Why men fear therapy
Several years ago, I was on a family trip, sitting on a bench with my wife in a plaza in Paris. Loaded down with shopping bags, she asked me to grab her purse and carry it over to a new spot across the plaza. That's all. Yet even though I knew I was being stupid, I couldn't do it. The 15 seconds being seen carrying a purse were beyond my capacities as a card-carrying male. My wife looked at me like I was nuts and shook her head in disgust.
So what was my problem? All I could envision were people smirking as they saw me publicly toting that damn purse, all of my hard-earned Guy Points accumulated from my half-century of being male suddenly vanishing without a trace.
Shame may be the least understood dimension of men's inner experience--by both men themselves and the people who live with them. In Affliction, Russell Banks's classic novel about the tragedy of masculinity, a ne'er-do-well named Wade Whitehouse plans a special Halloween weekend with his 11-year-old daughter, Jill, who lives with her divorced mother, Lillian. Wade's clumsy efforts to make sure Jill has a good time succeed only in making her feel anxious and out of place, and she winds up pleading with him to take her home. But instead of her distress, what stands out for him is his sense of failure: he's shamed by the fact that she's unhappy.
Eventually, still searching for a way out of the pain, Wade gets into an ugly brawl with his ex-wife and her new husband, after Jill secretly calls them to pick her up. As irrationality, belligerence, and self-destructiveness take over, Wade becomes a good man behaving badly, blinded by the specter of his own shameful failure.
Men who've experienced toxic doses of shame early in life will do anything to avoid reexperiencing it as they grow older. It can originate from family experiences, from peer experiences, or just from the culture at large. 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. Sometimes the smallest signs of withdrawal of affection will trigger old wounds, and they'll suddenly lash out at those they see as slighting them, even as they're unaware of the dark feelings stirring inside them. This is a state of mind that many of us in the field call shame-o-phobia, an endemic condition throughout Guy World.
With their profound fear of appearing weak or--god forbid!--feminine, most men will do whatever it takes to prove their manhood. In one recent study, men were assigned to three different groups and given the task of keeping their hand in painfully icy water for as long as they could. Those who were told that the ability to withstand the discomfort was a measure of male sex hormones and an index of physical fitness showed greater cardiovascular reactivity, reported feeling more performance expectations, and kept their hand in the water the longest. This was in contrast to the group who were told the test was a measure of high levels of female sex hormones and the ability to bond with children, and with the third group, who received no explanation at all.
What does this tell us? The length of time a guy will tough it out with his hand submerged in freezing water depends on whether he thinks his masculinity is in question. For some men, their hand could fall off before they'd risk the shame of not seeming "man enough" to take it.
Women feel shame, too, of course, and much of the emotional experiences for men and women are more similar than not. But there are still some fundamental differences in how men are both hardwired and acculturated that can't be ignored in the therapist's office. Even as infants, boys are more overstimulated by direct eye contact and show less ability to regulate arousal through intimate connection. These infant boys then grow up in a Guy World culture that emphasizes successful performance and deemphasizes reliance on others as a way to self-realize. Furthermore, evolutionary psychology teaches us that men are wired for procuring and performing (while females are wired for tending and befriending)--a trait that may provide a biological backdrop to the modern male focus on success. Without that, he ain't much--or so he feels.
To ignore the powerful effect of shame-o-phobia is to risk not really "getting" men, even if you happen to be a man yourself. An otherwise benign or mildly embarrassing event--like carrying the purse across the plaza, or a daughter who isn't having a good time at a Halloween party--can overactivate a man's fear that he's failing at some central task of being a real man.
The Broken Mirror
A metaphor from self-psychology, the broken mirror, is particularly helpful in understanding the dynamics of male shame. This sensitivity to shame--to feeling incompetent, not valuable, unloved, unneeded, unimportant--is often governed by the psychological relationships with mirroring-self objects in our lives. It works like this: the response from others serves as a mirror, reflecting an image that governs our sense of well-being. Sensitivity to mirroring-self objects and broken mirrors isn't gender-specific, but men are more vulnerable to experiencing these mirrors as referenda on their performance and personal value. When the mirror image is negative (or is perceived as negative), the reflection can reactivate a man's narcissistic injury and deliver a blow to his feeling of competence. There's no more potent a mirror for a man than the one reflected by his intimate partner. If she (or he, in a gay relationship) is unhappy, he's failed. If she offers even a normal, nonabusive criticism, it's as if she's yelling at him: "You've failed at making me happy." And the shame-o-phobic man, vulnerable to broken mirrors and narcissistic injuries, will hear that message whether it's unintended or not.
A few years ago, I was interviewed on a radio show about the psychological concept of the broken mirror. Afterward, the (male) interviewer said to me off-air: "Damn! Now I get what happened to me yesterday! I came out of the bathroom after shaving and I'd nicked myself a little on the cheek. My girlfriend looked up at me and said ÔWhat happened to you? That's the second time you've done that this week?' And I just went off. I started yelling at her, and then I stormed off, and our plans for the day were ruined. And it was all because I had a manhood attack. I know she didn't mean anything like that, but that's what I heard. What the hell's wrong with me?"
This man experienced his girlfriend's comments as a stab at his masculinity. It was as if she'd said, "What kind of loser are you that you can't even shave properly? Any man should be able to pull that off!" To a guy whose self-esteem--particularly his masculine self-image--feels vulnerable (this includes most men), this simple interchange, silly as it sounds, can feel like as an unbearable assault. My radio interviewer, as best as I could tell, didn't suffer from a narcissistic personality disorder, nor was he particularly outside the norm. He experienced the broken mirror and reacted in ways that are typical, in one form or another, for many of us men.
Men and Therapy
The field of counseling and psychotherapy hasn't done a particularly good job of creating a user-friendly environment for male clients. The problem begins with a lack of awareness about the profound impact of shame-o-phobia and the vulnerability to broken mirrors. Furthermore, there's a mismatch between the relational style of many men and the touchy-feely atmosphere of most counseling and psychotherapy.
Think of what we typically ask a man to do in therapy settings: recognize that something is wrong with him, admit that he needs help, openly discuss and express his emotions, get vulnerable, and depend on someone else for guidance and support--all extremely challenging tasks in Guy World.
Too often therapists--both male and female--try to massage men into being more like women in the ways they express themselves and experience their emotions. So it isn't surprising that only one-third of psychotherapy clients are men. Either men have fewer psychological problems (not likely!), or else many are too turned off by the whole therapy enterprise to seek the help they need. In fact, men usually get therapy only because someone else has insisted on it. When I ask men in an initial therapy session, "What are you doing here?" the answer I hear is "My wife told me I needed to be here." Other times, it may be their boss or their grandmother or their doctor, or even a probation officer. They perceive the decision to use the therapeutic services and the process of using them to be not particularly helpful and not particularly masculine--often even downright threatening. It's our job, as counselors and therapists, to adapt our approach to these realities.
Part of what makes treating men challenging is that they generally don't signal their psychic pain as clearly and straightforwardly as women. In the postfeminist turmoil of shifting relationship dynamics, men have been struggling to find a way to relate intelligently, parent sensitively, and manage their emotional needs with more consciousness and depth. Many of us haven't figured out a way to do all these things and still really feel like men. Author William Pollack describes men's anger as their "way of weeping"--an expression of underlying pain that women would more likely display with tears or more direct expressions of sadness and loss. Men also "weep" by drinking, withdrawing, acting defensive, blaming others, getting irritable, being possessive, working excessively, becoming overly competitive, suffering somatic complaints and insomnia, and philandering.
As therapists, we have two choices: shoehorn men into a process that's traditionally been more user-friendly for females, or reshape what we do and how we present it to better reach male clients.
Rules of Engagement
Men often resist standard therapy because they have a hard time admitting that anything is wrong or, if they think something is wrong, they struggle to identify what it is. Another reason they avoid therapy is that they can't tolerate the internalized stigma--the felt shame--associated with feeling needy, dependent, or incompetent. A third disincentive, even with men who know they need help, is the very idea of sitting in a room, talking out loud about all this touchy-feely stuff; it creeps them out.
Finally, many men are simply confused and anxious about the strange, mysterious, and--for all they know--occult process of therapy. They worry about what they're supposed to say, worry about what might be expected of them, and worry about when, how, or if they should disclose anything too "personal." This is uncharted territory, and they want very specific information and instructions--a kind of user's manual--about just what's going to happen to them, how they should behave, and what exactly this strange "therapist" person intends to do with them. I understand this because I feel exactly the same way in new and unfamiliar situations--I want to have all the parameters laid out before I get into anything, so I don't make a fool of myself. If I'm going hiking in unfamiliar territory, I want maps, I want accounts by other people who've been on this trail, and I want a weather report. And if I'm going with unfamiliar people, I like to have some idea of whether they like to chat a lot or enjoy the hike mostly in silence.
Since men tend to loathe the language of psychotherapy, including the name itself, by all means call it something else in your advertising. You don't even have to call it counseling. You can call it stress management, skills training (including parenting skills and building better relationships), coaching, or consulting. Whatever works to get a man in the door and relax his defenses!
An interesting piece of evidence that selling therapy as an "untherapy" works better for men is revealed in a study conducted at three West Coast college campuses by John Robertson and Louise Fitzgerald and published in the Journal of Counseling Psychology in 1992. The researchers created one brochure that described the center's counseling services in traditional terms and one that used terms like consultations (rather than therapy) and emphasized self-help, classes, workshops, seminars, and a circulating videotape library. Among the men with a positive attitude toward traditional counseling (assessed by questionnaires about help-seeking), the second brochure made almost no difference. But men who scored higher on traditional masculinity measures, like John O'Neil's Gender-Role Conflict Scale, significantly preferred the alternative brochure and reported that they were much likelier to use these services. This is the audience that we often have difficulty reaching.
Let's assume a man has walked sheepishly into your office for the first time and mumbled a response to your initial greeting. He doesn't understand the process, can't stand the words therapist, feelings, issues, unconscious, and inner child, would prefer to be anywhere else in the world, and believes his manhood may be hopelessly compromised just by his presence in your office. What are you going to do to engage his interest and curiosity, lessen his anxiety, and convince him that he might, just might, find something interesting and helpful in therapy?
Before you begin, bear in mind the type of overarching, nonshaming message that helps to create a therapeutic alliance with male clients: "You're a good man, and you've been making some mistakes," or "You sometimes act badly," or "You can do better," or "Your kids need you to be an even better model for them. We can work together on this."
How do you explain the goals of therapy in "guy talk"? When I work with men who withdraw or become reactive and belligerent whenever a conflict looms with a spouse or partner, I naturally want to help them react with more maturity and insight. I frame this goal in terms of masculine independence, self-control, and personal agency: "We want you to be really powerful. Not over others, but over yourself." "We want to make sure that the everyday crap that comes up for all of us doesn't control you or provoke you into reactions that aren't good for you or the others around you." "We want you to be in charge, not the stuff outside of you."
It's axiomatic that most men have trouble not only talking about feelings, but openly expressing those feelings, so the next step is to normalize their feeling of discomfort with this feature of therapy. Clinicians Matt Englar-Carlson and David Shepard, professors at California State University, Fullerton, have developed excellent strategies to disarm male discomfort and resistance. For example, how do you help a man who emotionally freezes when his wife reveals that her previous boyfriend once raped her? If he can't describe his feelings at hearing this news, the therapist can acknowledge the client's anxiety: "It's got to be difficult to talk about feelings in front of a woman who's more comfortable sharing her feelings and a therapist who does this all the time!" If the therapist is male, he can normalize by identifying: "We weren't trained for talking personally about things, were we?" If it looks like the client is failing at the task of offering his partner the emotional connection she's seeking (when all it would take would be to say "I feel so horrible, but I'm so glad you told me this"), the therapist can reframe for positive intentions: "I know you want to feel connected to your wife, but it's just hard to find the right words."
The idea is to send out the good-men-behaving-badly message. In this way, the man--and, maybe more important, his partner--hears that the problem isn't that he's a bastard with a cold heart and no soul. His heart is warm and in the right place, but he doesn't know how to put thoughts and feelings into words and actions.
Therapeutic self-disclosure can be another effective way to reduce avoidance and defensiveness by nipping shame in the bud. You can create an atmosphere of trust and intimacy by offering a carefully calibrated glimpse into your own life--acknowledging that you've experienced some of the same struggles and conflicts. 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 tell them about times when I've been in therapy and how I've fought with therapists who were telling me things that I took as narcissistic injuries. By showing that even though I'm a therapist I've also had problems, 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.
Respect Resistance and Differences
There's a time and place to point out and confront male resistance and defensiveness, but, at least in the early days of therapy, it's usually much more productive to respect defenses. Typically, when we allow men space to protect their own pride, they don't feel so pressed to perform on demand and, consequently, they become more at ease--and less defensive.
In the beginning of therapy, it's therefore 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.
It's helpful to cultivate the fine art of schmoozing. Men like to feel that the conversation--even in therapy--is "normal." Normal means that the therapist relates in a real fashion, not like a shrink. Normal also means discussing the little events that men talk about, like yesterday's football game, something goofy that happened on the way in to the session, a new contract his company is working on, the latest Blackberry gadgets. Humor helps, too. There's no reason, of course, not to keep these principles in mind with female clients, but it's especially important with men. The more phobic men are about therapy and emotionally vulnerable, the more important schmoozing becomes.
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.
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.
Not all the problems men have with therapy, and the therapy milieu, occur in therapy; they often extend to situations with loved ones and friends. Stephen Bergman, a leading researcher on male psychology, coined the term "relational dread" to describe men's sense of being ill-equipped for the arduous task of discussing feelings and processing relationship issues, even with the people they love most. This dread not only keeps many men out of therapy, it impairs their ability to connect intimately. How does a therapist, engaging in a quintessentially "relational" practice, reach men who suffer from relational dread?
Let's say a guy's marriage is on the line because he can't even identify his emotions, much less express them, and feels under constant pressure from his wife to do so. You can open the conversation with what might be called a clinical icebreaker, saying, "It's hard to talk about these feelings when, for your whole life, you've kept them to yourself." Or to a man who's really struggling, you might offer a teasing, but empathic, comment like, "Man, aren't you glad you showed up here today?"
Then, because he probably feels ashamed of his inability to offer her what she seems to need, you can give him a little encouragement: "I know you don't feel like you're very good at this and that your wife is disappointed," followed by words of encouragement like, "I'm going to help you figure out how to do this, and I know you can do it."
When guys are terrified that any discussion of feelings or relationship issues with their partners--for example, that dreaded question, "So, what did you talk to your shrink about?"--will turn into unbearable marathon sessions, you can throw them a life preserver. Say to them, "When you talk about this issue at home, set an alarm for 10 minutes. Discussion ends then, no matter what." If even 10 minutes is too long for a man who can't tolerate the inherent lack of structure in "feelings-and-relationship" conversations, teach him some very specific relationship-friendly strategies, like "active listening."
For the man who just goes dumb at the critical moment and can't think of the "right" words when he needs them most--a variant of stage fright--be a coach for him. Try the old Virginia Satir technique of "doubling" (standing right next to him and speaking for him): "I'm really trying to be more of the man you want me to be--I'm just freaked out that I might fail at this. That's why I shut down so much." This shows your respect for the fact that his heart may be in the right place, even though his words aren't. By hearing you do it, he gets a model for how it can be done.
Terry Real introduced the term relational heroism in working with men in his book I Don't Want to Talk about It. 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.
What could be more heroic than that?
In one of my men's groups, Robert described a "relational hero" moment that the casual observer might not notice. He and his wife had separated after months of tension and discord. By mutual consent, she'd taken their 6-year-old daughter with her to stay with her family in another state for a couple of months. Then she and Robert decided they were ready to give the relationship another try.
When his wife and daughter arrived back in town on a Greyhound bus, Robert met them at the station. His little girl came running up to him, yelling "Daddy, Daddy, Daddy!" with the kind of gusto that only a 6-year-old girl can generate. He swept her into his arms and hugged her tight, then turned to his wife, who was walking more slowly toward him, to embrace her. She turned away and said she was hurt because she should have been the one he hugged first.
Later Robert described his thoughts at that moment: What a bitch! What am I supposed to do, not hug my own daughter? I can't believe this shit! But instead of retaliating and venting, he made a decision to stay calm. He told his wife that he was sorry. He didn't mean to hurt her feelings. He was really glad to see her. He reassured her, "I really love you, and I'm really happy to see you!"
She paused for a second, then smiled and reached out for him. Just like that, it was over--he'd passed a test. Maybe she shouldn't have reacted as she did to his hugging their daughter first, but that's the way it goes sometimes in all of our imperfect relationships. He can either tell himself he won't put up with it and dig in his heels, or he can try and find some way to reassure her. Robert found a way, and it brought out the best in both of them. At that moment, he was a relational hero.
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 Honor of Men
There's a haunting scene from the movie Good Will Hunting in which Will Hunting (Matt Damon) and his best buddy, Chuckie (Ben Affleck) talk in characteristically male style about an emotion-laden subject. In passing, Chuckie asks Will about how things are going with his girlfriend, Skylar. Tonelessly and abruptly, Will informs his friend that she's "gone." There's a pause. After a few grunts and monosyllabic responses, Chuckie uncovers the fact that Skylar left Boston for medical school in California--a week ago!
Taking in this information about the sudden, sharp turn in the relationship, Chuckie sips from his can of beer, raises his eyebrows a little, and observes, "That sucks."
The empty spaces in this conversation are deafening. It's hard to imagine an exchange like this between two best friends who are women--especially a week after a breakup in one of their lives! But while Chuckie may not have said much, there's a sense of shared, unstated understanding that resonates deeply. Despite the absence of words and explicit emotion, the audience watching this moment between these friends can feel all the solace and sense of connection being conveyed in the spareness of "That sucks."
When we learn to recognize and honor how men communicate their caring, we'll have a better shot at helping them get relief from unnecessary pain and be able to receive and give more in their relationships. When we respect their defenses, honor their intentions in doing the work, speak to them in Guy Talk, and engage them with therapeutic transparency and self-disclosure, the differences in treating men and treating women diminish dramatically.
As women who are in relationships with men who can reveal their vulnerability know so well, it's extremely rewarding to be part of the process through which a man opens up and finds that he still feels like a man, or even like more of one. A client recently said to me, "I think I'm getting the hang of talking about things I've never talked about before without feeling like a wuss." We can all get better at helping men get there, and it's so worthwhile.
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