Except for my first experience in therapy, I spent years working with psychiatrists (back in the days when they did more than write prescriptions), depressed the whole time, perhaps getting a temporary lift, but quickly losing whatever short-term benefit the sessions may have provided. According to many therapists, as I explain below, this is a common experience for men. Usually the problem is traced back to the difficulty many men have in expressing feeling. They’re not comfortable with emotions (so goes the common idea about men, or at least, the social role men are raised to fill), 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, these articles ask, 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, as therapists like Wexler believe, 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.