This article originally appeared in TONIC.
Once you start to look at the intersection of men, masculinity, and mental health, it’s hard to avoid the sense you’ve stumbled on the source of so many of our national nightmares. Mass shootings. Sexual assault and harassment. Domestic violence. The behavior of Donald Trump. People who don’t know much about this intersection don’t always grasp its profound implications on our most serious social problems, says Ronald Levant, a former head of the American Psychological Association and professor at the University of Akron, who has spent decades researching men and mental health. But there’s another thing you notice when you look closely at men and mental health, which is that, while so much of the world is designed for the comfort and benefit of men, the world of psychotherapy is not. “Basically psychotherapy was originally created by men to treat women,” Levant says. And more than a century later, it still feels like it’s playing catch-up.
And, today, while the APA has issued guidelines for the treatment of a variety of specific populations—“ethnic," linguistic, and culturally diverse populations; girls and women; lesbian, gay, and bisexual clients; older adults; and transgender and gender nonconforming people—there are still no guidelines for the treatment of men and boys. (These guidelines are in the works, and Levant expects their release in the next two years.) One 2006 study of APA-accredited counseling training programs found that only one in four included men’s gender issues as a part of its curriculum.
It’s at the juncture of these two things—the dire need for men’s mental health care, and the fact that male-focused psychology feels a bit like an underdog in the academic world—where you find things like the recent article in the journal Australian Psychologist called “Men In and Out of Treatment for Depression: Strategies for Improved Engagement.” “We’re getting more and more men into therapy, but lots of them are not sticking with it," says Zac Seidler, psychologist, PhD candidate at the University of Sydney, and lead author of the study.
The research polled 20 men who have received treatment for depression and asked them about experiences in therapy. Most troublingly, he says, despite a recent push throughout the Western world for men to get treatment, male suicide rates haven’t dropped significantly. “So I wanted to know, what is going on with these guys in treatment?” he says. “What’s happening with them? What do they like? What do they not like? And how can we make it better?”
The answers range from an expressed desire for clinicians to focus on collaboration with male clients, to offering “specific and achievable goals” for treatment and straightforward descriptions of the therapy process and how it works. One anonymous participant used memorable language to express how transparency from his therapist would ease his distrust of the process. “If you just tell me...like ‘dude, you’re a bit messed up you need about ten sessions, around $100 each, that’s 1,000 bucks,’ I’d be like, ‘cool bro.’ I’d budget for that,” he told researchers. (“You can’t imagine how good it felt to publish that [quote] in a scientific journal,” Seidler says.)
The study is part of a broader trend that indicates that, while many spheres in society are pushing for equal treatment of the sexes, therapy rooms are actually becoming more attuned to their differences. Seidler says that within the overall field of medicine it’s become the norm for practitioners to tailor their care to individual patients, but psychotherapy has taken a bit more time.
The statistics about men’s mental health are alarming. Men complete suicide at more than three times the rate of women. And, as the National Institute of Mental Health reports, “Men are more likely than women to use almost all types of illicit drugs...and illicit drug use is more likely to result in emergency department visits or overdose deaths for men than for women.” Beyond these facts, we also know that men’s mental health literacy lags behind women's, that they report higher levels of mental health stigma, that they seek mental health help less frequently, and that once they do, they tend to have a harder time expressing their emotions. (Romantic partners of men might be interested to learn that there’s actually a technical term for the frequency with which men struggle to articulate their feelings: “normative male alexithymia.”)
So how do you fix a problem that’s this big and multifaceted? According to Wizdom Powell, a clinical psychologist and director of the University of Connecticut’s Health Disparities Institute, everyone has a role to play. “I often talk about how complicit we all are in maintaining these more harmful, toxic norms,” she says. “So I would say the first thing we can do is to try to create a culture to disrupt the narrative around silent suffering and the expectations for men to be strong, stoic, and silent.”
Some of this work has taken place on a marketing and public awareness level, like the National Institute of Mental Health-backed “Real Men, Real Depression” campaign from the early- and mid-2000s. And within the field of psychology, there’s been talk about the idea that men might be more amenable to entering treatment if it were called “coaching,” “consulting,” or “training,” instead of “therapy.”
That’s an idea that appears in a 2012 Journal of Counseling Psychology article that collected and distilled best practices for treating men from 475 mental health professionals. The results encouraged therapists to avoid expressing negative stereotypes about men—the idea that men are inherently aggressive or abusive, for instance—during therapy. Findings also encouraged adaptive, flexible gender identities for clients and for therapists to acknowledge some men's needs to discuss emotions gradually, while also avoiding the assumption that all men are emotionally illiterate. One section notes that “the use of sports or car analogies was frequently mentioned as helpful when working with male clients.” (Maybe there’s some value in stereotypes, after all?)
The following year, Aaron Rochlen, a University of Texas professor of psychology, co-edited a book called Breaking Barriers in Counseling Men: Insights and Innovations. He emphasizes that, while he resists making sweeping claims about all men, he does acknowledge that the classic image of therapy (sitting on a couch with the Kleenex next to it, in a room with turquoise walls) may not be the most welcoming place for traditionally-minded men.
Old-school guys may “go running for the doors if you ask them about their feelings and their mothers in the first five minutes,” he says. As a result, he’s tweaked his practice to include sometimes walking and talking side by side with a client, as opposed to the traditional sitting face to face. He also gives men positive reinforcement when they make significant emotional disclosures and works with men to help them negotiate changing gender roles. For instance, Rochlen says it’s imperative in today’s world that men re-think what it means to be a “provider.” Guys who may question the manliness of buying groceries or helping out around the house need to realize that this isn’t necessarily ‘women’s work,’ and that “providing and necessities are not linked to dollar bills any more,” he says.
Toward the end of the Australian Psychologist paper, Seidler and his co-authors note that “in the present study, those men with the most positive therapeutic experiences were those with both a transparent, collaborative clinician, and an openness to flexibility in their masculinity. For these men, questioning long-held masculine ideals and practices was integral to their recovery from depression.” In other words: For men, the act of simply becoming more aware of how they engage with societal expectations of masculinity might be a step toward improved mental health.
With that in mind, one of the useful things I can do as a journalist—beyond publicly stating that I’m a man who goes to therapy, and it’s been wonderfully helpful—is to call your attention to a paper Ronald Levant and other researchers published in 1992, in which the authors boiled down traditional masculinity to seven basic norms: avoidance of femininity, homophobia, self-reliance, aggression, achievement/status, attitudes toward sex, and restrictive emotionality.
If you’re a man, perhaps it’s time think about how you relate to these ideas. And if you’re a woman, feel free to tell a dude about Levant’s Male Role Norms Inventory online quiz. Seidler says that, in the world of psychotherapy, he wants to help bring an end to the days of masculinity acting as a silent, unspoken factor in the treatment process. After all, he notes masculinity is closely tied in with identity, and depression can be a disorder of a person’s identity.
A guy’s mental health and his conception of manhood are often closely linked. Levant says that while millennial men seem to be more comfortable straying from rigid gender norms, for most men, particularly those over 35, “pretty much everything you learned about being a man when you were a kid is wrong.” The world has changed, he says, and men need to re-learn ways of being in the world that are more flexible and emotionally generous. Men need to stop being afraid of their feelings, he says—and being scared of therapy, too. “If you’re suffering, then you owe it to yourself to get help,” he says. “And there’s substantial research that shows that psychotherapy indeed does help, and in many cases is better than psychiatric drugs.”
As society pushes forward in its awareness of the unique mental health needs of men and boys, it’s also important to remember that this isn’t just about the guys. “Part of why I do this work is because I believe that our fates are linked,” Powell says. When men suffer from mental health problems in silence and fall victim to substance abuse or suicide, it’s often women and girls who are left to pick up the pieces and take on caregiving burdens, she says. “So this is really about creating healthier families and communities and creating better mental health for everybody.”