Therapists and Depressed Men

I spent years in therapy, depressed the whole time, perhaps getting a temporary lift, but quickly losing whatever short-term benefit it may have provided. Apparently, this is a common experience for men, and usually the problem is traced back to the difficulty many men have in expressing feeling. They’re not comfortable with emotions, resist therapy and won’t let it work, even if they give it a try.

For the most part, I’ve accepted that explanation. Even though I had many doubts about the different types of therapy I had tried, I well knew that I had never really let the therapists see everything going on in my emotional life. I had rarely found therapists (luckily there were a couple of wonderful exceptions) who were willing to discuss, let alone rethink, their own approaches in any depth. The guiding assumption: We know this form of therapy works. It’s all up to you.

It was startling, then, to read an entire issue of a professional magazine devoted to the question: Why aren’t therapists more effective with men? The editors start with a couple of facts. Only a third of all psychotherapy clients are men, and that can’t mean they have fewer emotional problems than women do. They also regress after treatment much more often than women. So what’s wrong with what we in the psychotherapy community are doing?

I’d never heard therapists evaluating their own methods and suggesting that the reactions of men, though obviously not good for them, weren’t all that surprising. Yet that’s what these articles are all about. They find that many in the profession don’t really know how to respond and adapt to the needs and styles of men.

Writing in the latest issue of Psychotherapy Networker, four therapists describe the psychological dynamics that guide many men and offer examples of the techniques they’ve used to create more responsive and effective therapeutic experiences. The articles don’t talk specifically about depression, but many of the ideas are particularly relevant to depressed men. While all these articles are full of interesting insights, I found one especially helpful.

David Wexler, in Shame-O-Phobia: Why Men Fear Therapy, focuses on two critical dimensions in the lives of many men.

First is the effect of shaming experiences men often have in childhood at the hands of parents and others whose support and respect they most need:

A shamed boy becomes a hypersensitive man, his radar always finely tuned to the possibility of humiliation. His reaction to slights—perceived or real—and his ever-vigilant attempts to ward them off can become a kind of phobia. Tragically, the very men who are most desperate for affection and approval are the ones who usually can’t ask for it: instead, they project blame and rejection and perceive the worst in others.

The second dimension is what he calls the “broken mirror.” By that he means the need of people with inner shame to gain approval from others in order to feel good about themselves. Those reactions – imagined or real – assume tremendous psychological importance. Getting approval is a desperate need, losing it a devastating experience.

Shame-driven fear and the impact of mirroring make therapy difficult because it asks such men to do something they already know they don’t do well. Since it’s geared toward disclosing emotion, therapy can seem designed to meet the needs of women who are often more comfortable expressing and talking through feelings. The environment doesn’t feel safe to a great many men.

Wexler believes that emphasizing the need for emotional openness from the start of therapy only plays into the fear of failure. To make therapy more welcoming to men who are skeptical and nervous about it, he recommends to other therapists several methods that have worked in his practice.

Here are of some drastically edited summaries of these techniques.

Destigmatize Self-Disclosure: Therapeutic self-disclosure can be an effective way to reduce avoidance and defensiveness by nipping shame in the bud. … I often tell men stories about times I’ve yelled at my kids, said nasty things, and stupidly overreacted to them. I tell men about the many times I’ve stubbornly insisted that my wife and I do something my way without really thinking through how this would affect her. … I reassure them that self-revealing will not lose them my esteem or confirm their worst fears of what will happen if they let down their guard. This is destigmatizing.

Permission to Disclose Gradually: In the beginning of therapy, it’s … important to give men permission to disclose gradually. It’s easy for therapists to get impatient when men take a while to warm up to the counseling experience. Often I’ll treat a man who initially minimizes the mistakes he’s made, blaming everyone else—his wife, his kids, his girlfriend. I don’t mess with this at first, because I know he needs to do this until he feels safer and more confident that he’ll get a fair shake in my office.

Provide Specific Plans: Since many men feel anxious about what they perceive as the vagueness of the whole therapy process, give them as much concrete information as possible. Tell them exactly how long the sessions are, what the length of therapy might be, the role you can and can’t play, and what’s expected of them to get therapy right. Offer homework, action plans, and the rationale for using them, since men’s needs and learning styles favor direct, clearcut explanations and instructions. I’ve found this valuable with almost all the men I see.

Clear, Brief Assignments with Time Limits: Recently, one of my male clients told me that his son had complained that he was making that “angry face” again—and my client had no awareness of it. The instant homework assignment: “Ask everyone in your family to let you know every time they notice your angry face or angry voice, and tell them that this is a direct assignment from your therapist.” He understood the rationale: you need feedback to improve performance. And he liked the clarity of the task.

Another problem comes up when men are urged to begin discussing their feelings and relationship issues with their partners. Many men delay this because they’re afraid it will turn into unbearable marathon sessions. So Wexler suggests setting a limit. “When you talk about this issue at home, set an alarm for 10 minutes. Discussion ends then, no matter what.”

Recognize Heroism: I tell men that, every day, they have an opportunity to give to their loved ones, including their kids, a man who’s generous, empathic, and honorable. A man can choose to inform his partner about what he’s feeling, rather than just withdrawing or acting out. I call this, or any of a thousand other “unnatural” pro-relationship behaviors, an act of genuine heroism. To choose a path that’s hard, unfamiliar, awkward, and even frightening—but which is more in keeping with what really matters to them—takes the kind of courage and resolve that characterizes, well, real men. … Men perk up when I implore them to act like heroes or reward them for doing so—rather than simply telling them to be more sensitive or more accommodating.

The goals of therapy remain the same, but these adaptations can make the experience much more approachable for many men. I’m not so sure, though, that they would have worked for me when I was trying hard, often quite unconsciously, to defend against revealing my deepest feelings. It was so unthinkable to let myself go that often I wasn’t even aware of what I was doing. Looking back, I realize I intuitively resorted to strategies designed both to seal off spontaneous emotion and to win the approval of the therapist. In my case, Wexler gets it right. Shame-driven fear and broken mirrors guided me all the way.

Adapting therapy, as Wexler suggests, to help resistant men open up is certainly a good idea. But a therapist can only do so much. A lot of depressed men like me can outmaneuver any number of sound methods. Getting lasting benefit from therapy is still up to me.

Some Rights Reserved by Travis Hightower at Flickr

9 Responses to “Therapists and Depressed Men”

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  1. Jenny Ledd says:

    Although men are less likely to suffer from depression than women, 6 million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men’s suicide rises, reaching a peak after age 85.
    Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.

    Men’s depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

  2. Will C. says:

    As far as therapy “not taking” and men reverting to past behavior after counseling, my experience has been that the supportive environment of therapy can be too far removed from the “real world.” Had I support mechanisms available to me which could reinforce what I learn in counseling, I mightn’t needed that counseling to begin with. Generally speaking, my depression revolves around the absence of such support; my greatest difficulty with counseling stems from paying a relative stranger to provide a necessary daily social ingredient which I can’t seem to find elsewhere. Until I solve this, counseling has little further utility save as a crutch to prop up my depression when it becomes overwhelming.

  3. Anon says:

    After reading this, I feel like a man trapped in a woman’s body! This sounds an awful lot like me, but I’m not a guy.

    • john says:

      Hi –

      Join the crowd! Anytime someone writes about the differences between men and women in handling emotion, they’re using stereotypes. I think more and more people don’t match the “expected” behavior.

      Thanks for commenting.

      John

  4. Evan says:

    Hi John, I haven’t written about men’s issues directly.

    This is probably because I feel pretty much an alien in the stereotypically male world – I don’t have any interest in sport, I don’t identify myself with my work (I haven’t seen the consequences of this in my own father and others – and they aren’t nice), and I grew up in Evangelical Christianity (in Australia, where I’m from this is a somewhat feminised milieu in terms of style – Australia was more like England than the US in this way, at the time).

    Also blogs are pretty verbal, and I’m a very verbal person. The blogosphere from my feeling (and there is some fragmentary research about this I understand) tends to be biased towards women and the tertiary educated. So I tend to stick to the verbal. So I don’t write much about the alternatives. I try to make my posts immediately useful and this also means I pretty much stick to verbal stuff. When I have run retreats I’ve used other modes than the verbal.

    It would be interesting to see if we could think up a kind of therapy sport – or construct it as a martial art: you are willing to face an opponent – are you willing to face yourself?, kind of thing.

    I don’t want to sound just negative (though I’m pretty impatient with the therapy culture), I think all the adaptations proposed are good and should be helpful to many people.

  5. WG says:

    What a great article and an important subject. I can see how it would be so much harder for a man to ask for this kind of help and to accept it.
    I think another issue (according to my reading but it could easily be a stereotype) is that men tend to act-out emotional issues whereas women internalise things. Therefore men are more likely to end up in the legal system than the therapy room.
    I’m glad there are people writing about this and raising awareness.

    • john says:

      Hi – and thanks for the kind words. There’s always the danger of stereotyping, but there are certainly a lot of men who get angry and aggressive in response to inner pain they don’t want to acknowledge. But there are at least as many, I think, who beat themselves up with that anger – drinking, isolating themselves, undercutting their own success at work, hating the sight of themselves in a mirror. But you’re right, men do end up more commonly in the legal system, especially for physical abuse. Either directed outward or inward, the anger and acting out are incredibly destructive.

      By the way, I like the idea for your crazymaking site. I’ll check out those links.

      John

  6. Evan says:

    Therapy being largely voluntary it will often work with those who need it least (those who realise they have a problem and want to do something about it).

    Therapy does use methods that are regarded as feminine in our culture (talking about emotion – expressing it fully is a bit of a different story. Therapy culture often has problems with anger – being a ‘negative’ emotion and so on).

    It sounds like the agenda of the articles is to do things to men more effectively. I find this a bit of a worry.

    I don’t subscribe to ‘thou shalt disclose’ – I think it makes it more likely that people will refuse. It is possible instead to get people to pay attention to how they keep secrets (and why should I tell my secrets to a stranger exactly? Because they say I should?) and what they choose to reveal and what not.

    Do any of the therapists contemplate not using talking about feelings? A TA therapist I knew was working with prison warders. They were happy to talk about different coloured stamps (ie feelings) rather than naming feelings directly. I think this could be a useful first step. It would be possible, as a thought experiment, to imagine therapy as tasks that are done without much talking – what would this be like? Would it be easier for men to do therapy this way? I’d like to see the way therapy is done being seriously challenged.

    Thanks for a very interesting and stimulating post.

    • john says:

      Hi, Evan –

      I can see your first point – that men full of denial are the ones who need therapy the most. But the ones who admit they have a problem and seek help don’t necessarily need it any less. Therapy won’t work at all unless someone believes it can and really commits to the process.

      The therapists in this group all try to get men comfortable with talking about feelings, but they have interesting ways of using different frames of reference and words – verbal symbols – to evoke safe associations. It’s also interesting to think about the approaches you mention. They’re more common, I think, with children and people who can no longer communicate coherently because going through psychotic illnesses. Art therapy, dance and music therapies and psychodrama are ways of trying to get around verbal inhibitions – but wouldn’t go over all that well with the types of men these articles are talking about. The postage stamp idea is great – sports can also be an effective medium in terms of finding the right symbolic talk to reach the emotions.

      These alternatives would be a great subject to write about. Have you done that yet?

      John

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