Crossing the No Cry Zone: Psychotherapy With Men by Fredric E. Rabinowitz, Ph.D. 4 Credit hours - $59 Last revised: 06/03/2008 Course content © copyright 2006-2008 by Fredric E. Rabinowitz, Ph.D.. All rights reserved. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

Learning Objectives

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

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

Introduction

Male clients present a unique challenge to the psychotherapist. Men are socialized to fear core components of the therapeutic process: the language of feelings, the disclosure of vulnerability, and the admission of dependency needs. Male clients’ discomfort with the developing intimacy of a therapy relationship can manifest as early termination, anger at the therapist, unproductive intellectualizing, and other forms of resistance. Yet, cutting edge theory and research, emanating from what has been termed, “The New Psychology of Men,” 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. Depression and Suicide
2. Other Problems:
1. Relational problems
2. Male survivors of abuse
3. Male survivors of trauma
4. Violence and antisocial behavior
5. Addiction
6. Sexual orientation
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 the “new psychology of men” conceptualizations and research that account for internal emotional dynamics as well as cultural gender role socialization (Levant & Pollack, 1995).

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

A psychodynamic formulation of early male development

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

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

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

While Chodorow's analysis acknowledges the complex interplay between cultural values, attachment, and gender identity in early life, Pollack (1995) postulates that perhaps little boys are pushed from connection to their mothers at an early age in conformity with our cultural values related to masculine independence. It is possible that little boys experience this push from the maternal orbit as a deep loss. Such an abrupt, often premature, separation experience is viewed as a “traumatic abrogation of the early holding environment, an impingement in [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, 2001). To the extent that such developmental trauma is “normative” for boys, they are as a group more likely to have character structures distinguished by a firming of self-other boundaries, conflicts around dependency and relatedness, and an overvaluing of autonomy in service of preserving these structures (Rabinowitz & Cochran, 2002).

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

The impact of socialization on boys and men

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

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

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

In response to the civil rights, women’s, and 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, Good, & Holmes, 1995) verified the existence of four discreet elements of male gender role strain: conflicts between work and family relations; restrictive emotionality; restrictive sexual and affectionate behavior between men; and success, power, and competition issues. Continued research has shown that the endorsement of items that reflect a high degree of gender role strain are correlated to higher levels of psychological distress (Good et al., 1995), depression (Good & Mintz, 1990; Good & Wood, 1995), and avoidance of mental and physical health care venues (Good, Dell, & Mintz, 1989).

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

Diversity Among Men

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

Although many men try to maintain a colorblind perspective, America is still racially divided. It is difficult for white men to comprehend the subtle harassment that men of color experience on a daily basis. Questionable stares, increased scrutiny, and automatic suspicion by peers, strangers, and police are regular occurrences for these men who work and live in the mainstream culture (Majors, 1994). Not only are they subject to the stresses of traditional masculinity, they must also cope with the overlay of subtle and not so subtle racism. A layer of anger related to this cultural predicament 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, 2001).

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

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. 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.

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. 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 language. 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. 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.

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

Assessing men’s conflict zones in therapy

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

Ambivalence about relational dependence in boys and men

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

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

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

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

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

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

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.

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 (Rabinowitz & Cochran, 1994).

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

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

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.

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.

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 IV 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, 2000).

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, 2000).

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, 2000).

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, 2000). 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 double the depression rate of men (Nolen-Hoeksema, 1990). While early data was derived from studying admission rates to psychiatric hospitals, more recent 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).

Perhaps men are masking the symptoms of their depression by self-medicating with alcohol and mood altering substances (Cochran & Rabinowitz, 2000; Pollack, 1998). 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, and 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, and Leltzer, 1998; Girling, Barkley, Paykel, Gehlhaar, Brayne, Gill, Mathewson, and 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 (Rabinowitz & Cochran, 1994).

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, 2000). 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, 2000).

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, 2001; 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).

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, in press.)

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-IV 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.

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

Masculine-Sensitive Assessment of Depression

A. Review of DSM-IV 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

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. 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 Prozac, Paxil, Celexa, and Lexapro, for example, have made this class of antidepressants the most prescribed medication in history (LeDoux, 2002).

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) 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, 2001).

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, in press). 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, 2001). This can be seen in the following exchange between Carlos and his counselor:

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, in press)

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, in press).

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. 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.