Many of my clients are men. This perhaps reflects the fact that I am a male therapist with research interests in men’s mental health. Much has been written about the possible barriers to men seeking therapy (therapist–client power imbalances, influence of dominant masculinities, the arguably feminised nature of psychotherapy, for example1). These barriers have been implicated in low rates of help-seeking2 and poor health outcomes for men.3
Much theoretical work has been devoted to accounting for these phenomena (see, for example, Jim O’Neil’s gender role conflict paradigm4), as well as practical attempts to make the therapeutic encounter ‘male-friendly’ in order to improve engagement. These efforts encompass everything from behavioural-based strategies, such as using euphemistic jargon and specific therapeutic approaches, to the introduction of pool tables and sports magazines in therapy waiting rooms.
Engagement and collaboration underpin therapeutic work, regardless of the client’s gender. One of my interests is how these principles are best applied to our work with men. Collaboration has been defined in various ways but often refers to collective responsibility in planning and engaging with the therapeutic process.5 Is collaboration with men best achieved by providing a male-friendly physical space and adopting specific therapeutic techniques? While these approaches may have some merit (possibly excluding tabletop games and glossy magazines), I believe there are other means by which we can achieve our goals of collaboration and a positive therapeutic experience for men.
I have been particularly interested in the self-initiated coping strategies men use when faced with adversity. Using a client’s existing coping repertoire as a basis for therapeutic work may enhance buy-in and collaboration because an intervention can be built on this foundation of existing skills, rather than therapist-led ‘feeding’ of strategies. This, of course, is not a new idea (this is the basis of strengths-based and solution-focused methods), but working in this way can potentially address many of the purported barriers to an effective therapeutic experience for men. However, many of our male clients are tied to a narrow range of coping strategies through the influence of restrictive (and toxic) forms of masculinity. So, when building on a client’s skills base, we may also need to encourage them to be willing to accept different forms of masculinity and to try new coping strategies through the concept of ‘flexible masculinity’.
This process is the subject of my research, and this article.
Identifying men’s coping practices
Men’s coping practices are sometimes portrayed in narrow and stereotypical ways. Phrases such as ‘the strong and silent type’ or ‘boys don’t cry’ come to mind. Some researchers have challenged assumptions of this kind, such as the notion that men are more likely to use hands-on or problem-focused coping strategies.6 Qualitative research reveals a far more nuanced picture of men’s coping across a range of psychological, medical and psychosocial challenges. A strength of this research is that the coping strategies are not determined before data collection (unlike in quantitative research, where different coping skills will be listed in a structured questionnaire). I have, with colleagues, published reviews of qualitative research on the coping strategies men used when faced with three major life challenges – depression, prostate cancer and caring for a physically ill family member.7-9 We synthesised the findings from a total of 48 studies and interview data from approximately 1,000 participants, and found a very varied picture. Men self-reported numerous coping strategies, including those more frequently associated with women, such as talking to others and seeking support, looking for meaning in adversity, using humour or positive coping statements and seeking information (in the case of health conditions).
We were able to group these strategies into four categories.
1. Avoidance and minimisation
This category refers to the mental/cognitive and behavioural strategies men used to avoid, downplay, distract from, deny, or conceal psychological distress. Therapists will be familiar with the examples of substance use and social withdrawal, but we found other coping strategies in this category. For instance, a group of men with arthritis reported physically overexerting themselves and missing medication in order to prioritise social activities.10
2. Resisting change and using existing masculinities
This encompassed coping strategies that subscribed to a dominant or hegemonic version of masculinity as a guide to managing thoughts, feelings and behaviours. It included many of the stereotypical male coping behaviours referred to earlier in the article, along with attempts to maintain the status quo in life, such as resisting change to daily routines and seeking to exert control over others (thereby illustrating strength, dominance and power). Men in one study of carers11 treated the care role like a job, minimising emotional aspects and attempting to ‘take charge’ of care-related duties.
3. Positive adjustment, acceptance, and reframing
This category described a set of largely cognitive strategies entailing personal growth and adjustment through re-evaluation, reflection and repositioning of values, beliefs and behaviour. Several studies have found that men cope with adversity by finding meaning or purpose in the challenges they face. One participant in a study on living with prostate cancer talked about how his diagnosis gave him the opportunity to live a full life.12
4. Flexible masculinity
This category included strategies that sought to challenge and reinterpret dominant or existing views of masculinity in the pursuit of a more flexible representation of gender roles. It encompassed challenging existing beliefs, undertaking new coping responses and social roles, seeking help and assisting others. One example was expanding the definition of ‘strength’ to include seeking help in the face of pressure to manage alone. ‘Reworking manhood’ was cited in one study where unemployed men sought to undertake and legitimise roles such as ‘Mr Housework’ and ‘househusband’.13
Of these, flexible masculinity is perhaps the most interesting coping category for me. More attention has been given to forms of masculinity perceived to be damaging and restrictive, as evidenced by the large body of theoretical literature on concepts ranging from Joseph Pleck’s gender role strain paradigm14 to Raewyn Connell’s hegemonic masculinity.15 There has also been strong focus in empirical literature on the relationship between masculinity and negative health and behavioural outcomes, referred to at the start of this article. However, recent research suggests that interest in flexible masculinity is growing. Examples include a US study of the ways in which adolescents actively resist masculine norms16 and a description of a ‘positive’ form of masculinity for use in psychotherapy.17 The broader construct of psychological flexibility has been associated with positive wellbeing.18 These examples show that flexibility is a relevant and important idea in psychotherapeutic practice, and the research also demonstrates some ways in which therapists can work with male clients to develop this flexibility and so broaden their coping skills.
Developing coping strategies
One implication of the above findings is that we should challenge stereotypical notions of what men’s coping looks like – our own and those prevalent in wider society. The above categories illustrate the range of self-initiated coping strategies a therapist may encounter with male clients. Some of these responses are perhaps more diverse than those that are more commonly portrayed within academic circles and in the media and in movies.
Another implication is that therapists should reflect on our own assumptions about men’s coping. Do you hold preconceived or stereotypical views of how men respond to adversity? I can get caught in this trap, particularly when a male client presents with behaviours that might fit a prevailing stereotype (for example, using drugs or alcohol to avoid painful emotions). If we are unaware of our own biases, it can mean that we fail to recognise the full range of a client’s actual coping strategies and may miss potentially important opportunities for therapeutic collaboration and skill development. Therapist self-reflection can therefore be useful in preparation for coping-skills work with male clients.
To further counter the negative effect of any unhelpful assumptions, a therapist should explore male clients’ existing strategies when assessing their coping repertoire. The above categories could be used as a framework for such an assessment, and the exploration itself may enhance our male clients’ engagement and collaboration. If we can identify coping skills that come under these four categories, we can then look to develop these strategies with clients. Be aware that these four categories are not exhaustive – male clients may use others not included here, such as rumination or self-harm.
Once client and therapist have developed a picture of the client’s current coping strategies, we can move on to critically evaluating their usefulness. One helpful tool from the behavioural paradigm is functional analysis. This allows us to explore the functions (contingencies) of coping behaviours and, ultimately, the ‘workability’ of these strategies (to borrow ACT parlance). Therapists can also explore this issue with clients by examining the short- and long-term consequences of a particular coping strategy. Many approaches have short-term appeal (for example, negative reinforcement through avoiding an anxiety-provoking social event) but may exacerbate an underlying problem if used habitually (for example, reduced circle of friends and social support).
Collaborative working in this case may involve helping the client discern between situations in which social avoidance has some value (for example, minimising distress during a crisis) and circumstances where another approach may be more appropriate. In this way, existing strategies can be acknowledged but used more strategically for maximum benefit. The therapist can then work with the client to develop his distress-tolerance skills, using relaxation training and positive coping statements, for example. In this way the client can be helped to find it easier to ‘sit with’ difficult emotions when experimenting with new coping approaches – as when discussing an important but distressing topic with a partner, instead of closing down on him/her.
Promoting flexible masculinity
It may be helpful to consider both increased flexibility and retrenching to stereotypical representations of masculinity when exploring the influence of gender socialisation on male clients’ coping choices. One tricky issue for therapists is that the construct of psychological flexibility is conceptually broad and will be defined in various ways, depending on your academic or therapeutic orientation (namely, flexibility in terms of neuropsychological functioning vs the ability to engage with a range of emotional experiences). The description of flexible masculinity as a coping response provided earlier may be useful here, as it refers to a broad, malleable cognitive and behavioural perspective on identity and coping.
How can therapists promote flexible masculinity? This is an important question – psychological and gender-role flexibility are both associated with positive wellbeing.19 There are many potential tools available for this purpose. One approach is for the therapist to model a wide breadth of interpretations of masculinity in sessions. Or they might encourage a male client to spend time with men with a wide variety of occupational, socioeconomic, religious, sexual and ethnic identities. This may allow the client to see masculinity as pluralistic (existing in various forms), rather than as a monolithic, rigid and toxic stereotype. In sessions, clients could be asked to think about encounters in their own lives with different ‘types’ of men. Reflecting on what can be learned from these observations can help men challenge their views on masculinity. Popular therapeutic models such as CBT or acceptance and commitment therapy (ACT) offer specific tools for developing flexible masculinity. For example, in CBT, the therapist might challenge restrictive assumptions about how men ‘should’ behave; in ACT, the client could be encouraged to try out mentally unhooking from habitual, judgemental thinking – such as feeling like a ‘failed man’, for example.
Coming to therapy can be an anxiety-provoking and challenging experience (and not just for men!). Gender socialisation can make it harder for men to engage with therapy and benefit from it. Working with men’s existing coping strategies can be an effective way to engage them by forming a collaborative working relationship. Men adopt a wide range of coping strategies to cope with life’s adversities. Some will be adaptive, others unhelpful, but we can use them as a basis on which to build male clients’ coping capacities. The concept of flexible masculinity may have much to offer in that it takes a client’s thinking beyond what men ‘should’ and ‘shouldn’t’ be and encourages a broad conceptualisation of how men think and act.
Jason Spendelow is a research-active clinical psychologist in practice since 2005. He is registered with the Health and Care Professions Council and is a chartered member of the British Psychological Society. Jason has specific interests in men’s mental health, psychological issues in medical conditions and carer wellbeing. www.jasonspendelow.com
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