Written evidence submitted by Martin Seager (IMH0001)

Authors

Martin Seager & John Barry

Introduction

Whilst there is a current tendency in the social sciences on the subject of sex and gender to privilege similarities over differences (e.g. Hyde, 2005), there is also significant evidence that sex/gender differences do play a role in mental health outcomes as in many other spheres of life (Tamres et al., 2002). However, such differences are not emphasised in the training of psychological practitioners and therapists, which means that the needs of male clients might not be met (Morison et al., 2014; Barry et al., 2021). Whilst respecting sex/gender differences, it is of course important to recognise that these constitute averages, and that individuals within any category vary on a spectrum. No individual therefore is defined by their sex or gender. All psychological interventions must above all tune in to the unique individual world of the client, without prejudging a person based on any identity category. The following is simply to provide more detail and information for psychological practitioners about the gendered aspects of men’s lives so as to enrich and improve their formulations and interventions. These guidelines are not therefore prescriptive, ‘one size fits all’ or based on simplistic generalisations or stereotypes about men and boys. Their purpose is to enrich and widen psychological practice with respect for sex and gender as one of many interacting variables.

PRINCIPLES AND BACKGROUND

1 There is to date little research into the differential impact of therapies on men and women. Most research tends to adopt a gender-neutral approach, aggregating data across gender; yet in those few studies that have explored this question and separated the data, some significant differences have been found.

2 Little research has been done into the relative preferences of men and women for the gender of their therapist, but such evidence as is available points to this being an important factor for some male clients (Liddon et al., 2019).

3 There have been relatively few attempts within mainstream services to design, deliver and research gender-specific interventions for men in comparison with traditional approaches. However, where male-friendly approaches have been tried, the evidence to date – both experimental and anecdotal – is highly promising (Kiselica & Englar-Carlson, 2010). Such approaches show that men can and do talk in their own ways and in the right context. ‘Men’s Sheds’ for example has proved to be one particularly effective male-friendly approach to improving male mental health (e.g. McGrath et al., 2022).

4 Most counselling and therapy approaches are designed around the traditional assumption that direct emotional exploration and verbal expression within a personal face to face therapeutic space are essential conditions for psychological change and improvement. This general assumption within the culture of ‘talking therapies’ is, arguably, more suited to how women in general deal with their problems than how men in general do (Morison et al., 2014).

5 Most counselling and therapy approaches can also be described as ‘medicalised’ or ‘pathologised’ in the sense of offering psychological equivalents to medical ‘treatments’ that cast the client / patient in a more passive ‘sick role’ as the recipient of expert intervention rather than as an active agent or participant of change. In view of male archetypes relating to control and agency, such an approach may explain some of the differential responses of men and women to the very idea of therapy.

6 Men seek therapeutic help significantly less often than women do (Addis & Mahalik, 2003), but this has been attributed primarily to characteristics or deficits in men (e.g. stubbornness, stoicism) themselves rather than to characteristics or limitations of the therapy models and services.

7 The following guidelines therefore are based on the following scientific principles and humanitarian values:

a Talking therapy should not be the only option, although men can and do talk in the right setting. Action-oriented and community approaches should also be considered, including due consideration of culturally appropriate settings.

b Being gender responsive is a key factor that should be taken into consideration in formulating and selecting approaches to respond to the problems and needs of men and boys.

c Group and community approaches where men can identify with others like themselves may encourage rather than deter help-seeking.

d Problem-solving and action-oriented approaches will have, on average, greater appeal for men.

e Coaching and mentoring approaches show promise as male-friendly interventions.

f The relative absence of male therapists as mentors and role models for men and boys within the culture of psychology and professional care generally is an important consideration in improving the uptake and outcomes of therapy for men and boys. This of course does not detract from the general observation that is the quality of therapeutic relationships rather than gender alone that contributes most to good outcomes.

g Therapy for men and boys, as for any demographic, should be based on empathy and respect for the identity of the client within the human spectrum. Therapy models that take a positive and empathic view of masculinity are likely to be more attractive and more effective for male clients than therapy models that take the critical stance that masculinity itself requires reform and change. Of course, ‘masculinity’ in this context should not be defined narrowly or rigidly, and the client’s own experience must be paramount, as with all therapy.

h The male preference for ‘shoulder to shoulder’ rather than ‘face to face’ communication can be more greatly utilised in encouraging more genuine therapeutic connections with men and boys. BRIEFING PAPER Psychological interventions to help male adults.

ASSESSMENT AND FORMULATION

Psychological practitioners should be aware that:

1 There are gender differences in the presentation of mental health problems. Taking depression, perhaps the most common diagnosis, as the primary example, there is strong evidence that men are more likely than women to express depressed mood indirectly through ‘acting out’ (e.g. aggression, risk-taking, alcohol or substance abuse) than through direct verbal means (Whitley, 2021). Using traditional clinical measures, men appear to have lower rates of depression, but this could be because they do not self-report their feelings in the same way. The lower reported rate of depression in men seems inconsistent with the fact that men in almost all countries take their own lives at much higher rates than women do. However, using male depression scales (e.g., the Gotland Scale; Strömberg et al., 2010) a significantly higher rate of depression has been identified amongst male samples. The same applies to ‘post-natal depression’ which can often be missed for these same reasons, but also because of the gender specific assumption that only women have an emotional reaction to the life-change brought about by the birth of a baby. Psychological practitioners must be careful then to take account of gender differences in the presentation of mental health problems so that more male-specific symptoms of depression and other mental health problems do not get missed or overlooked during assessment.

2 Suicide risk is on average significantly higher in men. This means that psychological practitioners when assessing and formulating, need to be mindful of the potential and archetypal gender specific issues underlying these differences which may include: (a) relationship break-up (b) family breakdown and loss of access to children (c) loss of employment or the financial capacity to provide for/protect the family (d) shame about failures and loss of capacity to control events or provide for loved ones. In assessing suicide risk in men, it is important for psychological practitioners to look beyond the talk and verbal expression of the male client where shame might prevent a full disclosure of the extent of despair.

3 Traditional clinical psychological and counselling referral / assessment protocols may be said to be more suited on average to female than male styles of communication (Morison et al., 2014) and might not work as well for men in the longer term (Wright & Macleod, 2016). Some research suggests that in coping with distress, although women on average want to talk about their feelings, men on average would prefer to ‘fix the problem’ (Holloway et al., 2018). Men may prefer an active problem-focused approach where they are given specific information about strategies to improve mental health (Sagar-Ouriaghli et al., 2019). Men are more likely to be on the autistic spectrum and more likely to have attention deficit issues, both of which will impact communication (Chheda-Varma, 2019; van Wijngaarden-Cremers, 2019) This means that psychologists and psychological practitioners must be prepared to step outside the box in finding ways of attracting men into settings and approaches that might be good for their mental health. If talking therapies are ‘not the only fruit’, then traditional clinical interviews are not the only way of assessing mental health needs. Practitioner psychologists can help lead the way in using community approaches rather than traditional clinical settings to reach out to men who may be vulnerable, rather than waiting for them to seek help. This could involve connecting with men in places where they might feel less exposed, safer, more at home and more willing to talk.

Examples of such community settings where less formal assessments and gateways to help can be achieved are: Men’s Sheds, barbers/hairdressers, sports clubs, men’s support groups, fathers’ support groups, employment support groups, male-friendly helplines. There is some evidence that although most clients prefer one-to-one therapy, men like working in groups more than women do (Kiselica & Englar-Carlson, 2010; Liddon et al., 2019) and that male-only groups might work better for men than mixed-sex groups (Seager & Thümmel, 2009). These community approaches will often take an action-orientated approach, where men will engage in sports (Abotsie et al., 2020) or work together on a project (Morgan et al., 2007).

4 Evidence-based approaches should be used where possible. Where this is not possible, approaches that are unlikely to cause harm to the patient should be used. Ideological approaches should be avoided. The controversy surrounding the ‘patriarchy theory’ of men’s mental health, and questionable constructions of masculinity which include negative traits (Mahalik et al., 2003), indicate that it is not popular with the general public, who are of course the potential clients of psychologists. For example, as well as criticism from psychologists (e.g. Whitley, 2019; Ferguson, 2023), the American Psychological Association’s guidelines (APA, 2018) on therapy for boys and men were met with public distrust and headlines such as ‘Traditional masculinity can hurt boys, says new APA Guidelines’ in the New York Times (Fortin, 2019). Some research suggests that people tend not to like to have their problems blamed on their masculinity or femininity and are concerned about the impact of this negative narrative on boys (Barry et al., 2020). Another recent example was the public reaction to Gillette’s ‘We believe’ advert in 2019, which presented masculinity as violent and sexist, and lost Gillette $8 billion dollars (Ernst, 2019). The dangers of adopting such views in the BPS is that they might damage the therapeutic alliance, or even discourage men from ever seeking therapy. Interventions based on negative concepts of men and masculinity are also unlikely to be very effective (Babcock et al., 2004). This might be because they identify the cause of men’s problematic behaviour as due to masculinity or patriarchy, whereas some forensic psychologists suggest that issues such as male violence are often related to unresolved traumatic experiences (Murphy, 2018), a viewpoint that is widely recognised in cases of post-traumatic stress disorder (PTSD) due to military combat (KCMHR, 2018). Perhaps in reaction to the response to their controversial guidelines, the APA’S Division 51, The Society for the Psychological Study of Men and Masculinities, who were the main authors of the guidelines, have changed their mission statement so that it is now much less negative about masculinity (Barry, 2022). We hope this is the start of a more widespread move towards a more pragmatic approach to therapy with men.

5 Terminology that puts masculinity in a negative light, such as toxic masculinity, hegemonic masculinity, should be discouraged. Even if these terms are intended to describe specific behaviours, they almost inevitably imply that all men are dysfunctional in some way. The term ‘masculinities’ can also be problematic because it implies that masculinity is socially fluid without any core biological contribution. It is more helpful to understand masculinity as the result of interactions between social, biological, and evolutionary forces (Barry & Owens, 2019). Traits associated with masculinity tend to be observable globally and cross-culturally (Ellis, 2011). Masculinity is thus unlikely to be readily amenable to change, any more than sexuality is readily amenable to change. However, psychological interventions are by definition all about change. Whilst psychological interventions cannot change masculinity itself, they can help shape the expression of masculinity in terms of both positive and negative behaviours. There are many diverse ways of expressing masculinity, as with any other identity.

6 In considering a therapeutic approach, negative views of masculinity should be weighed against evidence showing that masculinity is associated with men’s mental health and wellbeing. This has been found in relation to self-esteem (Burkley et al., 2016), a positive mindset (Barry et al., 2020) and being protective against suicidality (Mansdotter et al., 2009). Masculinity can also help men to cope with depression (Krumm et al., 2017).

Clinical observations suggest that therapies with men can benefit from taking a male-friendly approach. This is not a specific type of therapy, nor a one-size-fits-all solution, but an approach based on men’s communication style in relation to help-seeking and coping with stress, which can potentially make a given therapy more acceptable to male clients. A list summarising these approaches and techniques can be seen in Figure 11.3 in Liddon and Barry (2021) and Figure 32.1 in Liddon et al. (2019), which recognise the importance of individual differences, such as age, race, and sexual orientation, to the approach to therapy. These figures do not give an exhaustive list of approaches and techniques, and emerging evidence – that needs further research – suggests psychoeducational approaches (Liddon et al., 2019), expressive writing (Wright, 2020), and internet-based approaches might suit some men especially if they cannot attend therapy during working hours.

CONCLUSION

The area of men’s mental health is a new and developing field, and we advise therapists to look out for updates to this document, as the pool of research continues to grow. Developments might emerge in a range of relevant areas – the prison system, the military, social services - helping to inform us of how to best meet the needs of men from different backgrounds, or of different personality types, with different presenting problems. Indeed, female clients, some of whom may have male-typical preferences for therapy, might well benefit too from advances in therapy for men. Our intention is that this document will encourage the development of theory and practice which will make therapy with men optimally safe and effective.

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