 2013). The traditional symptoms 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, 2005, p. 236):

Masculine-Sensitive Assessment of Depression

  1. Review of DSM-5 criteria for major depression (e.g., depressed mood, decrease of interest in activities, fatigue, sleep and appetite disturbance, thoughts of death and suicide, guilt, difficulty concentrating, etc.)
  2. Identification of important comorbid conditions
    1. Alcohol abuse and dependence
    2. Substance abuse and dependence
    3. Related personality features (antisocial, compulsive, and narcissistic traits)
  3. Masculinity-related symptom expression
    1. Somatic or physical complaints
    2. Increases in interpersonal conflict
    3. Work-related difficulties and conflicts
    4. Wounds to self-esteem (job loss or relationship loss)
  4. Culturally influenced manifestations of emotional distress
    1. Class and race considerations regarding emotional expressivity
    2. Level of awareness and acceptance of traditional male gender roles
    3. Family of origin role models and norms regarding emotional expressivity
  5. Suicide and homicide risk assessment
    1. Ideation, plan, means, access, and intent
    2. Alcohol and drug intoxication
    3. Psychotic or delusional features
    4. Capacity for cooperation with clinician
    5. Physical illness
Clinical Illustration

Carlos, a 55-year-old man with Hispanic ancestry, came to counseling at the urging of Helen, his wife of 30 years. She thought that he often seemed distant, preoccupied, and irritable. He often drank several shots of whiskey when he got home from his position as a mid-level manager of a large company. They had a poor sex life, and had not made love in over six months. Their two daughters were both out of the house and married. Helen had recently gotten involved in her own individual counseling and was finding it helpful in understanding how her past was influencing their relationship. Before engaging in couple’s work, Helen and her counselor thought it best that Carlos do some of his own individual work. Carlos had never been in counseling, but told her he would give it his best effort.

During the first session, Carlos told the counselor that he was there mainly to please his wife. It took a few more sessions of increased sharing about his life, assurances of confidentiality, and the building of a solid working relationship with the counselor for Carlos, who first appeared cautious and tentative, to become more animated and open. His big revelation was that he had been having an affair with a coworker, and this was not the first time he had strayed outside the marriage. He revealed that he had grown bored with his marriage long ago and had felt rejuvenated by the mainly sexual relationships he had taken up. His distant behavior at home was a result of his guilt and avoidance of his wife’s demands for intimacy.

For Carlos, the sessions represented a way for him to explore what had happened in his marriage, and try to understand why he was having affairs. Through counseling, Carlos recognized that he had been struggling with depression most of his adult life. He had medicated his low energy level and pessimistic thinking with alcohol, pornography and, eventually, sexual affairs. His father had died when he was 11 and, as the oldest boy in the family, he had taken on a very responsible role growing up. He had learned to give up his own needs to help his mother and younger siblings. To please the family and fulfill his cultural obligation, he married Helen after a short courtship, but he revealed in counseling that he had never felt “in love” with her. Aside from trying to decide whether he wanted to work on the relationship with Helen, Carlos talked emotionally about his father. He became aware that the loss of this significant relationship had had an impact on how he saw himself in the world. Underneath his competent exterior, he worried about fulfilling his expected male role as a provider, including whether he was a good father and made enough money. Carlos admitted that he often felt like he was an impostor and that attracting women and having affairs was a way to validate his sense of himself as a man (from Rabinowitz & Cochran, 2007).

As Cochran and Rabinowitz (2003) note, an important aspect of assessment with men presenting with depression is to evaluate suicide risk. Many authors (e.g., Bongar et al., 1998) have presented comprehensive approaches to evaluating suicide risk; these techniques work well with men. Presence of ideation, plan, means, and intent are important topics to cover. In addition to these aspects of suicide risk assessment, it is important for the clinician to be sensitive to masculine gender role derived risk-taking behavior and its possible relation to self-destructive behavior. Careless and risky driving practices, heavy alcohol or substance use, extreme risk-taking in leisure pursuits, and other practices that may be sanctioned by the culture of masculinity that disdains self-care or help seeking may actually be manifestations of a wish to die. Such considerations are important for the counselor to recognize and discuss directly with the male client.

In addition to the clinical interview and history-taking in the initial sessions, the counselor may also utilize various scales to assess the male client's depression. Magovcevic and Addis (2008) created the Male Depression Scale, a self-report inventory to identify atypical symptoms of depression found in men. The Beck Depression Inventory (Beck, Steer, & Brown, 1996) is one of the most commonly used and most “user-friendly” assessment instruments available on the market. It is comprised of 21 items that assess symptoms of depression, to which the client answers on a scale from zero to three, with higher endorsement indicating higher levels of depression. The Beck Depression Inventory has very impressive reliability and validity data to support its use. Other, masculine specific scales that the counselor may choose include the Zung Self Rating Depression Scale (Zung, 1965) and the Hamilton Rating Scale for Depression (Hamilton, 1967).

Treatment Options for Depressed Men

It is a dilemma for many men to seek treatment for any kind of health concern, let alone something as serious and shame-provoking as mental health. Men are often told to "man up" when faced with life problems. Cultural norms around self-reliance, emotional control, and power compromise self-initiated help seeking in men (Addis & Mahalik, 2003). While some men find relief in physical workouts like running or weight lifting, feelings of doubt, shame, and depression are not so easily resolved in this manner. Often it is someone other than the man himself who initiates the possibility of psychiatric or psychological treatment; such as a concerned partner, family member, coworker, or even a legal sanction. It is not uncommon for a man to first seek out his primary care physician with tangible complaint like sleep problems; sexual performance concerns; headaches; or pain in the back, neck, or gut. Physicians who do not probe deeply about a man's psychological state may find themselves prescribing pain medication, sleeping pills, and erectile dysfunction drugs when a man is really experiencing depression. Since men are often less than forthcoming about describing the depth of their mood disturbance, depression must sometimes be inferred from the configuration of symptoms. As stated earlier, masculine-specific symptoms can include manifestations that might be misdiagnosed as being typical male reactions to stress, like eating and drinking too much, irritability, fatigue, lack of sex drive, watching too much television, or difficulty with concentration (Cochran & Rabinowitz, 2000). When depression is diagnosed, medication is often a first step in treatment. Many men feel more comfortable with a medical model approach that emphasizes their condition being a biochemical abnormality that needs a biochemical treatment.

Psychopharmacological Treatment

In recent years, there has been a proliferation of antidepressant medications introduced that are effective in altering the amounts of neurotransmitter substances in the brain. The three major types of antidepressants are monoamine oxidase (MAO) inhibitors, tricyclics, and selective serotonin reuptake inhibitors (SSRIs). MAO inhibitors allow the neurotransmitters dopamine, norepinephrine, and serotonin to remain at the synapse of the individual neurons longer, resulting in more being available and a corresponding subjective lifting of the depression (LeDoux, 2002). Unfortunately, one of the side effects of this drug is the breakdown of the amino acid tyramine, leading to life-threatening high blood pressure when certain fermenting foods are digested including wine, beer, and cheeses. Tricyclic antidepressants with the brand names Tofranil and Elavil also increase norepinephrine and serotonin at the receptor sites by blocking the transportation of these substances back into the releasing neuron’s terminal (LeDoux, 2002). The side effects from these drugs include dry mouth, constipation, urinary retention, and sometimes confusion (Preston & Johnson, 2005).

The most common antidepressants prescribed today are the SSRIs (Kraemer, 1993). With significantly fewer side effects, this class of drug selectively targets either serotonin or norepinephrine receptor sites, leading to the alleviation of depressed mood. Most of these drugs take 4-6 weeks of continuous use to become fully effective. For men, the main side effects of these medications has been found to be sexual dysfunction in the form of lower libido and delayed ejaculation (Stuart, 2000).Drugs marketed under the names of Pristiq, Symbalta, Prozac, Paxil, Celexa, Zoloft, and Lexapro, for example, have made this class of antidepressants the most prescribed medication in history (Pagura, Katz, Mojtabai, Druss, Cox, & Sareen, 2011).

Electroconvulsive treatment (ECT) for depression, also popularly known as shock treatment, involves inducing an epileptic-like seizure in an individual. This treatment, which takes place over several consecutive days, is used on a limited basis for individuals with the most severe catatonic forms of depressive disorder and who have been resistant to other interventions. ECT, which has been found to increase short-term memory loss and cause some confusion, has also been found to be effective in alleviating severe depressive symptomology for several months at a time. The mechanism for its effectiveness is thought to be a resetting of the neurotransmitters serotonin, norepinephrine, and dopamine, but is still not fully understood (Mayo Clinic, 2007).

Psychotherapy Treatment

Research suggests that SSRIs alone may not be as effective without concurrent counseling. Clinical trials pitting psychotherapy against antidepressant medication as well as combinations of the two suggest that cognitive psychotherapy is as effective as medication and that a combination of the two may be the best long-term strategy for recovery from depression (DeRubeis, Hollon, Amsterdam, Shelton, Young, Salomon, O’Reardon, Lovett, Gladis, Brown, & Gallop, 2005; Jacobson & Hollon, 1996).

Even though only one third of all visits to psychotherapists are made by men (Vessey & Howard, 1993), those who do attend treatment for depression have a success rate equal to women (Cochran & Rabinowitz, 2000). Often a visit to a psychotherapist or counselor is at the urging of a concerned partner, who observes that even with SSRI medication and some alleviation of the depressed mood, a man’s negative thinking and strained interpersonal style may persist. Some men seek help for other male-specific symptoms that the medication doesn’t address or may exacerbate like overeating, sexual dysfunction, difficulty finding pleasure in life activities, alcohol or drug abuse, addiction to pornography, or outbursts of anger (Cochran & Rabinowitz, 2003).

The National Institute of Mental Health’s Treatment of Depression Collaborative Research Program demonstrated that for mild to moderate depression, both cognitive-behavioral and interpersonal approaches were equally effective (Elkin, Shea, Watkins, Imber, Sotsky, Collins, et al., 1989). Cognitive-behavioral therapy for men focuses on confronting unrealistic expectations of the male role, and distortions in thinking and behaving that lead men toward a depressed outlook and mood (Mahalik, 2001). Interpersonal therapy emphasizes examining and improving how the depressed individual approaches relationships and communicates needs and desires to others (Elkin, et. al., 1989).

Recently, more innovative approaches to psychotherapy have shown promise as treatment for depression. Pollack (1998) has proposed a therapy that focuses on repairing childhood relational trauma, which has resulted from the abrogation of important interpersonal relationships. Cochran and Rabinowitz (1996) have described a counseling process that addresses the accumulation of losses at various developmental periods of life that make men more susceptible to depression. Osherson and Krugman (1990) and Shepard and Rabinowitz (2013) emphasize in their therapeutic approach the role of shame in the experience of men’s depression. All three of these approaches have shown that vulnerability to male depression has a strong interpersonal component that should be addressed in treatment.

If the male client is receiving antidepressant medication, it is important for psychotherapists, regardless of approach, to collaborate with the individual’s psychiatrist or physician. Mood changes, side effects, and reports about the effectiveness of a particular medication are relevant information for both the psychological and psychiatric treatment of the individual.

After the initial consultation and assessment, the psychotherapist’s primary task is to create a therapeutic alliance based on explicit empathy for the man's experience (Pollack, 1990). Although an initial awkwardness is to be expected, it is the counselor's job to make the creation of a therapeutic relationship a less threatening process. Starting with the present symptoms rather than quickly delving into the past can facilitate this. Some small talk, humor, and humanizing self-disclosure by the therapist can reduce the shame-based intensity of the encounter (Rabinowitz & Cochran, 2002).

By carefully listening to the story the male client weaves, the counselor can combine in his or her responses empathy for the losses and traumas expressed, as well as relevant questions about history and suicide risk that don't change the context or flow of the story being told. Most men seem more receptive to revealing themselves when their experience is framed by the counselor as a rich revelation of their life journey. Rather than asking a man to respond to a series of clinically oriented questions, it may be more effective to reduce anxiety and shame by asking open-ended questions that give permission for a man to tell his story with its own unique emphases and timing (Rabinowitz & Cochran, 2002).

Paradoxically, the depressed male client seems to want the counselor to have the energy to help him and at the same time, feel as depressed as he does. Exhausted by enough "yes buts,” the eager clinician cannot help but descend into the client's depressed emotional state. The energy drain that depressed clients seem to have on the therapist is a reminder that he or she must be willing to enter into the "low psychic space" of the client. It is only from this space, that the clinician can truly empathize with the patient's experience and offer an existential kinship with life's downside (Yalom, 1980). This willingness by the counselor to be with a man experiencing negativity in his life often gives the male patient hope and a sense that he is understood. In group therapy, this function can be shared among supportive group members (Rabinowitz, 2008).

For the depressed man, engaging the contemptuous and shame-inducing "critical parent" or “internal judge” is often a crucial piece of the work that must be faced in psychotherapy (Rabinowitz & Cochran, 2007; Shepard & Rabinowitz, 2013). This introjected self, which often has the voice of a parent, carries much power and when turned against the self has the capacity to immobilize the individual with anxiety and depression. Often, this is projected onto the therapist. For instance, a man in therapy may feel like he is not living up to the expectations of the counselor, despite the counselor’s judgmental neutrality and emotional support. He might state to the clinician, “You must think I am such a loser. I can’t even imagine how you could stand to listen to me talk about this crap. Some kind of man I am. Good thing you are getting paid for this.”

Drawing out the projection on the counselor allows these negative messages to be said aloud and confronted. Often, a man does not realize how much impact these ideas have on his self-esteem and behavior. Assumptions about what it means to be a man, including being a son, father, partner, or worker, may be a big part of the unrealistic thinking in which a depressed man might engage (Mahalik, 2005). This can be seen in the following exchange between Carlos and his counselor:

Clinical Illustration

Carlos: I never seem to be satisfied with anything I do. It is never enough.

Counselor: Sounds like someone in your life may have told you these words, and you bought them hook, line, and sinker.

Carlos: Damn right I did, and now I can’t shut down the voice.

Counselor: Whose voice is it?

Carlos: Beside mom, my wife, and every boss I’ve ever had?

Counselor: Didn’t realize you had a whole team cheering you on, huh?

Carlos: It often feels more like an army.

Counselor: How does it feel just saying this to me now?

Carlos: Familiar, but I’ve never really talked about it to anyone. It is usually a private berating with myself.

Counselor: Perhaps it is a part of why you have felt a sense of depression over the years.

Carlos: I think you are right. That feeling that it’s never good enough makes me always feel like I am not a real man. Nothing I do measures up except when a woman is interested in me. That perks me up and takes me away from self-pity. If she likes me, then temporarily I’m okay.

Counselor: It gets to be quite a pattern, but it only works for a short while?

Carlos: Yes. I thrive on it, but then I am just waiting for her to figure out I’m an impostor.

Counselor: Then what do you do?

Carlos: Feel bad. Get quiet. Drink. Mope around the house.

Counselor: Then Helen starts to notice.

Carlos: You know it. She doesn’t realize what I am feeling. She just sees I am withdrawn and I just say it has do with work.

Counselor: What would happen if you told her the truth?

Carlos: It would be too much.

Counselor: Too much for her or too much for you?

Carlos: Maybe too much for both us. I want to tell her everything, but I don’t trust how she is going to take it.

Counselor: You have really established a pattern and it is hard to break. Withdrawing is familiar. Talking about it is still not comfortable for you.

Carlos: Talking to you is easier than I thought it would be. You aren’t judging me and I trust you. I still don’t know for sure if I want to be with her. I’m still not sure it’s good for me.

Counselor: You sure that that’s not an excuse for not talking?

Carlos: You might be right. I’m just not there yet. Maybe when I actually stop beating myself up and accept myself, I can be more open.

Counselor: You seem to be getting closer.

Carlos: I hope so. (Rabinowitz & Cochran, 2007.)

Held up to the light, depressive thinking is not very convincing. Distortions, generalizations, exaggerations, and all-or-nothing thinking can be confronted (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). A man who can articulate the thoughts that go along with his depression is more open to changing them and replacing them with less harsh, more positive ideation (Vodde & Randall, 1994). A man who is frozen by his depression can be gently motivated by a counselor’s sense of humor, appropriate self-disclosure, patience, mild confrontation, and encouragement to break through self-imposed self-devaluation (Rabinowitz & Cochran, 2002). Often, the emotional retelling of hopes, triumphs, mistakes, and failures opens a man to see connections and patterns that he had never before noticed. It is not uncommon for a man to realize that his pursuit of a particular career or woman had its roots in both intrapsychic conflicts and male gender role socialization (Cochran & Rabinowitz, 1996).

With reflections of meaning and feeling by the therapist, an isolated series of life events can be transformed into an intricately organized web of pictures, emotions, and connections. The therapy relationship itself serves as a model of relationships in which a man can be less than perfect, and emotionally open, while still being valued by another adult. By fully investing in the therapeutic relationship, it is possible for a man to have breakthrough feelings of anger, deep sadness, joy, and laughter. Coming at this later point in the process, the sharing of emotion feels less alien and much more congruent and meaningful than when he first came to counseling (Rabinowitz & Cochran, 2007).

Although it is rarely what he thought he was looking for, a man who can feel and express a range of emotion perceives himself less broken, and more whole. By learning how to disarm the shame brought on by his own harsh self-criticism and society's script for him as a male, he opens himself up to the world of connection and emotional aliveness. The outcome of psychotherapy is not necessarily a permanent removal of depressing feelings but rather an acceptance of the emotional spectrum that comes with living life authentically (Rabinowitz, 2008). In addition, being able to practice what was learned in therapy in his everyday world encourages a man to establish new patterns of behavior in which depressive thinking can be counteracted.

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. It is also possible that underlying depression might exacerbate or even be a root cause for interpersonal difficulties.

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 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 he had noticed 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, yeah. 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 facade 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. Yeah, I feel like I want to fill myself up but I don’t know how.

T: Do you feel it right now?

R: Yeah. 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, and certain personality disorders. They are also more likely to come to the attention of clinicians (Lisak, 2005; 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 for men who have been abused or witnessed abuse in childhood (Cashmore & Shackel, 2013).

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, 2013).

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 general irritability, outbursts of anger, and a tendency to withdraw from intimacy. 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-5 (American Psychiatric Association, 2013) 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 (2010) 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, 2010).

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: Yeah. 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: Yeah.

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: Yeah. It was horrible.

T: You having a flashback?

C: Yeah. (Shuts his eyes and grimaces)

T: It’s safe here. You know that.

C: Yeah. 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.

Domestic Violence

It is common in warrior cultures for there to be a sanctioned masculine ideology that encourages toughness, independence, fearlessness, and aggressiveness toward others (Lisak, 2005a). 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, 2005a). 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 inter-parental 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; Wexler, 2013) have shown success in dealing with male violence issues.

Attachment researchers suggest that many men who engage in intimate partner violence enter a cycle of rejection and abuse that is difficult to stop (Brown, James, & Taylor, 2010).  The cycle begins when a man who has insecure attachment from childhood and adolescent experiences, encounters rejection in his main interpersonal relationship.  This rejection leads to a sense of inner shame that he defends against through denigrating his partner and rejecting the message she is sending. If this does not work to soothe his experience of rejection, he is likely to escalate to defend against shame by being psychologically and/or physically abusive (Brown, James, & Taylor, 2010).  Therapists should be cognizant of this cycle as they intervene with men who are act out in this way.

The most popular approach for men who have anger or violence problems is cognitive-behavioral therapy. 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; Wexler, 2013).

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: Yeah, but I’ve learned not to let anyone know.

T: Sounds like her criticism reminds you of being scolded as a child.

D: Yeah. 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.


It is not unusual 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 or to minimize the emotional pain associated with trauma (Woodford, 2012). 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; Woodford, 2012).

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 supercritical 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: Yeah. 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: Yeah, 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 a 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: Yeah, 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 Alcoholics Anonymous, Narcotics Anonymous, and Sexaholics 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, 2005). 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, 2012).

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.

Sexual Orientation

Gay and bisexual men are more likely than heterosexual men are to seek counseling and psychotherapy (Haldeman, 2005). 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 for this population (Haldeman, 2005).

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 (Nadal & Rivera, 2014).

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-old 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, yeah. 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: Yeah, 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: Yeah, 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, which supports the notion that heterosexuality is the norm for behavior (Haldeman, 2005). 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).

Transgender Men

Gender identity is distinct from sexual orientation. Transgender boys and men were assigned as female based on genitalia at birth, but deeply feel an inherent sense of being a boy, man, or male (American Psychological Association, 2015). While the identification with maleness may feel natural and healthy, many transgender men experience distress associated with the discrepancy between their biological sex assignment and their gender identity (Coleman, et. al, 2012). In addition, prejudice and discrimination around basic rights like bathroom choice, healthcare access, and workplace treatment add to feelings of alienation. Verbal harassment and physical assaults are much higher against this population of individuals (Bradford, Reisner, Honnold, &Xavier, 2013).

Clinicians working with transgender men should become versed in the developing literature around transgender individuals in order to be most effective (American Psychological Association, 2015). Singh and Dickey (2016) describe how to best approach and support transgender individuals in the therapy process, carefully tackling underlying mental health issues that may accompany, but not necessarily be caused by transitioning. Awareness of one’s own biases about gender identity may need to be thoroughly explored to ensure that transmales are treated with objectivity and affirmation.

Clinical Illustration

Price, 19, sought therapy as a part of his transitioning process from a biological female to a transgender male. He had begun hormone treatment and had been referred by his primary physician to talk with a therapist about how he was handling the process. Price had revealed to the therapist that as long as he could remember he felt like he was a male “trapped inside a female body.” Price expressed relief that he was now able to go through the process of transitioning to be more in alignment with how he experienced himself.

The following is from an early session:

P: After all I have been through, I am really hoping that I will finally feel some sort of closure. It has been hard to live a double life, knowing that most people, including my parents really didn’t get it.

T: Like you never felt understood?

P: More that I was always alone with my internal thoughts and feelings. I don’t think they could fathom the amount of pain I was in every time I looked at myself and saw someone I wasn’t.

T: Must have felt pretty lonely.

P: You could say that. I still fear that everyone thinks I am pretty crazy. I mean who goes through all of this to change their gender identity?

T: How do you feel about it?

P: Well, I am sure betting on the hormones and surgery to make me who I really am. To be honest, I sometime have some doubts.

T: Say more about that.

P: Well, what if I am just a lonely, confused person who is counting on a gender identity transition to make me feel normal? Sometimes I wonder if I could pull off being kind of gender ambiguous. That way I could lean one way or the other based on who I am with but this would leave it up to them to project onto me who they want me to be.

T: How might that play out for you?

P: You know, I tried it. What ended up happening was that I gave all the power to others to define me. It was definitely a safer option, but in many ways made me more anxious about myself.

T: It sounds like it feels better to you to make a definite decision about your identity than to leave it up to those around you.

P: Yes. But I am still a little scared that I am being drastic. I can’t believe I am saying this given all I have been through.

T: Most things in this world are rarely so defined in a binary way. It seems like you are feeling like you must choose an identity even though most of us have some gender fluidity in our thoughts, feelings, and behavior.

P: Exactly. It feels like I need to do this, but in reality I am not some extreme version of a guy. I am still pretty sensitive to others and appreciate my relationships, and the aesthetic parts of life. Sometimes I fall into the trap of having to prove my maleness by being some extreme version of myself.

T: Yes. All men struggle with this. The gender role norms sometimes make us feel like we are supposed to be a certain way, even though most men only fit the stereotype superficially.

P: It is good to hear you say that. It is easy to fall into that trap. I know I have a long way to go to figure all of this out.

T: You seem like you are taking on the challenge with openness and bravery.

P: That may be the best I can do. I appreciate you hearing me out.

In this session, the therapist is able to listen without judgment to some of the ambivalence that this transgender male is experiencing. By being affirmative to Price’s complex emotional experience, the therapist allows for a talk about what it means to be male, something that often isn’t directly addressed. This opens the conversation to talk about gender roles as a wide ranging construct, not restricted to a binary gender identity. Price is given room to express some of his doubts and fears, even while being committed to a life journey as a man.

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 (Rabinowitz, 2012). 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 couple’s 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, the therapist 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 (Rabinowitz, 2012). 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, Brooks, Lusterman, & Nutt, 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 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 fear 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 of 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, yeah. 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 him 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: Yeah. 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 is 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 (Blasband & 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 his 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 (Rabinowitz, 2014a).

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, 2014).

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 girlfriend. 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 (Rabinowitz, 2014a).

Men's groups give hope and rebuild confidence in their 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, 2005). 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, 2005). 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, 2010).

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 (Rabinowitz, 2014a).

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 greater 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, 2005).

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.


A recent survey of 475 professionally licensed clinical therapists who work with male clients pointed to ten themes for clinical practice (Mahalik,Good,Tager,Levant, & Mackowiak, 2012):

  1. Be aware of how potential negative stereotypes and biases might impact how you approach a man who presents in therapy.
  2. Be aware of how male gender role socialization may impact how a male client expresses himself in the therapeutic situation.
  3. Be cognizant of potential bias in over diagnosing certain disorders like ADHD and under diagnosing disorders like depression and PTSD.
  4. Be careful to not shame men when raising the issue of what it means to be a man in our culture.
  5. Help men work with their emotions, assisting them in differentiating feeling states and normalizing the experience of acknowledging their existence.
  6. Address clients in a male-friendly manner, utilizing words and metaphors in line with a man’s socialization.
  7. Be mindful of potential emotional, physical, and sexual abuse in a man’s background and be willing to ask about it.
  8. Be open to discuss male sexuality in a positive and affirming way, making it easier for men to talk about this potentially difficult topic.
  9. Address other identities that intersect with masculinity such as race, culture, ethnicity, and sexual orientation.
  10. Be willing to discuss men’s intimate relationships with partners, family members, and family of origin in therapy.

Engaging with men in the therapeutic process 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.

Clinicians should be aware that for many men, underlying depression might be at the root of problems such as anger, irritability, relationship conflict, and addiction. It is important for clinicians to pay attention to their own countertransference issues and blind spots when working with men. A sampling of the potential countertransference issues in working with men can include a suspicious approach based on negative past experiences in relationships with men, as well as parental, competitive, and erotic forms of relationship distortion (Rabinowitz & Cochran, 2002).

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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