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It is good to hear you say that. In environments where the work is with those who have been traumatized, it is important for clinicians to have their own support systems in the form of supervision, personal therapy, and outlets for emotional expression. I mean he looks great. John sought therapy to address his feelings of boredom and lack of motivation for his work. Some of his activities, like motocross racing or white water rafting, were considered dangerous or risky. Although an initial awkwardness is to be expected, it is the counselor's job to make the creation of a therapeutic relationship a less threatening process.

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On the other hand, men were being asked to be more relational and sensitive by the women in their lives. These include the expectations to be strong and in control but to also be sensitive and responsive the gender bind , to be physical and active but also savvy and in command of oneself the kinetic bind , and to take risks and challenge oneself but also care and nurture oneself the hero bind. Continued research has shown that the endorsement of items that reflect a high degree of gender role strain are correlated to higher levels of psychological distress Good et al.

This early restriction on emotion and self-expression leaves many men in adulthood with problematic communication skills and normative alexithymia. Alexithymia is defined as an inability to put words on emotions Levant, Ethnic and cultural identity interacts powerfully with gender role influences to shape masculine expectations.

Although many men try to maintain a colorblind perspective, America is still racially divided. Even with the recent incidents of shootings of black men and the protests generated by Black Lives Matter, it is still difficult for white men to comprehend the subtle harassment that men of color experience on a daily basis. Not only are they subject to the stresses of traditional masculinity, they must also cope with the overlay of subtle and not so subtle racism.

A layer of anger related to this cultural predicament is common in many men of color, even those who are trying to live by the rules of mainstream society Franklin, Men of African, Hispanic, and Asian descent face unique challenges because of racial stereotypes that hardly reflect the realities of most men. Therapists are encouraged to not only study the macro-level of cultures not their own, but also attend to the many variations that occur within groups.

Particularly important is the level of acculturation of the client. Men who are unemployed or who work in the blue-collar work sector may feel alienated from those in white-collar jobs. In many places in America, gay men are fearful of expressing aspects of their sexual orientation in the presence of their straight counterparts. Transgender men are especially vulnerable to prejudice and misunderstanding, but also susceptible to mental health distress that few clinicians are trained to address APA, Jews, Muslims, Christians, and men from other religious backgrounds also feel ambivalence about how public they should be in acknowledging their religious identities.

Men with physical and psychological disabilities can be subject to unwanted scrutiny and judgment from other men.

Men struggling with issues of under or unemployment may present with defensiveness that belies underlying fears of being judged for not living up to perceived masculine ideals. Clinicians should be sensitive to the predicaments of men who do not fit the middle-class, Caucasian, heterosexist norms.

In particular, it is important to note that different cultural heritages can have very different gendered norms relating to male emotional expressiveness, self-disclosure, and initial trust of the therapist. Due to male socialization and the psychodynamics of relational intimacy, many men are uncomfortable with a therapeutic process that asks them to be open and vulnerable about themselves. As difficult as it was to get to the office, it is still a huge obstacle to make the most of the therapeutic situation.

Many men are anxious about what they should disclose. Often the reason a man is there is shameful to him. Talking personally about an emotional experience is not a usual part of his repertoire. It should come as no surprise that many men share only the surface of what is going on with them.

Often it is framed intellectually with little emotional expression. Sometimes it is minimized or discussed in brief. If the therapist is a man, the client may feel a need to present himself in a strong light. A man who is used to being in competitive environments with other men may find himself trying to show the male therapist that he is strong and competent, and has most of his life together. With a woman therapist, a man may try to display behavior that might make him feel attractive and important.

Underlying the initial display of bravado is an insecurity and feeling of shame about having to admit to failing in some aspect of being a man. Brooks has a matrix for male clients who come to therapy based on their readiness to engage in treatment.

The male client most resistant to change is the individual who has not questioned his own behavior and has little outside pressure to do so. Only occasionally do these men come to therapy. A therapist engaging this type of man needs to be more of an educator about how male gender role pressures may keep him from doing everything he might. It is not expected that the client will stay in treatment very long from this position, but by having an experience of therapy as a non-threatening situation, this man might return in the future.

A rare, but significant male client is the one who is ready to change, but has very little environmental support to do so Brooks, In this case, the individual is feeling internal pressure to make a change, but fears that in doing so he will upset the equilibrium of his support system.

Joe, a police officer for the past ten years, came to therapy because of his extreme sensitivity to the emotions of those in his environment. Joe grew up in a low socioeconomic neighborhood, excelled at school, and became a policeman when it was suggested by a respected teacher. Joe enjoyed the interpersonal aspects of the job, but had grown increasingly troubled by the pain he could read on those with whom he had to interact, especially troubled teen-agers.

He was bothered by the cavalier and prejudicial attitudes of his colleagues. Joe appreciated having a place to talk about feeling overwhelmed, since his outside life left him few opportunities to be authentic. It also gave him a chance to work on changing the dynamics of his family relationships. The most common male client is one who is in the pre-contemplative stage of change, but who is being highly pressured to come to therapy by the environment Brooks, This involves the therapist acknowledging the resistance a man might have to being in treatment, while building a strong therapeutic alliance.

The male client who is ready to make changes and has the environmental support to do so is likely to require the least amount of direction from the therapist. Brooks suggests that the therapist act as an empathic, collaborative facilitator who encourages the male client to pursue his goals.

The therapist in this scenario is more likely to be able to confront a male client when he is falling back into old patterns or is internally fearful of how change will affect his life. One important task for clinicians is to become educated on the ways in which the traditional male gender role both inhibits and complicates the expression of male distress, and how some aspects of the traditional male gender role may actually be called on in service of treatment.

In addition to cultivating male-friendly attitudes and a comfort with addressing male gender role socialization issues directly with male clients, psychotherapists may also become sensitive to the actual physical décor and layout of their offices. Décor that may be intended to make some clients comfortable, such as pillows, stuffed animals, candles, or other physical objects that may be perceived as feminine by a male client should be employed judiciously.

A more casual arrangement of furniture that encourages the male client to situate the seating to reflect his level of emotional comfort with the clinician can help set the male client at ease, especially in early sessions where close quarters, face-to-face interaction may be felt as too intrusive for the male client.

Metaphors often resonate more than abstract concepts with men McKelly, Other male clients may have limited emotional vocabularies and may benefit from the psychotherapist prompting the expression of emotions simply by suggesting or offering feeling words. The following is an exchange between a male client Jake and his male therapist. The names and identifying information in all the clinical illustrations in this course have been changed to protect the identities of clients.

The following is an exchange between a male client, Jake, and his male therapist in the first session. Jake is coming to therapy at the request of his wife who told him he needed to work on himself, or else the relationship would be over. I work in the insurance business. I do pretty well. I have two kids that I love with all my heart. I just have a little problem I need some advice on.

I feel like I could have sex anytime. She hardly ever wants to, though. Not that I know of. Note in the initial exchange how cautious Jake is about revealing much about himself. His disclosures remain on the surface. The competitive dynamic of having to open up to a male therapist seems to encourage Jake to show his strength as a worker, father, and sexual being. Jake does not want to be in a one-down position in this relationship, yet he feels like he is and must compensate.

Having empathy for the difficulty of sharing personal information in a strange environment is likely to go a long way toward helping Jake feel more like he is understood and less like he is being judged. We had differences and decided not to stay together. How about you, Jake? You worried about splitting up?

I think it is good for them to have two parents living at home. I wish we were getting along better. While it looks like Jake has turned the tables on the therapist, the self-disclosure by the therapist is helpful in getting Jake to feel more comfortable talking about himself. The therapist has disclosed some of his vulnerability, leaving Jake to feel a little less like he is in the weaker position.

The therapist does a nice job of modeling disclosure, and masterfully turns the question about being married around so that Jake is talking again about his situation. Even though he is not talking with emotional depth about his concerns, the first session is really a testing of the relationship. Steven, a year-old man, has come to the office of a female therapist in her mid-fifties.

Steven has recently split up with his partner of 15 years. He has been feeling depressed and using marijuana to soothe his emotional pain. I knew it was coming. Because the therapist is a woman, a different transference dynamic has emerged with this male client.

Since he is ostensibly coming to therapy because of rejection by his female partner, talking about something that he thinks destroyed the relationship feels a bit unsafe. Therapy is feeling uncomfortable for Steven, yet the therapist does a nice job of being nonjudgmental and understanding. It allows for an important exchange that lets him know that the therapist has experience and will likely react differently than his partner. It surprises me that you were able to listen to me talk about the affair.

Most women would be angry and upset at me. I just assumed that you would think it was sleazy to have someone on the side just for sex. I really love Georgia. Elaine and I just see each other in a physical way. Seems like you got your needs met but it broke the rules that you and Georgia had set up for your relationship. I was wrong about that.

She feels I cheated on her. Like I said, I was getting my needs met, and I thought I was giving her a break on my sexual demands. At the start of therapy, Steven wants to talk rationally about his perspective. It is important for the therapist not to push too hard for the feeling level too soon. In this case, Steve is stating his perspective, and going further in verbalizing and looking at his own actions because he is not feeling judged.

Sweet reminds women therapists who are working with men to be aware of their own countertransference reactions to men in the session. She asks women clinicians to look honestly at their own feelings about men. These conflict zones include ambivalence about relational dependence; prohibition against sadness, grief, and mourning; problematic masculine-specific self-structures; preferences for doing instead of being; and the emotional wounding that has brought a man to therapy and is exposing his emotional depth and vulnerability.

How does the developing little boy, who is initially unaware of the way his culture devalues his dependence, negotiate this experience? The little boy is dependent on his early caretakers for feeding, holding, and shelter as well as love and support.

This is a universal human developmental experience, yet in our American culture, dependence and its psychological meaning are often seen as contraindicated with masculinity. Often, the longing and gratification that the little boy experiences is culturally devalued as he grows into manhood. Males are confronted by cultural messages that they are unmanly and abnormal if they experience gratification from their dependency needs.

Boys are prone to internalize contradictory, mixed interpretations of their experience because of their underlying ambivalence about dependency. On the one hand, they experience affirmation and gratification of dependency in their early relations with mother and other important adults.

On the other hand, they learn that such an experience is to be disavowed if they are to be accepted. Other powerful forces in the social landscape that may also reinforce this learning include parents, teachers, coaches, and especially same-sex peers. Disapproval and shame become associated with the presence and enactment of dependency needs.

It also may result in a distancing in interpersonal relationships so as not to appear needy or dependent. In the therapeutic relationship, the conflict about dependence manifests itself in several ways. The fact that few men even make it to a therapist reflects the avoidance of men in our culture of involving themselves in a potentially dependent relationship, even if it is for their own good.

Another demonstration of this conflict results in the devaluing of the therapeutic relationship, particularly early in the process. Bill was a thirty-year-old single man who requested therapy after being asked to move out of his cohabiting relationship with his female partner, Anne. After a ten-month courtship, they had decided to live together, and had been sharing a house for the past two years.

They held many common values, and Bill described to his therapist how he perceived them to be very happy together. Bill and Anne each had professional jobs and they enjoyed a comfortable living. In therapy, Bill had a hard time explaining his behavior from a rational framework, as illustrated by this short exchange with the therapist.

She was everything I wanted in a woman. I don't get it. I wish I could have made the commitment. It was like something in me felt repelled, like I was going to suffocate if I let her get any closer. Bill's situation is a common one for many men seen by psychotherapists for help with relationship problems. This then leads to increased frustration and disappointment with the relationship for both partners.

Out of frustration, a man may thus be referred for therapeutic consultation. The roots of this dilemma lie deep for many men.

Adult intimacy is often associated with vulnerability and, ultimately, with disconnection; the man unconsciously remembers his connection — then disconnection — with his earliest love object. From an early age, little boys are presented with both overt and covert messages suggesting they suppress their emotional experience and their expression of feelings. Such values expressed by parents and other caretakers profoundly shape the growing boy's interpretation of his experience of loss and grief, and have a long-lasting impact on the manner by which he eventually learns to mourn his losses.

This is particularly problematic in light of the fact that both boys and girls experience disappointments, betrayals, and losses from birth onward. Just as girls and women are often perceived to be more comfortable with these emotions, boys and men seem alarmed by them. As a result, boys and men frequently dissociate themselves from these feelings and repress them deep into the hidden realms of their inner lives.

Dissociation, as a defensive psychological process, compromises natural mourning that occurs as a result of the making and breaking of intimate emotional attachments to others throughout the lifespan. When this normal process of grieving is truncated and thrown off course, anger, shame, and control-oriented defenses often arise as a means of self-protection.

This also creates conditions that invite self-medication and acting out to relieve the discomfort caused when these emotions threaten to break through into consciousness. In the therapeutic relationship, issues of grief and loss and the accompanying emotional experience of sadness may be elusive or difficult to acknowledge. Therapy that encourages male clients to talk about loss experiences can facilitate the unclogging of the emotional ice jam that has been maintained by shame and the fear of losing control.

John sought therapy to address his feelings of boredom and lack of motivation for his work. He had been employed as an assistant professor for two years, and was experiencing serious work inhibitions.

As he described his situation to his therapist, he began talking about his childhood and his experience as a boy growing up in his family. John's father was a practicing alcoholic who was away from the home for much of the time when John was a boy.

His mother was a grade-school teacher who over-functioned in this role as well as in the role of homemaker. He had a sister who was two years younger. John recalled a great deal of conflict in his relationships with his sister and his mother.

Adding insult to injury, he felt little support from his father who was rarely home. As a result of this family of origin experience, John felt he had never developed a healthy, positive sense of himself in general and as a man in particular. I feel like a big whiner. Plenty of people have had rougher childhoods. No one hit me or abused me. Maybe no one hit you, but you feel like you missed out on something important when you were younger.

I sure wish he had been more there for me. Living with my mom and my sister was pretty brutal at times. I guess those are the breaks. Trying to rationalize your way out of the feelings you have of missing your dad. You're pulling away from looking at your sadness about this. I keep thinking I can redefine myself and get on with my life without acknowledging his absence.

I wish I could just let out all this damn emotion and be done with it. I want to feel free. I want to move on. For many fathers and mothers , being a good provider often means being away from the home for much of the time. As a result, John left home with a poorly defined sense of self, highly negative associations about his masculinity, and a pattern of negative interactions with women. His longings for connection with his father, his needs for support of his own growing interests, and his poor interpersonal experiences with women left him deeply wounded and sad.

As he made his way through secondary school and then college, he began to be acknowledged for his sharp intellect and his biting wit. This carried him until he was faced with the self-activation required of him as an assistant professor.

As a result of this activation, his repressed sadness and longing for more intimate and meaningful connection broke through into consciousness, overwhelming him with grief that he was unaccustomed to managing. Jose entered psychotherapy after dropping out of his second year of medical school. He had been succeeding at his academic work, but had not been enjoying the classes and was becoming increasingly unhappy with his choice of a career in medicine.

He explained that he had become gradually withdrawn from his classmates, and finally had stopped attending classes all together. A phone conversation with his parents had convinced him to take a leave of absence from his studies and spend some time clarifying his purpose and direction in life. He described his situation in an early interview with the therapist. Everything just gradually became empty this year.

It was as if the color just faded from everything. Nothing gave me pleasure or interested me much. Nothing was any fun. Oh, I could still make the grades. That a really vivid way to put it, Jose. The color faded from everything. Have you ever had this kind of experience before? Well, my junior year in college, things were pretty gray.

I had broken up with my girlfriend. Or I should say she had broken up with me. I decided then to take the MCATs and go to medical school. It gave me some purpose. A direction, I suppose. But things were pretty gray during that time. I feel really alone and hurt by getting dumped by her. So the decision to go to medical school was made on the heels of being dumped by your girlfriend?

Well, now that we are talking about it, I guess it was. I never really thought about it that way before. I just figured it was something to do, go to medical school. I always got good grades, and I thought helping people would be a good way to use my talents. I have to have somewhere to go. Well, I would agree with you on the helping people with your talents part. But then we have to figure out why medical school lost so much of its appeal all of sudden. I wonder if the original motivation for going was to take your mind off the ending of your relationship.

What do you think? This is really interesting. I remember now that when I was in high school, I got dumped by my very first serious girlfriend when I was a senior.

This was right after a disastrous spring break for us. Then, all the college acceptance letters started coming. It was a great way for me to keep my mind off my relationship with Michelle. But thinking back on it now, I was pretty miserable during that spring. I wonder what is worse for you, making a major decision about your future or being jilted in a relationship. Making these decisions about my future this way just keeps me away from the pain.

I think what all this means is that I need to look at this rejection and pain, and see what is so difficult about it for me. That fits for me. I can feel sadness just sitting here thinking about this stuff.

The client realized that his actions were geared toward the avoidance of relational loss and that this was having an impact on his life in the present. The combination of psychological losses of relational discontinuity along with the failure to live up to masculine ideals of being in control and strong may lead men to experience an unidentifiable sadness and loss of interest in their lives.

The optimal outcome of working with men in therapy is a blend of sadness and acceptance of the inevitable losses and limitations of life. The affective acceptance allows a man to be more internally driven and focused on finding meaning in the life he is living.

Little boys are given mixed and incongruous messages about how important others view their masculinity. Such messages often conflict with their inner experiences of emotional need and desire.

The development of a coherent sense of self with a positively valued facet of masculinity is therefore a significant challenge for many boys. As many boys venture into puberty, problematic aspects of their masculinity have been well-learned and suppressed, resulting in a flattening of the emotional expression of sadness, anguish, fear, and tenderness. As boys begin to construct masculine-specific self-structures, they must balance how peers, family, and the cultural influences of school and the media view certain aspects of masculinity with their own acquisition of masculine traits.

Often, these outer definitions of masculinity conflict with inner needs, wishes, and values. Conflicting masculine self-structures are often one of the reasons a man may come to therapy. Understanding the conditions under which these self-structures have been created and working on dismantling the dysfunctional elements is an important therapeutic focus of gender-sensitive psychotherapy for men.

Craig came to therapy to discuss a number of problems he felt he was having both at work in his career and at home in his relationship with his partner, Jim. After exploring the elements of his problem, it became apparent that Craig was oblivious to the impact of his aggressive style on his coworkers and his supervisor, that latter of which was a woman who approached her supervisory duties through teamwork and collaboration.

The immediate incident that brought Craig to the EAP was a situation where he had given some valuable team information to a potential customer who had then used it to negotiate a better purchase price with a competitor in the industry. Craig's partner, Jim, while sympathetic, could see the supervisor's point of view since Jim often felt that Craig was impulsive and self-serving in their relationship.

I work hard and do what I think is right. I may have screwed up but at least I was trying my best. I was taught that you take a stance and follow through. My dad taught me to be strong and trust my instincts. All this corporate sensitivity to how others feel really runs against my upbringing. It happens at home, too. Jim tells me I come on too strong sometimes. I don't take his needs into consideration. He was confused and angry.

He was genuinely stumped by the consequences of his actions. It was apparent that an exploration of his masculine self-structure, composed of his gender role history and the messages he incorporated in his development as a man, would be a relevant element of his therapy.

In observing a typical school playground, it might be noticed that boys are often involved in competitive, active play within larger groups. Girls are frequently involved in smaller groups of more relational, cooperative play. It is out of this elementary experience of being held and nurtured that the capacity for true doing arises.

Despite believing that both men and women can experience both states, Winnicott noted that girls and women seemed to be more comfortable with being , and boys and men more at home with doing. As noted, the little boy may prefer active, physical play on the playground with his friends at an early age.

In addition, boys and men appear to prefer more action-oriented means of problem solving that may have adaptive as well as maladaptive consequences.

Adaptive doing is seen in active problem solving, a willingness to take risks to protect others, and a capacity for hard work that characterize many men. As the unpleasant and destructive consequences of a life that is based on an over-reliance on doing accrue, therapists can help men recognize the value in cultivating their capacity for being , and strive to strike a balance between doing and being.

Relational bonds that have occurred through productive doing can be strengthened by a therapeutic approach that intertwines activity in the therapy relationship along with a focus on being with the feelings that emerge.

The familiar doing approach can often act as an entryway to the being world. With an appreciation of the meaning of both of these elements for men, a sensitive psychotherapist may be better able to facilitate the attainment of this balance. Dave sought therapy after his third arrest for operating a motor vehicle while intoxicated. He had been pulled over while driving home from a party at a friend's house. Some of his activities, like motocross racing or white water rafting, were considered dangerous or risky.

Although he had many friends, Dave disclosed his frustration at not having a more permanent or serious significant relationship. He had dated a few women in college, but now, fifteen years after graduation and with several failed relationships behind him, he was unhappy and worried. He began to notice the double-edged nature of his preference for doing.

Namely, while he was active and busy, racing his bicycle and going on camping excursions, he avoided close interpersonal connections with any potential partners.

I probably have scared them off. Do you think your need to do the crazy stuff, as you put it, is worth this lonely feeling? I'm beginning to wonder. I really feel lonely a lot of the time. I just don't have the same connections I had when I was younger. Like many men, Dave had been socialized to be active, outgoing, and fun-loving.

He did not immediately perceive any particular costs to this lifestyle. However, as his sessions unfolded, it became clear to both Dave and his therapist that his high intensity, risk-taking lifestyle left him devoid of intimate interpersonal contact.

Dave was still the fun-loving, fast-moving guy. He was, however, beginning to recognize the limitations that his lifestyle imposed on the fulfillment of his emotional needs. Most, if not all problems that men present to a psychotherapist have an element of wounding. Wounding refers here to the nature of the experience that has precipitated a visit to the therapist.

Interpersonal conflict and rejection, failure experiences, and frustrations with not meeting expectations of life all can be construed as wounding experiences for many men. A rejection in an intimate relationship has an obvious element of wounding.

Failure at work is a similar wounding. A man who is fired or laid off from his job experiences a sense of failure and inadequacy. In addition, his identity as a provider is challenged.

Gerald sought consultation with a therapist after he and his spouse had decided to discontinue marital counseling. As he met with a new therapist for an initial consultation, Gerald outlined the problem areas that he perceived in his relationship with his spouse. Well, she wants to just sit at home on the couch and rent a movie and make some popcorn. I just get real edgy and feel claustrophobic when we do that.

I would prefer to do something. And Anne can pick right up on it, then she gets frustrated and hurt, and then we usually just get into a fight. I feel like I just want to leave, and go drive around in my car or something. What do you think would happen if you were to sit down with your wife, eat some popcorn, and watch a movie?

This makes me feel uneasy just talking about it. And I think that would just devastate her. Note how the conflict zones are illustrated in this case example. Gerald is straightforward about his hesitation and second thoughts regarding his marriage and his relationship with Anne. We might expect that this conflict would have significant emotional and historical underpinnings that could be further explored.

Further exploration might help Gerald to integrate these emotions, examine his own dependence on Anne, and take a look at his own fears of what would happen if he were honest with her about his feelings. Restrictive emotionality in men and avoidance of intimacy and emotional expression are common themes of male psychological conflict.

His fantasy of escape involves going and driving around in his car, clearly a doing mode as opposed to a being mode. The escape into an apparently solitary doing activity might be the result of gender-based learning. First, the anxious feeling that Gerald gets when he thinks about sitting down with his spouse on the couch and watching a movie represents a bodily manifestation of what appears to be a core conflict with a likely history of wounding.

Through either of these portals, Gerald and his therapist will discover his authentic, true feelings about himself and his life. Even when the crisis is as major as sexual abuse, family violence, traumatic victimization, and major interpersonal loss, many men are hesitant to consult a therapist to deal with the emotional pain.

This section will address the issue of depression and suicide in men. Beginning with a brief summary of the literature on depression, this section will contrast the typical DSM-5 criteria with a proposed male-specific perspective on depression.

In addition, clinicians will be given some tools for assessing male-specific depression and suicide, as well as strategies for treatment. Depression is a psychiatric disorder with several different forms and variations. Major depression, at its extreme, is characterized by a subjective sense of several of the following: Dysthymia, which often includes low energy, low self-esteem, poor concentration, insomnia or hypersomnia, poor appetite or overeating, and subjective feelings of hopelessness, is a less intensive and debilitating form of depression that is present for two years or more American Psychiatric Association, Bipolar disorder is another variant of depression that involves the symptoms of major depression punctuated by shorter periods of manic-like symptoms, including high energy level, inflated self-esteem, racing thoughts, distractibility, little if any sleep, and engagement in high pleasure activities without regard for consequences American Psychiatric Association, Seasonal Affective Disorder, a recently distinguished disorder, involves depressive symptoms manifested during the winter months, when there is less sunlight and more indoor confinement.

The heterogeneity of depressive symptomology makes it difficult to identify the exact mechanisms in the brain that are responsible for the disorder. Neurotransmitters are chemical messengers that connect the various areas of the brain through electrical and chemical processes. The neurotransmitters serotonin and norepinephrine have been implicated in understanding depression, with lower levels associated with depressive symptomology Hammen, The effectiveness of antidepressant medication has made the case for this relationship, with drugs that increase serotonin and norepinephrine resulting in the amelioration of depressive symptoms over time.

During stressful situations, the release of the hormone, cortisol, into the bloodstream mobilizes the body to cope with danger. In a short-term stress event, cortisol levels return to normal relatively quickly.

Cortisol can have damaging effects if the stressor is long lasting, or of high magnitude LeDoux, It is believed that excessive cortisol can destroy portions of the hippocampus, the brain center responsible for integrating new experiences into more long-term memory, leading to problems with new memory formation. This is often experienced as a loss of interest in previously engaging activities, dulled perception, and an agitated, negative mood state.

The stress reaction theory is bolstered by the robust findings that depressed individuals often have higher levels of cortisol in their bloodstream than nondepressed individuals do LeDoux, While early data was derived from studying admission rates to psychiatric hospitals, later findings have come from large population-based studies.

One such study, sponsored by the National Institute of Mental Health, examined samples from five population areas in the United States. Interviewers trained to detect the signs and symptoms of mental illness had in-depth interviews with 19, persons in New Haven, Connecticut; Baltimore, Maryland; Raleigh-Durham, North Carolina; St.

Perhaps the most powerful evidence for the expression of male-specific depression is the high suicide rate for men when compared to women. For example, suicide rates of men between the ages of 15 and 24 and for men over 80 are seven to fifteen times the rate of women of the same age. This data supports the hypothesis that because fewer men seek treatment for underlying depression, they are at a higher risk for a worsening of their mental condition with the result of self-inflicted death Cochran, Recent evidence supports the hypothesis that men may indeed experience depression differently than women.

A study of a large, nationally representative sample of U. Non-acculturated Chinese Americans living in Los Angeles were found to have no gender differences in rates of depression, but those who were higher on indices of acculturation showed the normal 2: These findings taken together suggest that cultural practices, as well as developmental stage of life, may have an impact on the gender normative way that depressive symptoms are expressed or suppressed.

Traditional Western culture gender role norms encourage a diminutive emotional response to many life events for men. Men are taught to suppress impulses to cry, to be strong in the face of adversity, and to solve problems independently. Showing emotional pain is thought to signify weakness and vulnerability. The consequences of not asking for help are often dire. Men are less likely to seek timely healthcare for medical and emotional problems, are less likely to share important information about their physical and mental health when they do make contact with a health care professional, have higher death rates than women for all 15 leading causes of death, and will die nearly seven years younger than women will Courtney, Men raised in a culture that values the suppression of distressing emotion may express depressive symptoms in a way that varies from traditional diagnostic observations.

Termed masculine-specific depression , these symptoms are often mistaken as normative male behaviors Cochran, ; Pollack, Since many men have been trained to avoid negative feelings by distracting themselves with mood altering activities, and because women have been reinforced for ruminating about distressing moods, it is not surprising to find that men are less likely to report depressive symptoms.

While effective in the short term, it still leaves open the question about whether this is a good long-term strategy. Cochran and Rabinowitz have outlined a gender-sensitive protocol for approaching the assessment task with depressed men that incorporates research findings that are derived from gender-specific findings and clinical case reports of therapists working with depressed male clients.

This protocol recommends first assessing for the more traditional symptoms of depression noted above, then covering the symptoms more likely to be manifested by men, addressing any culturally salient aspects of the presenting situation, and finally, assessing for suicide risk since men are at increased risk for committing suicide in the throes of a depressive episode.

Some men will simply present themselves as depressed and show the traditional DSM-5 symptoms such as sad or depressed mood, loss of interest or withdrawal from typical activities, sleep difficulties, trouble with concentration and thinking, thoughts of death and suicide, and so forth. For most clinicians, these types of presentations will be relatively straightforward and present minimal difficulties with assessment.

The main task for the psychotherapist in meeting men who present in this fashion is to create a welcoming and positive space for the male client to feel comfortable expressing these symptoms since they will most likely be uncomfortable for him to admit. Once the therapist creates this welcoming environment, typical follow up inquiry into the duration and severity of symptoms, family history of mood disorder, and evaluation of risk factors such as suicide can be accomplished in a straightforward fashion.

However, a sizable portion of male clients will present more oblique and difficult to decipher clusters of symptoms related to depression.

Men who are experiencing chronic physical pain are also likely to show irritability and interpersonal distress indicative of underlying depression Linton, Often, these men may be referred by a third party or coerced into a visit with a therapist in order to stay in a relationship or to be retained in an employment situation.

Obviously, these men present more challenging assessment tasks. They will often have difficulty with self-disclosure, preferring at first to respond to questions with minimal replies. Several researchers suggest that clinicians assess depression from a masculine-sensitive approach in order to get a more accurate read on male symptomology Addis, ; Cochran, ; Martin, et. The traditional symptoms such as dysphoria, thoughts of death, appetite change, sleep change, fatigue, diminished concentration, guilt, psychomotor changes, and loss of interest in previous activities should also be supplemented by the following criteria Cochran, , p.

Carlos, a year-old man with Hispanic ancestry, came to counseling at the urging of Helen, his wife of 30 years. She thought that he often seemed distant, preoccupied, and irritable. He often drank several shots of whiskey when he got home from his position as a mid-level manager of a large company.

They had a poor sex life, and had not made love in over six months. Their two daughters were both out of the house and married. Helen had recently gotten involved in her own individual counseling and was finding it helpful in understanding how her past was influencing their relationship.

Carlos had never been in counseling, but told her he would give it his best effort. During the first session, Carlos told the counselor that he was there mainly to please his wife. It took a few more sessions of increased sharing about his life, assurances of confidentiality, and the building of a solid working relationship with the counselor for Carlos, who first appeared cautious and tentative, to become more animated and open. His big revelation was that he had been having an affair with a coworker, and this was not the first time he had strayed outside the marriage.

He revealed that he had grown bored with his marriage long ago and had felt rejuvenated by the mainly sexual relationships he had taken up. For Carlos, the sessions represented a way for him to explore what had happened in his marriage, and try to understand why he was having affairs. Through counseling, Carlos recognized that he had been struggling with depression most of his adult life. He had medicated his low energy level and pessimistic thinking with alcohol, pornography and, eventually, sexual affairs.

His father had died when he was 11 and, as the oldest boy in the family, he had taken on a very responsible role growing up. He had learned to give up his own needs to help his mother and younger siblings. Aside from trying to decide whether he wanted to work on the relationship with Helen, Carlos talked emotionally about his father.

He became aware that the loss of this significant relationship had had an impact on how he saw himself in the world. Underneath his competent exterior, he worried about fulfilling his expected male role as a provider, including whether he was a good father and made enough money. As Cochran and Rabinowitz note, an important aspect of assessment with men presenting with depression is to evaluate suicide risk.

Presence of ideation, plan, means, and intent are important topics to cover. In addition to these aspects of suicide risk assessment, it is important for the clinician to be sensitive to masculine gender role derived risk-taking behavior and its possible relation to self-destructive behavior.

Careless and risky driving practices, heavy alcohol or substance use, extreme risk-taking in leisure pursuits, and other practices that may be sanctioned by the culture of masculinity that disdains self-care or help seeking may actually be manifestations of a wish to die.

Such considerations are important for the counselor to recognize and discuss directly with the male client. In addition to the clinical interview and history-taking in the initial sessions, the counselor may also utilize various scales to assess the male client's depression. Magovcevic and Addis created the Male Depression Scale, a self-report inventory to identify atypical symptoms of depression found in men. It is comprised of 21 items that assess symptoms of depression, to which the client answers on a scale from zero to three, with higher endorsement indicating higher levels of depression.

The Beck Depression Inventory has very impressive reliability and validity data to support its use. It is a dilemma for many men to seek treatment for any kind of health concern, let alone something as serious and shame-provoking as mental health. Men are often told to "man up" when faced with life problems. While some men find relief in physical workouts like running or weight lifting, feelings of doubt, shame, and depression are not so easily resolved in this manner. Often it is someone other than the man himself who initiates the possibility of psychiatric or psychological treatment; such as a concerned partner, family member, coworker, or even a legal sanction.

It is not uncommon for a man to first seek out his primary care physician with tangible complaint like sleep problems; sexual performance concerns; headaches; or pain in the back, neck, or gut. Physicians who do not probe deeply about a man's psychological state may find themselves prescribing pain medication, sleeping pills, and erectile dysfunction drugs when a man is really experiencing depression.

Since men are often less than forthcoming about describing the depth of their mood disturbance, depression must sometimes be inferred from the configuration of symptoms. When depression is diagnosed, medication is often a first step in treatment. Many men feel more comfortable with a medical model approach that emphasizes their condition being a biochemical abnormality that needs a biochemical treatment.

In recent years, there has been a proliferation of antidepressant medications introduced that are effective in altering the amounts of neurotransmitter substances in the brain.

The three major types of antidepressants are monoamine oxidase MAO inhibitors, tricyclics, and selective serotonin reuptake inhibitors SSRIs. MAO inhibitors allow the neurotransmitters dopamine, norepinephrine, and serotonin to remain at the synapse of the individual neurons longer, resulting in more being available and a corresponding subjective lifting of the depression LeDoux, Unfortunately, one of the side effects of this drug is the breakdown of the amino acid tyramine, leading to life-threatening high blood pressure when certain fermenting foods are digested including wine, beer, and cheeses.

With significantly fewer side effects, this class of drug selectively targets either serotonin or norepinephrine receptor sites, leading to the alleviation of depressed mood. Most of these drugs take weeks of continuous use to become fully effective.

For men, the main side effects of these medications has been found to be sexual dysfunction in the form of lower libido and delayed ejaculation Stuart, Electroconvulsive treatment ECT for depression, also popularly known as shock treatment, involves inducing an epileptic-like seizure in an individual.

This treatment, which takes place over several consecutive days, is used on a limited basis for individuals with the most severe catatonic forms of depressive disorder and who have been resistant to other interventions. ECT, which has been found to increase short-term memory loss and cause some confusion, has also been found to be effective in alleviating severe depressive symptomology for several months at a time.

The mechanism for its effectiveness is thought to be a resetting of the neurotransmitters serotonin, norepinephrine, and dopamine, but is still not fully understood Mayo Clinic, Research suggests that SSRIs alone may not be as effective without concurrent counseling. Cognitive-behavioral therapy for men focuses on confronting unrealistic expectations of the male role, and distortions in thinking and behaving that lead men toward a depressed outlook and mood Mahalik, Interpersonal therapy emphasizes examining and improving how the depressed individual approaches relationships and communicates needs and desires to others Elkin, et.

Recently, more innovative approaches to psychotherapy have shown promise as treatment for depression. Pollack has proposed a therapy that focuses on repairing childhood relational trauma, which has resulted from the abrogation of important interpersonal relationships. Cochran and Rabinowitz have described a counseling process that addresses the accumulation of losses at various developmental periods of life that make men more susceptible to depression. All three of these approaches have shown that vulnerability to male depression has a strong interpersonal component that should be addressed in treatment.

Mood changes, side effects, and reports about the effectiveness of a particular medication are relevant information for both the psychological and psychiatric treatment of the individual.

Although an initial awkwardness is to be expected, it is the counselor's job to make the creation of a therapeutic relationship a less threatening process. Starting with the present symptoms rather than quickly delving into the past can facilitate this. By carefully listening to the story the male client weaves, the counselor can combine in his or her responses empathy for the losses and traumas expressed, as well as relevant questions about history and suicide risk that don't change the context or flow of the story being told.

Most men seem more receptive to revealing themselves when their experience is framed by the counselor as a rich revelation of their life journey. Paradoxically, the depressed male client seems to want the counselor to have the energy to help him and at the same time, feel as depressed as he does. The energy drain that depressed clients seem to have on the therapist is a reminder that he or she must be willing to enter into the "low psychic space" of the client.

It is only from this space, that the clinician can truly empathize with the patient's experience and offer an existential kinship with life's downside Yalom, This willingness by the counselor to be with a man experiencing negativity in his life often gives the male patient hope and a sense that he is understood. In group therapy, this function can be shared among supportive group members Rabinowitz, This introjected self, which often has the voice of a parent, carries much power and when turned against the self has the capacity to immobilize the individual with anxiety and depression.

Often, this is projected onto the therapist. Some kind of man I am. Good thing you are getting paid for this. Drawing out the projection on the counselor allows these negative messages to be said aloud and confronted.

Often, a man does not realize how much impact these ideas have on his self-esteem and behavior. Assumptions about what it means to be a man, including being a son, father, partner, or worker, may be a big part of the unrealistic thinking in which a depressed man might engage Mahalik, This can be seen in the following exchange between Carlos and his counselor:. Sounds like someone in your life may have told you these words, and you bought them hook, line, and sinker.

It is usually a private berating with myself. Perhaps it is a part of why you have felt a sense of depression over the years. I think you are right. Nothing I do measures up except when a woman is interested in me.

That perks me up and takes me away from self-pity. She just sees I am withdrawn and I just say it has do with work. Maybe too much for both us. You have really established a pattern and it is hard to break. Talking about it is still not comfortable for you.

Talking to you is easier than I thought it would be. You might be right. Maybe when I actually stop beating myself up and accept myself, I can be more open. Held up to the light, depressive thinking is not very convincing. Often, the emotional retelling of hopes, triumphs, mistakes, and failures opens a man to see connections and patterns that he had never before noticed. With reflections of meaning and feeling by the therapist, an isolated series of life events can be transformed into an intricately organized web of pictures, emotions, and connections.

The therapy relationship itself serves as a model of relationships in which a man can be less than perfect, and emotionally open, while still being valued by another adult.

By fully investing in the therapeutic relationship, it is possible for a man to have breakthrough feelings of anger, deep sadness, joy, and laughter. Although it is rarely what he thought he was looking for, a man who can feel and express a range of emotion perceives himself less broken, and more whole. By learning how to disarm the shame brought on by his own harsh self-criticism and society's script for him as a male, he opens himself up to the world of connection and emotional aliveness.

The outcome of psychotherapy is not necessarily a permanent removal of depressing feelings but rather an acceptance of the emotional spectrum that comes with living life authentically Rabinowitz, In addition, being able to practice what was learned in therapy in his everyday world encourages a man to establish new patterns of behavior in which depressive thinking can be counteracted.

Poor intimacy skills in the form of shyness, isolation, and limited emotional expression may also lead to disturbances in relationships for men. It is also possible that underlying depression might exacerbate or even be a root cause for interpersonal difficulties. Depending on the stage of relational disturbance, a therapist must identify the form of therapy that would be most likely to be beneficial.

Often, a clinician will see a man who is in the final stages of a deteriorating relationship or one that has recently resulted in separation. In this circumstance, a therapist is more likely to work with the man individually to deal with unresolved emotional issues.

While individuals grieve in distinct ways, Worden has suggested that those going through relationship separation or divorce have the following psychological tasks to manage — accepting the reality of the loss, experiencing the emotional pain of grief, adjusting to a life without the partner, and detaching from the ex-partner in order to be psychologically open to new relationships. Male socialization issues often keep a man from fully acknowledging the impact of relationship loss.

A façade of self-reliance and strength often belies the anxiety, uncertainty, and depression that have brought him to therapy. It is more likely that his emotional response is being acted out in other venues. A Guide for Men. Whilst we have worked to make the Guide something that might be useful for all men who have experienced sexual abuse, we recognize that there are specific issues that particular groups of men face. We believe it will be useful to develop specifically adapted editions for Indigenous men, and for Men from Culturally and Linguistically Diverse Backgrounds, for example.

We would welcome contact from service providers or groups of men interested in working with us to suitably revise and adapt version for their communities.

On Tuesday the 10th of May , Living Well: The book has been updated and re-released several times since. Sources that contributed to the development of the Living Well: A Guide for Men booklet include:. Your email address will not be published. Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments via e-mail.

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Out of a fear of the unknown, they prefer suffering that is familiar. Accessing a copy You can access an A6 hard copy by contacting Living Well , or you may view and download an electronic version of the booklet below.

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