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Aversion to Therapy: Why Won’t Men Get Help?

• June 25, 2012 • 4:00 AM

Research shows that men benefit from talk therapy just as much, if not more, than women. Yet most men still won’t go.

Twenty years ago, Bob Smith’s wife questioned his commitment as a father. She demanded he see a psychiatrist. Smith (not his real name) grudgingly obliged. He went. Once.

“The idea of paying some guy $300 an hour to massage your issues,” says Smith, a Los Angeles-area attorney in his early 60s, “is ridiculous.”

In fact, the psychiatrist Smith talked to found plenty of issues to massage. His 45-minute assessment suggested that Smith was toting a veritable luggage store full of psychological baggage that needed unpacking. He recommended twice-weekly counseling sessions.

Smith was having none of it. Like millions of other American men, he simply couldn’t see paying good money for spilling his guts.

Fast-forward a couple of decades. Last year, Smith was diagnosed with a particularly virulent strain of prostate cancer that required immediate surgery, then radiation treatment. Still, he was disinclined to consider confiding in a professional all that he was enduring emotionally.

“I’m pissing in my pants and I can’t ejaculate and I want to talk to somebody else about that?” the Harvard Law School grad explains. “It’s a misapprehension that talking with a psychiatrist or a psychologist is going to move the ball forward. Some things … are what they are. The sooner you deal with them objectively, the better off you are.”

Smith is convinced. But increasingly, studies show that men like him who equate seeking assistance with weakness, or the appearance of not being able to handle their own problems, experience more soured relationships with their significant others, higher rates of debilitating illnesses, and earlier death.

The cathartic benefits of reaching out for help are hardly a secret. As scientists have come to better understand the inner workings of the brain, they have documented the potentially catastrophic consequences for individuals, particularly men, who go it alone when confronted by profound emotional challenges. Some men have started to take heed. Yet they remain a small minority. In 1998, about 1.47 of every 100 men in the United States sought outpatient help for depression; by 2007 it was 2.12 men per 100, according to a study sponsored by the federal Agency for Healthcare Research and Quality.

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Often, that help has come in the form of “magic bullet” pharmaceuticals instead of traditional “talk therapy.” In 1998, the study shows, 56.2 percent of men who chose treatment for depression did so by sitting down and discussing their issues with a therapist. By 2007, only 42.5 percent of men interested in treatment chose therapy. Meanwhile, those who popped prescription pills in an attempt to tackle their emotional issues increased from 68.8 percent in 1998 to 73.3 percent in 2007.

While clinicians and academicians may haggle over the pros and cons of treatment approaches—many advocate a combination of psychotherapy and pharmaceuticals—there is no denying the toxic consequences of untreated depression at its most feared extreme. Distraught men are dying by their own hand in ever-greater numbers.

Suicide overtook blood poisoning to become the 10th leading cause of death in the U.S. in 2009. Meanwhile, calls to the National Suicide Prevention Lifeline have continued to escalate every year since 2008, the beginning of the so-called Great Recession. That year, calls to the help line soared a staggering 36 percent.

Men account for nearly 8-in-10 suicides in the U.S. today, even though women are diagnosed more often with depression and make far more suicide attempts. Such numbers are hardly exclusive to U.S. males. Men perish by their own hand in greater frequency in virtually every other corner of the globe. Nowhere, in fact, do female suicides appear to outnumber those of males. Researchers the world over have struggled to explain why. More than a few believe that socialization, not biology, lies at the root of the deadly disparity.

University College Dublin sociologist Anne Cleary published a study in the journal Social Science & Medicine this year that found a common theme among 52 young Irish men who survived suicide attempts: all expressed reluctance to disclose to anyone the “significant, long-lasting” emotional pain that had threatened to overwhelm them.

They “used alcohol and drugs to cope—which exacerbated and prolonged their distress,” Cleary wrote. “Over time this led to a situation where they felt their options had narrowed, and suicidal action represented a way out of their difficulties. … They opted for suicide rather than disclose distress and seek help.”

Frank Ferrante, 60, knows the feeling.

Now a professional speaker living in San Francisco, Ferrante spent a turbulent childhood in the “very gritty, very volatile, very, very pessimistic” Italian neighborhood in Brooklyn that Martin Scorsese brought to life in Goodfellas.

From his passionate but mercurial father, a Merchant Marine born in Sicily, Ferrante began to formulate what he now sees as a “really corrupt notion of what it was to be a man.” John Wayne, Humphrey Bogart, and the larger-than-life wiseguys who lived down the block just reinforced the definition: “A man is someone who can endure as much pain as possible without letting anyone know.

“As an 11-year-old watching a gigantic black-and-white TV, I wanted to be a poet. I wanted to be a writer. I wanted to be a flamenco dancer,” he recalls.

None of which were acceptable—antithetical to masculinity, in his mind, as were the vulnerability, anxiety, and depression he struggled to hide from everyone. “What I was, was a chameleon. I guess I was good at it. But one could say, my ego smelled a rat.

“I escaped into the construction world. I did it for the next 30 years,” he says, pausing for a long moment before muttering, “Jesus Christ. ”

Even before he dropped out of high school, drugs silenced Ferrante’s doubts, reassuringly blurred his memories. He looked at narcotics as “curative”—the perfect self-medication.

It came crashing down along a twisted, violent road that included a corrosive marriage, arrests, and what he vaguely calls “more subtle things: not being present, not being available in my relationships.”

At the worst point, Ferrante, stoned, jumped onto the tracks where he hoped a subway train would provide a solution. But he misread the light he thought meant a train was approaching. Someone pulled him to safety, for the moment.

Eventually, he found his way to therapy (after getting into a 12-step program) where he explored his past, his regrets, and the very structure of his beliefs.

“It’s been a slow and arduous process of clearing stuff up,” he says. (In 2010, three San Francisco filmmakers produced a documentary, May I Be Frank, about Ferrante’s experiences. See the trailer below.)

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SUICIDE RATES AMONG MEN AGES 40 TO 49 have been rising for the past quarter century, and rates among men ages 50 to 59 sharply increased between 1999 and 2005, according to the most recent government statistics available. Though the numbers are not yet in for the years since, experts say that this grim trend may well have been exacerbated by the nation’s ongoing economic malaise, in which twice as many men as women lost their jobs.

The so-called “man-cession” sent overall male unemployment rates into double digits by 2009. It hit men in the prime of their work years especially hard, with nearly one in five men ages 25 to 54 left jobless. The pallid jobs recovery of 2011-12 has favored males over females, yet about one in 13 U.S. men remained unemployed as of April 2012. That figure contains ominous subcategories, including almost 3 million men unemployed for more than 27 weeks (three times as many long-term unemployed as in the last 40 years of record-keeping), and a million unemployed veterans (many carrying the wounds of war along with the burden of being without a job). Not counted at all are the nearly 35 million American men who have simply exited the workforce.

Many psychologists worry particularly about the recession’s ultimate toll on men who once may have defined their self-worth through their roles as breadwinners, only to lose those roles amid corporate downsizing and layoffs. How have men coped? Some, evidently, by drowning their sorrows. Alcohol sales rose every year during the recession, including a 9 percent rise in 2010.

In 2003, the federal National Institutes of Mental Health began posting online public-service spots in a “Real Men. Real Depression” campaign aimed at assuring those in the throes of depression that, “It takes courage to ask for help.” The campaign uses a firefighter, a police officer, and other men who’ve struggled with depression to illustrate that there is light at the proverbial end of the emotional tunnel—but only if they first muster the strength to ask for it.

Retired Air Force First Sergeant Patrick McCathern, among those who appear online in the NIMH spots, says he’d drink to “numb my head” to the depression that tormented him. CBut then you wake up the next day and it’s still there. … You have to deal with it,” McCathern warns.

It’s a cliché, but sometimes it’s true: many men would rather be lost in the wilderness than ask for directions; and they don’t like asking for help.

“We’re self-reliant. We want to do it ourselves,” asserts Fordham University psychology professor Jay Wade, president of the American Psychological Association’s Society for the Psychological Study of Men and Masculinity.

Oh sure, one guy might ask another to help him move a fridge if he absolutely can’t do it himself, Wade says. He may bend his bloody knuckles around the phone to call a plumber when the faucet’s still leaking after six trips to the hardware store. But when men at the highest rungs of the masculinity scale are faced with profound emotional pain, “they suck it up, move on, bury it, repress it,” according to Wade. “It doesn’t go away, obviously.”

Consider “Gary” a former big-city newspaper reporter and avid private pilot who was assigned to cover a midair collision between a small plane and a commercial airliner in Southern California in which everyone was killed, including several people on the ground. He arrived minutes after the crash. Homes were on fire. Body parts were strewn everywhere.

“You block it all out,” Gary says. “You tell yourself that detached head laying under that little tree can’t possibly be what you think it is, and do your job.”

Officials later that day released a list of names, people who had been aboard the stricken airliner, including a handful who were merely identified as “lap children.” Gary had two young children of his own. The thought, he says, of what it must’ve been like for the children and their parents as the jet fell out of the sky left him shaken.

When he got back to his newsroom, Gary says, his editor asked if he was okay. He assured him he was. To admit otherwise, he says, would’ve sent a message that he was incapable of handling tough assignments—professional suicide in the news business.

Though haunted by what he saw that day, Gary never sought counseling and says he eventually got over it. It would take him more than 10 years before he could will himself to pilot a small plane again.

“Would I have gotten back into flying sooner had I gone to see somebody? Probably,” he says. “But I just didn’t feel like talking about it, especially to a stranger.”

Statistics show that men are far less willing to visit a doctor of any kind, even when they’re having chest pain or experiencing other life-threatening symptoms, despite the fact that men die in greater numbers from 12 of the 15 most common causes of death. (Remember, women outlive men by an average of five to seven years.)

A study published last year by Rutgers University sociologists Kristen W. Springer and Dawne M. Mouzon found that health-care avoidance is most pronounced among “macho men,” those most invested in the belief that a “real” man is self-reliant and strong to the point of physical invulnerability. In their study of about 1,000 65-year-old men, those least likely to follow preventive health-care recommendations were more likely to favor traditional sex-role beliefs, measured by their endorsement of statements like, “A man should always try to project an air of confidence even if he really doesn’t feel confident inside” and, “When a man is feeling pain, he shouldn’t let it show.” Not surprisingly, those men were also less healthy.

If traditional men refrain from exposing their physical vulnerabilities in a doctor’s office, it stands to reason that they’d be unwilling to expose their emotional vulnerabilities in a counselor’s office, and that’s exactly what the evidence shows, according to Wade, the professor who heads up the masculinity division at the American Psychological Association.

To be sure, not every man needs to see a psychologist or psychiatrist, Wade and others are quick to point out. Many people adjust well on their own even in the face of catastrophic trauma, drawing on inner resources, resiliency, and guidance from family and trusted friends. But it doesn’t take a social scientist to realize that, sometimes, a genetic predisposition to depression or anxiety—perhaps exacerbated by the stresses of ordinary life—can add up to the kind of angst that threatens to overwhelm an individual’s coping mechanisms. Some individuals may initially try to “numb themselves out” by throwing themselves into their work as a distraction. As evidenced by the Irish study, alcohol and drug use are also common avenues of escape.

For many a manly man, a police DUI checkpoint and court-mandated counseling mark the first stops on the path to the therapist’s office. Often as not, it’s a wife or girlfriend who finally says, “Go see somebody or I’m leaving you.” But forcing men to sit through counseling sessions, mental health experts say, can itself be a minefield. Some men become resentful and even more noncommunicative if they are essentially sentenced to talk, even if the disempowering decision was ostensibly “for their own good.”

Where does it all begin, the foundation that in many men becomes a nearly impenetrable wall of stoicism?

It turns out, guys aren’t born as strong, silent types, just as girls aren’t emotive yakkers in the nursery. “The general public thinks masculinity comes with a Y chromosome,” says Ronald Levant, a professor of psychology at the University of Akron and the editor of the academic journal Psychology of Men & Masculinity. “In truth, decades of research show that sex differences between men and women and girls and boys are very small.”

A reluctance to share feelings is hardly exclusively a “man thing.” Many women also shun any form of help that might expose their emotional vulnerabilities. The real difference is the way most boys are socialized to act tough—and suffer social consequences when they don’t, says Levant, whose own traditional upbringing during the 1950s in hardscrabble South Central Los Angeles, where “all the fathers worked at Firestone or General Motors,” was a ready-made laboratory for his future academic studies.

Studies show, perhaps surprisingly, that most male babies actually start out more emotionally expressive than females. It’s not long, however, before they pick up on clear messages from those around them, especially parents and grandparents, that boys are strong, that they don’t cry and never complain no matter what. Sure enough, by age 2, boys are less verbally expressive than girls.

Consider, Levant says, what happens when a boy scrapes his knee while learning to ride a bicycle or playing sports. If the boy cries, his dad or coach will demand he walk it off. By ages 4 to 6, boys are less likely to register their emotions on their faces. As early as fourth grade, Levant says, boys are more reluctant to ask for help in resolving conflicts with peers. These behavioral patterns extend into adulthood.

While it may not seem obvious in these days of macho yoga and stay-at-home fatherhood, the truth is that many American men hold to traditional values: real men are embodied by the archetypal “strong, silent type” characters played by Clint Eastwood or Chuck Norris. Psychologists like Levant even have a term for it: “normative male alexithymia,” which literally translates as “without words for emotions.”

Swept up in the counterculture environment of Berkeley in the 1960s, Levant says his exposure to feminism, civil rights, and sexual freedom made him begin to question his conformity to male “rules.” But it wasn’t until years later, as a single father, that it dawned on him that he was not alone in questioning the emotionally repressed models of masculine behavior from his youth.

In 1995, he helped to create a division within the American Psychological Association dedicated to men and masculinity. The group explores, scientifically, the consequences of and alternatives to rigid social expectations of masculine behavior as a means of “enhancing men’s capacity to experience their full human potential.”

It might sound like so much psychobabble, but a critical component of his mission, Levant says, is to help men learn to be more in touch with their own feelings, to the extent that they can at least recognize when those feelings are symptomatic of a real problem—the psychological equivalent of chest pain.

As Tony Soprano learned when he finally sought help for his panic attacks, psychotherapists today, likely as not, wear lipstick. Nearly three in every four licensed psychologists who hold doctorate degrees are female, as are almost 80 percent of master’s-level students in psychology-related fields of study. This disproportion, experienced counselors say, can pose both an advantage and a disadvantage for male patients.

On the one hand, men who are interested but hesitant to sit down with any psychotherapist may regard a woman as more nurturing, empathetic, and less threatening. The patient may ultimately be more willing to open up. On the other hand, female psychotherapists who tend by their training and their own socialization to be emotive, run the risk of alienating men by trying to counsel them, however subtly, to be like them.

Instead, psychologists like Jay Wade start their counseling sessions by commending reluctant male clients for the courage it took just to show up. Then they strive to cultivate the image of therapist-as-partner. The approach is less like a sensitivity trainer beseeching, “How do you feel?” and more like a golf pro paid to help refine your swing.

Bob Diddlebock, 59, a clinically depressed freelance writer in Denver, says he tried counseling but found sessions with the female psychologist he was referred to, to be distracting.

“All I wanted to do was [have sex with] her,” Diddlebock says.

His brother-in-law at the time, a “cool guy” whom Diddlebock admired, suggested a male psychologist he was seeing. That was in 1995. Diddlebock’s been going to that psychologist ever since, as often as three times a week.

“That guy has basically thrown me a lifesaver,” Diddlebock says. “There have been times I’ve crawled in on my knees. And I’ve been able to walk out.”

That he and the therapist are contemporaries helped, Diddlebock says. So did the fact that the therapist was “very intuitive and insightful, both in a clinical and real-world way. He can go real deep on what [stuff] means, and how it reflects on my thinking. He doesn’t repeat himself.”

Diddlebock, who also takes antidepressants prescribed by a physician, figures he’s paid upwards of $30,000 over the years for services rendered. It’s been money well spent, he says. Still, Diddlebock’s younger brother, a building contractor who lives in Idaho’s Teton Mountains and enjoys elk hunting on horseback, called him a “wimp” for seeking psychological help. The brothers haven’t spoken in years.

The most optimistic psychotherapists envision a day when even the most macho of macho men will sit down with skilled counselors to off-load the emotional burdens of dysfunctional relationships and traumatic events. But old biases die hard: sessions, they predict, will likely be called “skills training” or “weekend solution workshops.” Anything but “psychotherapy.”

East of Los Angeles, at the University of Redlands college counseling center where Fredric E. Rabinowitz has practiced psychotherapy for three decades, change is already afoot. The 3-females-to-1-male ratio of students seeking therapy on campus has hardly budged over the years, Rabinowitz says, but the stigma of therapy among young men has. “They’re less judgmental about guys that go for counseling,” Rabinowitz says. “I believe that 9/11 was a big turning point for this generation. Men were seen crying in reaction to the carnage in New York.”

Depressed college men continue to find benefit in the “feel bad, take a pill” simplicity of antidepressants, Rabinowitz says, but the frequently experienced sexual side effects of these SSRIs often drive them in exasperation to his office.

“Once guys have made it into counseling, they like it,” says Rabinowitz, co-author of Deepening Psychotherapy With Men. “Once it is reframed as a sign of strength to seek help … most men find talking and processing their experience therapeutic.”

Most, maybe, but certainly not all.

Lawyer Bob Smith remains skeptical that he could ever possibly benefit in any measure from psychotherapy aimed at getting to the roots of what he concedes are anger issues and less-than-ideal relationships with others. He says he is comfortable with who he is, angst and all.

“As soon as you get in the hands of one of these guys, you suddenly have a whole panoply of problems you have to ‘work through,’” Smith says cynically. “They want you to set up meetings twice a week. I’m an attorney. I know how the game is played.”

Perhaps.

But experts warn that for men like Smith, the go-it-alone mind-set may exact its own grave price.

Betsy Bates Freed and David Freed
Clinical psychologist Betsy Bates Freed blogs on psychological issues for The Oncology Report and is a frequent contributor to Clinical Psychiatric News. David Freed, a screenwriter and former investigative reporter for Los Angeles Times, is the author of the new mystery novel Flat Spin.

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