Growing up in the '50s and '60s, I came of age in a world in which men ran the show, had the higher-paying jobs, and women were seen as second-class citizens. Like many women in my generation, I joined women's groups that questioned basic gender norms and envisioned a society that wasn't dominated by sexism and male privilege. At the same time, I was aware of how men were themselves being shortchanged by restrictive sex-role norms. I was struck by the higher rates of suicide and substance abuse among men, the prevalence of violence, and their shorter life expectancies. Among the men who were my friends and whom I dated, I saw how their need to appear tough, independent, and emotionally in control got in the way of their intimate relationships. When I brought up the subject of men's struggle to uphold macho standards of masculinity in my various women's groups, I was told I wasn't a "true feminist" because I was paying attention to men's needs.
As a graduate student, I became increasingly interested in how little the inner experience of gender is put into words on both sides of the gender divide. My growing curiosity about what it's really like to be a man and how much rigid male norms get in the way of healthy relationships led to my writing my doctoral dissertation on men's needs and fears in romantic relationships. In my research, I found that the women I surveyed thought men were actively choosing not to express their emotions, whereas the men said they didn't know what they felt, didn't have the vocabulary to describe their feelings, or were afraid to show their feelings for fear of feeling or looking like "wimps."
When I started my clinical training, I wondered about the impact of men's discomfort with emotional expression (and women's ignorance of this discomfort) on how male clients experienced therapy with female therapists. Unfortunately, there were no psychology-of-men classes in my doctoral program and no training on men's issues in therapy in my internship, so I found myself pretty much on my own in learning how to work with men.
My first male client at the clinic where I was hired right out of graduate school offered me an unforgettable glimpse into what can go wrong between a male client and a female therapist. George, a young man who was going through a difficult divorce and estrangement from his young kids, arrived for our appointment looking alternately frightened and hostile. Since I was the new therapist on the block, I'd been assigned the worst treatment room: a tiny closet of a space with no windows and a door that didn't stay shut unless it was locked. I welcomed George in, locked the door, and sat down in the chair between him and the door.
The first words out of his mouth were, "What's the calendar with the picture of the kids stuffed into a Christmas stocking doing on your wall? Did you put it there?" Instead of agreeing with this newly separated father of two that the calendar was an insensitive selection under the circumstances—perhaps even offering to take it down if it bothered him—I defensively explained that I hadn't been involved in decorating the room.
Things went further downhill when, before we'd established any real rapport, I decided to ask him, "From your intake form, it seems you're having a hard time right now in your marriage. Can you talk a little about it?" With his terse, mumbled response, he indicated that he wished to say very little about it indeed. Finally, I tried to put a more casual, friendlier spin on the session by saying, "Well, if we're going to work together, it would be good to get to know each other a little." To which he replied, "Why would I want to get to know you?" I was relieved when, after what seemed like an eternity, our session ended. George left without paying for the hour and never came back.
My early experience with George and other male clients soon taught me that working with men was going to present challenges different from those of working with women. Given most men's discomfort with the format of "talk therapy," I had to be prepared to create an atmosphere of comfort and safety that put them at ease early in treatment. Unlike with my female clients, there was no mutuality of experience to draw upon to smooth the process of forging the therapeutic bond. With my male clients, I became keenly aware that often I was seen by them as a woman first and a therapist second.
Emotional expression and intimate connection are part and parcel of what it means to be female. As a woman, I didn't feel unfeminine when I cried or leaned on others for help. But for male clients, trained to maintain a stiff upper lip and appear self-sufficient, the traditional model of therapy runs counter to much of what they've been taught about being a man. Through trial and error (along with some excellent advice from clinicians skilled in working with men), I slowly learned concrete ways to make therapy a less foreign and threatening experience for men. More important, I learned to see therapy through a man's eyes rather than through a woman's.
My women clients were more likely to ask for help because they wanted it (not because someone else suggested they needed it) and were more comfortable openly requesting assistance. Men more often came into therapy under pressure from someone else, frequently an unhappy spouse. If they came on their own because they wanted assistance with some circumscribed issue, they didn't seem to like feeling they were on the receiving end of a "helping relationship." I learned to listen closely to the language they brought into the first session and, using that language, to start working with them right away to create an action plan that emphasized collaboration and coaching. The focus was on what they concretely wanted out of therapy, what their goals were, and how the two of us could work together best to achieve those goals. To make sure that the early focus of treatment was positive, I learned to appreciate the value of asking the miracle question in the first session: "If you woke up tomorrow and everything was just the way you wanted it to be, what would be different? How would you be different?"
From many years of attention to men's language, attitudes, and needs, I've developed a specific approach to working with male clients. With a man, I introduce therapy as an educational experience, offering verbal and written descriptions of "what to expect in therapy." I use a variety of cognitive-behavioral techniques, including giving weekly homework assignments and using videotherapy and bibliotherapy. I find that structured assignments and role-playing exercises help men see the therapy process more as an educational experience and less as a pathologically-oriented excavation of their psyches.
I often rely on a sense of humor, down-to-earth language, and judicious self-disclosure to level the playing field between myself and my male clients. For example, I had a depressed male client a few years back who thought medication was "only for weak people." After trying every way I could think of to help him move out of this stance, I ended up sharing with him some of my own experiences with suffering, after which he looked relieved and said, "I don't feel so alone anymore. Maybe I'm not such a loser." He went on to take medication and improved dramatically.
I've found that terminating therapy typically is quite different with men. My female clients seem comfortable letting go of the relationship completely when they're ready and taking time to process their feelings with me about ending treatment. More often than not, my male clients end up arranging increasingly infrequent sessions, saying something like, "I want to schedule a session, but not now. I'm too busy." Then they call me in a few months (or even a few years), saying they want to run something by me. This strikes me as a way men have of maintaining control over the beginning and end of our connection—not really ever saying good-bye, but rather "see you later."
A basic problem for women who treat men is that, no matter how empathic we may be, we haven't had the same socialization they've had. Occasionally male clients will confront me directly about my "ignorance" of what it means to be male—"You can't possibly understand what it's like to be a man. How can you possibly help me?" Over the years, I've learned not to be defensive when a man confronts me in this way. Instead, I'll say something like, "You're absolutely right. I haven't had your experience, but I'm interested in what you've gone through. Tell me more." Often I'm able to turn this into an advantage by putting myself in the student role and making my male client the tour guide to what David Wexler has called "Guy World."
In one session with Tom, a man who'd just gotten laid off from his job of 15 years, after I said something I thought was supportive ("Wow! That must be tough"), he turned to me with annoyance and said, "How would you know? You don't have to provide for your wife and children." I agreed and I asked him to tell me more about what it meant for him to feel like he had to be the main breadwinner. He told me it was a great burden, and that he didn't think his wife really understood how hard it was for him. We talked about the usefulness of having her join us for a session, and then I went on to explore what his dad had taught him about the responsibilities of being the breadwinner and the shoes he felt he needed to fill. Through asking questions, I let him know I truly wanted to learn about how he experienced the demands of being a man.
Male anger or verbal challenges to women's authority can be especially difficult to handle for female clinicians, particularly those who've had to deal with angry, patronizing, or dismissive men in their own lives. Even if that isn't the case, men's physical size and deep, booming voices can be intimidating. Take Fred, for example, an angry male client who was working through some issues about his ex-wife, with whom he'd had a nasty divorce. Usually my approach with angry men is to allow them space to vent their feelings, and to check my own countertransference at the door so that I can really hear them. I often say things like "Tell me more about your anger," even though sometimes I feel like changing the subject, withdrawing emotionally, or showing disapproval. When my male clients can express their anger without my resisting it or getting judgmental, they're better able to get underneath the anger to the sense of rejection and sadness that may underlie it.
One of the most difficult types of client for me is the emotionally restricted man, who can talk about himself only in a detached fashion. I don't generally get bored in my therapy sessions, but when I do, I've learned that it's often a sign that the client is disconnected from his own emotions. A man's slower pace of disclosure can make me feel left out and irrelevant—feelings no therapist relishes. Accordingly, I've learned to slow down and take it easy—not to act as an emotional can-opener, but to let the client set the pace. Failing to do so can lead to losing a client.
Gerry was a client who came to me with anxiety that was crippling him at work and in his personal relationships. It turned out he'd grown up with a detached father and an emotionally abusive mother, who criticized everything he did. As he began to explore his repressed emotions, I encouraged him to express his fear, anger, and hurt with me. The more he expressed, the better I thought therapy was progressing, until one day, he said he didn't want to continue anymore. I realized too late that what I should have done with him was to let him go at his own pace, neither encouraging nor discouraging his affect, and checking in with him regularly to assess his emotional comfort level.
Sometimes, however, my boredom can offer insight into the detachment of a male client and open a new avenue of inquiry. For instance, one day I said to Ed, "You're losing me. I'm feeling a little detached and wonder if you are, too. What's going on right now?" It was a turning point in our work together. For the first time in his life, he realized that someone wanted to know more about him, rather than avoiding him or tuning out.
Like most female clinicians, I never received any training in how to deal with sexual feelings in the therapy hour with men, so most of my learning has been on the job. Tony came into therapy because he was lonely and wanted to find a romantic partner. As our sessions wore on, he said how close he felt to me and that he wished he could find someone just like me. He'd comment on how nice I looked or would ask about my experiences dating men. Instead of being scared of his attraction to me, I welcomed it as an opportunity to understand more about what intimacy meant to him. When he said how close he felt to me and that he wished he could date me, I said I was flattered and thanked him, but reiterated the roles of therapist and client, adding that therapy was an experimental laboratory for building a healthier self to take out into the "real world." He later started dating and would talk to me about his experiences, by which point I'd become more of a valued friend than a potential dating partner in his eyes.
With male clients to whom we might be attracted, the therapy relationship can get even trickier. In my first session with Charlie, I was instantly reminded of an old boyfriend. Newly single, I began to look forward to our sessions, paid special attention to what I was wearing, and altered my hours so I could accommodate his schedule. I began to feel an intimacy with him I didn't with other men in my life. I soon asked myself whether I was being unprofessional and unethical by continuing to work with him. The more I thought about it, however, the more I realized that my sexual feelings toward him were most likely the result of his own presenting issues (cheating on his wife) and his tendency to separate women into either sexual partners or companions, rather than anything having to do with my own need for a male partner.
I discussed the case with colleagues, did some reading about sexual countertransference and transference, and went back into therapy for a while to make sure I wasn't using Charlie for my own needs. Through these explorations, I used my own feelings to understand better what he was going through. I never directly said I was attracted to him, but explored his relationships with women and his tendency to split intimate connection into sex (the mistress) on the one hand and companionship (the wife) on the other. Finally, he saw that his compartmentalization left him lonely and was one of the main sources for his depression. Had I shied away from exploring this with him, I don't think he would have reached the insight he did. My advice? Don't ignore the sexual feelings that arise with a male client. Those sexual vibes will be a wonderful source of information for helping him with his issues.
While I've emphasized the challenges women experience in treating men, many men request female therapists. When asked why, they've said they feel safer with women because they expect them to be supportive and see them as the better "relationship managers," more experienced in giving feedback and advice about handling subtle relationship tangles. Many men are afraid of being vulnerable and open in front of a man, especially the imagined alpha-male figure of the therapist to whom they're turning for help.
Therapy can be a venue in which a man can explore his feelings toward women with a safe person with whom he's in a direct relationship. He can use her as a source of information about how women feel, get angry with her and watch how she handles it, be attracted to her and not be put down or rejected for his attachment. He can engage in a dialog with her about painful issues in his life in a way that can help him figure out how better to communicate with the other women in his life.
For female clinicians, one of the side benefits of working with men is that it can help us understand the other men in our own lives. Both genders win when we learn more about men. My compassion for men in my personal life has grown as I've learned more about what the world is like for my male clients—how hard it can be having to live up to the sometimes punishing male standards of competence, strength, stoicism, independence, and sexual prowess. I think working with men helps us be more useful to our female clients as well, since sharing our knowledge about men's issues can help them gain greater insight about the men in their lives. If we can move beyond the tendency to see gender issues as a zero-sum game (i.e., the more attention you give to men, the less attention women get), the more we all will win. That's my kind of game.
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