The Masculine Experience in Psychotherapy: An Examination of Clinical Processes and Outcomes

Anthony Cavalier

Recent decades have seen an abundance ofattention towards the subject of women’s mental
health, with a trend emerging that recognizes the influence of gender on both research in the field and on the therapeutic process. Contemporary psychologists such as Carol Gilligan and Jean Baker Miller, for instance, published numerous works in past decades that have aimed to elevate the construct of femininity to the forefront of current theory, and to inform the field of its unique implications for the clinical treatment of women. However, the subject of masculinity has received far less attention in psychological literature, perhaps representing a pushback against the male-centered theories that for so long dominated the field. Consequently, far less is known about the male experience in psychotherapy and how the pressures and confines of masculinity affect the clinical process. Thus, this review aims to synthesize the current research regarding the interaction between masculinity and psychotherapy, with a specific focus on the presenting problems associated with masculinity, the effect of masculinity on the therapeutic relationship, and masculinity’s association to clinical outcomes. Finally, this paper will suggest future directions for research and comment on the limitations of the current research.
Objectives of this Review
This review will present an overview of the literature regarding the male experience in psychotherapy. It will expound upon three specific aspects of the therapeutic process: the presenting problem that has brought the client into psychotherapy, the construction of the therapeutic relationship, and finally the clinical outcomes. The interaction of a masculine-oriented client with these processes will be of specific interest, and conclusions regarding the unique masculine experience in psychotherapy will ultimately be drawn based upon an examination of the current research.

What Is Masculinity?
For the present review, masculinity is assumed to encompass all traits that past research has systematically associated with maleness. Traditionally, these traits include, but are not limited to, independence, stoicism, aggression, competiveness, and rationalism, and together these traits compose the typical western archetype of a masculine individual (Ogrodniczuk, 2006). While examining the origin of these gendered traits would be beyond the scope of this review, researchers generally agree that they result primarily from socialization (Addis & Mahalik, 2003). Therefore, although this review will use the terms “masculine” and “male” interchangeably, this is notably not always the case. This review instead embraces a nuanced understanding of gender in which it is assumed that any individual has the capacity to express a range of both traditionally masculine and feminine behaviors. Thus, the conclusions reached about masculine individuals will presumably apply to anyone who displays such traits, including women.

The Unique Presenting Problems of Masculinity
With the exception of the feminist school of psychotherapy, very few psychological paradigms comment on the influence of gender and gender role adherence on a client’s development of symptomology, with most theories focusing on the interpersonal, contextual, or biological correlates of a client’s symptoms. As such, few clinical treatments involve an examination of a client’s adherence or resistance to a masculine gender role despite current research suggesting that our concept of our gender role influences a wide array of psychological functioning ranging from our own self-concept to the quality of our external relationships. Tyson, Baffour, and Duong-Tran (2010) for instance, argue that one’s adherence to gender roles norms significantly affects an individual’s self-concept, psychological well-being, and pathology, This is further confirmed by the research of Werner Kierski, who has conducted numerous exhaustive studies on the subject. He concludes, “taken as a whole, men’s conflicted gender roles can lead to dysfunction in many realms impacting work and love” (Kierski & Blazina, 2009).

Moreover, the experience of gender role conflict – a pattern of negative consequences related to one’s adherence to or rejection of a masculine gender role – has been linked to numerous pathological behaviors, and research has shown that clients often benefit from the therapist’s examination and discussion of how interaction with a masculine gender role has contributed to the client’s presenting problem (Mahalik, Talmadge, Locke, & Scott, 2005). Specifically, Kierski identifies “substance abuse, learning problems, long-term problems following divorce, perpetration of physical violence and higher suicide levels” (Kierski & Blazina, 2009, p.60) as being linked to such gender role conflicts. Additionally, research has found evidence for a link between gender role conflict and increased incidences of anxiety, depression, intimacy problems, relationship and job satisfaction, and such conflicts were also related to a decreased willingness to seek help on behalf of the client (Pederson & Vogel, 2007).

The issue of men’s reluctance to enter psychotherapy has been the focus of the multitude of research on masculinity and psychotherapy, as it is recognized that men currently enter therapy at significantly lower rates than do women. This trend has also been of particular interest to clinical researchers, who worry that the current mental health system is inadequately and unevenly serving clients. There have therefore been numerous explanations for why this phenomenon occurs, with many interpretations focusing on the purported conflicts between therapeutic techniques (introspection, disclosure, etc.), and masculine ideals. Pederson and Vogel (2007), for example, concluded that there exists empirical support for the argument that gender role conflict leaves men less willing to enter counseling, particularly when they are uncomfortable about disclosure and when they “self-stigmatize” about therapy. Additionally, a study by Park and Hatchet (2006) concluded that clients who scored higher on a masculinity inventory had more negative views about psychotherapy when compared to more feminine clients. Kierski and Blazina (2009) also suggested that “many men…are likely to disregard counseling…as the antithesis of masculine success” (p. 156). Therefore, it can be concluded that a correlation exists between masculinity and the decreased likelihood of entering a therapeutic setting.

Certainly, it appears that the masculine emphasis on traits such as self-reliance, stoicism, and autonomy often conflicts with many men’s perceptions of what it means to be in psychotherapy, which often includes ideas of extreme emotional disclosure and submission to analysis by a clinician. However the body of literature suggests that men are more willing to undertake the process of therapy when they find that their preconceived notions are incorrect and that, in fact, therapy need not be an emotionally demanding task. Thus, Pederson and Vogel (2007) suggest that men may be more willing to enter therapy when they are able to focus not on emotions but rather on cognitions, which are more stereotypically “gender-aligned” for males.

Ultimately, the research describes a tenuous relationship between masculinity and one’s development of pathological behavior and consequently their willingness to enter psychotherapy. Research has demonstrated that gender role conflicts are significantly related to psychological disorders and distress, and that numerous instances of psychological disturbances are related to one’s experience of gender (Kierski & Blazina, 2009; Pederson & Vogel, 2007). Thus, it becomes an increasingly important task for clinicians to recognize the symptoms that are related to a conflict in gender roles, as it is probable that few clinicians recognize seemingly common problems (anxiety, depression, substance abuse, etc.) as originating due to one’s conflict over their adherence to a masculine gender role. Therefore, clinicians should become familiar with recognizing the signs of a masculine gender role conflict before applying the appropriate treatment.

The Therapeutic Relationship
The therapeutic relationship is a fundamental aspect of the clinical process, referring to the unconditional helping alliance between a therapist and his/her client. This relationship remains an integral part of the clinical process, as the degree to which a client derives benefit from therapy is almost always contingent upon the quality of interaction with one’s therapist. Therefore, therapy is unlikely to succeed if a trusting relationship between the client and the therapist fails to develop. However, conformity to a masculine gender role presents many challenges to the construction of this relationship, and research has found that men who conform strictly to masculine norms often face difficulties in therapy related to the quality of the relationship with their therapist (Tyson et al., 2009; Owen, Wong, & Rodolfa, 2010).

In search of gender differences in the therapeutic process, Tyson et al. (2009) conducted a study examining the coping strategies of men and women in times of crisis. They argue that, in accordance with multiple therapeutic models, clients are thought to bring to therapy a powerful collection of strengths, coping strategies, and resilient traits that can be accessed to produce positive change in times of distress. While the researchers hypothesized that men and women would display distinct coping strategies, they found that, in fact, they were more similar in their choices of coping styles than dissimilar. One of the most interesting findings from this study suggested that men use relational coping strategies as often as women (Tyson et al., 2009), suggesting that the construction of a therapeutic relationship can be critical to the development of beneficial clinical outcomes.

As for the content of the therapeutic relationship, research has suggested that a client’s perceptions of the therapist can be influenced by one’s adherence to a masculine gender type. For instance, studies conducted by Owen et al. (2010) confirmed that a client’s perceived helpfulness of therapist techniques typically fluctuates in accordance with their conformity to masculine norms. This has significant implications for clinical practice, as it suggests that therapists must remain cognizant of the way that their clients perceive them and how those perceptions are related to the client’s gendered experience.

Further research has suggested that men have particular difficulty with the aspects of therapy that relate to emotional disclosure. Pattee and Farber (2008), for instance, posit that, “men tend to feel more exposed and vulnerable than women when revealing strong emotions.” They go on to argue that the lesser the degree to which one adheres to masculine norms, the greater their willingness is to commit to disclosure (Pattee & Farber, 2008). In spite of this, several researchers have proposed that therapists should provide clinical services that correspond to the client’s perceptions of therapy, so as not to force a novel and perhaps even frightening task on an already hesitant client. John Ogrodniczuk (2006), who remains a highly cited academic in the field, is one such researcher who supports this interpretation. He argues that the construction of a successful therapeutic relationship is contingent upon the client’s ability to trust the therapist, and that the development of trust can only occur when therapy unfolds in a manner that corresponds to the client’s distinct inclinations and needs. He writes that “providing relationships that are consistent with the preferences of women and men facilitate trust and willingness to work…in turn…enabling women or men to tackle different issues and engage in new coping strategies that otherwise would have been avoided” (Ogrodniczuk, 2006).

Subsequent studies have shown that is often the clinical techniques that clients find most challenging that are actually the ones that provide for the best therapeutic outcomes and for the most enriching therapeutic relationships, a fact that Ogrodniczuk alluded to above. He argues that, while a “neutral relationship” between the client and the therapist may best serve traditionally masculine clients, they also benefit greatly from “introspection and examination of uncomfortable emotions” (Ogrodniczuk, 2006). He suggests that this is largely due to the novelty of these measures to masculine-oriented clients who typically resist exposure to such therapeutic techniques. Indeed, these findings were replicated in observations of same-sex counseling groups, in which all-male groups were shown to exhibit counter-productive masculine behaviors such as aggression and dominance, while mixed-gender groups displayed more integrated therapeutic methods leading in turn to greater “cohesion” and “therapeutic evolution” (Currat & Michel, 2006). The research of Owen et al. (2010) confirms this, as they concluded that, when working with more masculine clients, therapists need not avoid therapeutic approaches that are “incongruent” with masculine values. In fact, such measures may be the therapeutic components that masculine clients find most useful. Therapists should take care, however, not to introduce these “incongruent” measures before a client is ready and able to sufficiently benefit from them.

In sum, the type of therapeutic relationship that traditionally masculine clients often find to be most helpful involves the gradual introduction of the clinical techniques that are typically perceived to be at odds with the masculine gender type (i.e. emotional introspection and disclosure). However, such clinical techniques should be instituted only after the construction of a therapeutic environment that is conducive to the client’s exploration of these “gender atypical” behaviors. Additionally, special care should be taken by clinicians not to overwhelm or discourage new clients by presenting them with therapeutic techniques with which they aren’t familiar or which they find initially discomforting.

Therapeutic Outcomes
Perhaps the majority of the research conducted on clinical settings in recent decades has focused on outcomes and so-called “evidence-based treatment.” Research on gender differences among therapeutic outcomes has received particular attention, with the overwhelming consensus being that therapeutic outcomes are not significantly affected by the client’s gender (Ogrodniczuk, 2006). However, the body of research on the subject has produced other findings of interest in regards to gender-role conformity, as evidence has emerged linking adherence to a masculine gender role with poorer therapeutic outcomes. For instance, Owen et al. (2010) concluded definitively that clients who recounted greater adherence to masculine roles experienced inferior therapeutic outcomes. This trend likely results from the challenges described in the previous section pertaining to the construction of a healthy therapeutic relationship, and in particular from masculine clients’ traditional rejection of introspection and disclosure.

Moreover, other researchers have found evidence for clinicians’ gender competency in treating clients, and have linked this competency to improved therapeutic outcomes (Owen & Wong, 2009; Heru, Strong, Price, & Recupero, 2006). Concepts of a therapist’s gender competency, by definition, encompasses his/her ability to effectively treat clients of both genders, and it assumes that clinicians are often better at treating either male or female patients. Owen & Wong (2009) conducted an empirical search for evidence that such competency is reflected through clinical outcomes, and concluded that the “findings suggest that psychotherapists’ ability to work effectively with men or women do account for a meaningful proportion of psychotherapy outcomes.” A study by Williams and McBain (2006) lends further support for these findings, as the authors argued that internalized concepts of gender significantly affect the work of therapists. They proposed that therapists develop concepts of appropriate client behavior based on the client’s gender, which in turn manifests itself in counseling. In support of these assertions the authors cited past studies that have found evidence for therapists’ differential treatment of clients as a function of their gender, for instance reporting findings that showed that therapists interrupted male clients less than they did female clients in counseling (Williams & McBain, 2006). Moreover, other studies have linked the development of a stronger therapeutic alliance to both the gender of the therapist and of the client, suggesting that there may indeed be an ideal therapist “match” for each client based around their gender or gender-role conformity (Wintersteen, Mensinger, & Diamond, 2005). Together these findings can perhaps explain the lack of evidence suggesting differential outcomes for men and women in psychotherapy, as previous studies assumed that therapists were equally competent to treat both men and women (Owen & Wong, 2009).

Current research has identified other factors that have been linked to gender-related therapeutic outcomes, with evidence existing that the effect of transference interpretations accounts for meaningful differences in therapeutic outcomes among men and women (Ulberg, Marble, & Hoglend, 2009). Transference, which represents a client’s tendency to reconstruct past or current relationships in the person of the therapist, is an important part of many psychotherapeutic models, and is especially important in the psychodynamic tradition. Thus Ulberg, Johansson, Marble, and Hoglend (2009) conducted a study that aimed to determine if men and women respond differently to transference interpretations. The researchers found that men and women had different responses to transference, with women apparently being the greater beneficiary of such a technique. Sex, according the researchers, was discovered to be a moderator of the effects of transference interpretations, suggesting that women benefit more from therapy involving transference interpretations, whereas men improve more when therapy does not feature transference interpretations (Ulberg, Johansson, et al., 2009). These findings provide further evidence for the existence of differential clinical outcomes in regards to male and female patients.

Ultimately, a client’s adherence to a masculine model appears to have an inhibitory effect on the success of psychotherapy. While research has failed to provide a definitive link between one’s anatomical gender and their success in psychotherapy, it has identified a relation between one’s conformity to a masculine gender role and decreased therapeutic efficacy. Thus, the task for therapists is one of recognizing and accommodating for the masculine patterns of cognition and behavior among clients that are related to these deficient outcomes. Furthermore, therapists would be well advised to be aware of the interaction between masculinity and therapeutic outcomes when analyzing their own efficacy in treating clients.

Suggestions for Future Research
The body of research on the topic of masculinity and its relation to psychotherapy is far from exhaustive, and there remain numerous gaps to be filled by future researchers. One of the most glaring limitations of the current research is its sample, as most studies recruit participants who were previously hoping to enter therapy or who were already enrolled. Thus there are likely to be systematic differences between those who voluntarily seek therapy and those who do not. Additionally, the vast majority of the studies reviewed focused on adult populations, and much less attention has been devoted to children, adolescents, and the elderly and their experiences with masculinity in therapy. Indeed, future research should focus on identifying longitudinal trends regarding the development of a masculine gender role and its interaction with psychotherapy.

The current research also lacks variability in the types of therapies selected for study. Specifically, interpersonal psychotherapies are well represented while cognitive-behavioral therapy has been all but neglected. Therefore the literature would be greatly enriched by studies that seek to examine the efficacy of multiple types of therapy in regards to masculinity. In addition, the majority of studies reviewed did not attempt to disentangle “masculinity” from “maleness,” and instead assumed that the two terms are equivalent. Thus future research should focus less on the male vs. female dichotomy, and instead on the outcomes and processes associated with masculinity and femininity.

Conclusion
Gender is one of the defining constructs affecting our perceptions and our experience of the world around us. As such, it is logical to conclude that adherence to a masculine gender role interacts significantly with the clinical process to produce a distinct therapeutic experience for masculine clients. The research undeniably supports this assertion, as the male experience in psychotherapy has been shown to be unique in terms of masculine clients’ presenting problems, as well as in terms of the therapeutic relationship and clinical outcomes. Thus therapists should remain cognizant of the interactions between a client’s masculine world-view and their experience in therapy, and should aim to tailor their therapeutic practices to the concerns of a masculine-oriented client.

References

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Author’s Biography

Anthony Nicholas Cavaller is a senior in the Applied Psychology program. His main research interests include gender studies and clinical practice outcomes. After graduating, he plans to take time off before pursuing a graduate degree.