The Futility of Psychotherapy: APA Guidelines for Psychological Practice with Boys and Men II.

Out Like a Lamb

Gore Vidal once said that since it is power, not sex, that is the true motor to human life, young people no longer swallow goldfish or pack phone booths. They kill themselves. As vast disparities in both wealth and power have emerged quite rapidly within a generation or so of our history, this problem is likely to be exacerbated. Applications of psychological practice involving methods for increasing empathy, modeling the control of aggression, and the increase of communication skills or problem solving would surely be useful. But again, let us not forget that some proportion of the problems addressed may not be ones of individual dysfunction, but broader social patterns which may be better addressed by collective action.

One of my personal obsessions (see "Disembodied Communication" blog from 3.16.2018) is in trying to get people to understand just why the use of text-based electronic communication is likely to include unhealthy emotional effects, as a direct consequence of abstracting out all of the cues like facial expression and vocal tonality, that make it possible to share other people’s emotional states, including any compassion for their suffering. Empathy in college students has been dropping over the last 20 years, but precipitously since smartphones became common, and students’ social skills and face-to-face interactions have declined in frequency and quality. (Twenge). During the last few years of my teaching career, I used to have students each talk with a partner for the last ten minutes of each class. It made some of them uncomfortable. It was remedial.

One of my wisest colleagues in graduate school, upon finishing his last clinical report after a two-year long internship at Boston Children’s, walked away from his clinical training. “I went into psychology because I wanted to help people. Given the size of the social problems producing the most suffering, trying to help people using psychotherapy is trying to remove the Rock of Gibraltar with a dental pick.” He moved to Portland and got a job in technology, so he could come home from work and say “Honey I’m home, get me a beer. This morning widget x didn’t work. Now it does." It’s hard to tell whether psychotherapy is actually doing much, though wishful thinking and self-justification in both clients and therapists is surely part of the happy placebo effect.

My doctoral mentor left clinical work because he said “When clients are grateful, you know they haven’t really worked out their dependency issues. The healthy ones think they pretty much did it themselves, and often, they did.” You know how many psychologists it takes to change a light-bulb? One, but the light-bulb must really want to change. The opposite of a patient is an agent, and it is mostly problems with agency that are at issue in therapy, hence psychotherapists work with clients, not patients, though too many of them want to remain patients. Perhaps the male virtue of self-reliance might be better taught. Michael Gazzaniga was one of the fathers of cognitive neuroscience, and the author of a series of well written and informative trade books drawing on this discipline. He joked once, about a huge Indiana University study of depression that, since the best buffer against depression is a wider range for possibilities of reward, that the cure for depression might be.money.

One wonders whether the APA Guidelines for Psychological Practice with Boys and Men, promoting gender-sensitive psychological services, might start with some more attention to biological sex, epigenesis, development, and neuroscience. Perhaps one should not attribute too much to the “traditionally masculinity ideologies” which are, after all, the ideologies under which most men are socialized, and draw attention to the “power and privilege” which are not only distributed quite differentially across class, race, ethnicity, and sexual orientation, but are, by admission, invisible to most men. Does it seem that the ideology embedded within the Guidelines themselves are likely to alter the “disproportionately low numbers of men served by psychological services”? Or are the authors of the Guidelines shooting psychotherapy in the foot?

The Guidelines acknowledge “normative practices in therapy that can be iatrogenic for men.” I love that fancy word “iatrogenic.” One of the flaws of the DSM-5, the most recent incarnation of the Diagnostic and Statistical Manual of the American Psychiatric Association (a different APA, to be sure, but the DSM has always been the bible of mental health diagnosis, and was once a necessary reference for third-party insurance payments for psychotherapy) is coming up with diagnoses produced by iatrogenic effects of pharmacological interventions recommended for certain first-order diagnoses, and then recommending further such interventions for the iatrogenic effects. “Iatrogenic” just means that the problems may be created by the practices themselves, again, recognized as normative in psychotherapy.

Therapists sometimes make harmful assumptions “that men are unable to express emotions or are hyper-sexual or aggressive” Yes, but in comparison to what ideals of behavior and where do those ideals come from? Are the ideal forms of expression feminine ones? “Clinical methods that emphasize the language of feelings, disclosing vulnerability, and admitting dependency needs can create expressive difficulties for males who adopt and adhere to traditional masculine roles.” Of what proportion of the male gender spectrum, or, for that matter, the male population, might this be true? Is the presumption that the ideology embedded in the Guidelines themselves has become the new orthodoxy, to which dilatory men should be acculturated (or indoctrinated, one of the purposes, other than higher education, that colleges have now come to serve)?

As I have suggested, getting together for a good face-to-face chat is far more prototypical for women than men, perhaps one of the reasons for the “disproportionately low number of men served by psychological practice.” I used to joke that the prototypical interaction style for men, might be more like that between a second baseman and a shortstop on a baseball field, both aware of the base between them, and the status of batter and ball, with communication limited to what is necessary to get the job done. How many women would likely seek psychological services that involved “baseball therapy?” Perhaps more should. Happily, the Guidelines do suggest that for more gender-sensitive psychological services for boys and adolescents, “shorter sessions, informal settings outside the office (e.g. playground), instrumental activities involving humor and self-disclosure, and psycho-educational groups may provide more congruent environments than traditional psychotherapy.” So, too, would the greater inclusion of the burgeoning research about the neurophysiology of emotion in the training of psychologists. I still think it odd that so few undergraduate programs in psychology have courses dealing directly with emotion, since it is emotion, not cognition or perception, that normally bring clients to psychotherapy. Substituting other terms for psychotherapy like “consultation, meeting, coaching, or discussion,” using less jargon, and being more active and directive may be particularly effective with men but is probably useful advice for anyone.

Challenging the stigma of mental health problems is always difficult, which is why Britney Spears voluntarily checking herself into a facility is a step in the right direction. I presume that challenging “socialized messages” about male stoicism and self-reliance might also be added to other methods, including normalizing psychotherapy as a regular kind of “cognitive-emotional tune-up.” I was a regular psychotherapy client for at least a dozen years, and still think a periodic “tune-up” to be as sensible as regular trips to the dentist, or taking one’s car for maintenance, hardly threatening to stoicism or self-reliance. I do confess that I still use cognitive tricks to get myself to ask for directions. We’re all works in process.

Now, I am not a clinician, nor ever was. When I was offered a clinical traineeship at the beginning of my graduate education in psychology, I turned it down. All more reason that I was happy to see Michael Gurian’s January 24th Psychology Today post, “Masculinity is Not Our Enemy”.Gurian is not only the author of the 2012 Saving Our Sons, but is also a clinician, a child advocate, and has daughters. His initial warning is about academic culture, and I think this is the kind of culture that produced the APA Guidelines. He points out that while there are a lot of powerful men at the top of society, that there is no demographic group in which males are doing better than females, whether health, grades, test scores, higher education, college graduation, and safety. As I have shown, even the Guidelines themselves are good at pointing out male difficulties, including suicide rates, depression, anxiety, addiction and violence. My analysis agrees with his, that the Guidelines’ problem is the overemphasis on traditional masculinity ideologies, and the process by which men are so socialized, despite, as I have said, some lip service to biological sex. Gurian further asserts that masculinity is a good thing, and that academic institutions, as well as the American Psychological Association want to treat the “Strength, stoicism, aggression, and power” to be male problems, due largely to socialization, which should be addressed in clinical practice. “Guidelines” are, of course, supposed to be just that, requiring clinical judgment as to their use. Here is a clinical judgment celebrating masculinity:

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“…if boys are to survive in a complex world, they must work to be strong (resilient, empowered, able to perform, and at appropriate times, stoic in the face of enemies and hardship), aggressive (assertive, motivated, able to battle against bullies, as well as help us fight our wars both abroad and at home), and powerful (successful in work, in life, in leadership, and, when needed, in followership to leaders who are morally sound). These qualities are intertwined with tenderness, compassion, spiritual vitality, empathy, fortitude, character, and fatherhood. We are able to have compassion because we are strong, we are able to live from a position of kindness because we have the power to do so.”

Curious that the APA Guidelines say so little about the positive virtues of masculinity, what I have called “the other side of the coin” in the context of discussing the negatives which the Guidelines so regularly attack. Gurian points out that “the most dangerous man is not one who is strong, aggressive, and successful, but who is depressed, unable to partner or raise children successfully, unable to earn a living, unable to care for his children.” The most dangerous man is not the one who has power, but one who feels powerless. Media has focused on the few men with power at the top, but not at the “other side of the coin,” on those millions who are neither powerful nor privileged.

What Gurian describes as the very heart of masculinity, is a “husbanding,” a “vision of strength, purpose, honor, power and compassion, that culminates in the art of building a strong enough male self to be able to give that self to others in love and marriage, in parenting and mentoring, in work and life.” He makes quite clear that if we are going to solve the issues faced by everyone on the gender spectrum, “we must challenge academic culture to go deeper into who boys are, and what most people in America see very clearly: boys need more masculinity, not less; more fathering, not less; more healthy manhood, not less.” Rough-housing is not part of toxic masculinity but is important to brain development. Of course, it is necessary for men to be accountable for bad behavior, to not countenance violence against women or children, and to be a protective force against violence.

I’ve got no problem with the Gillette commercial which does show some healthy intervention, though the emphasis on “wilding boys” and conformist men at their grills chanting “boys will be boys” is a bit overdone (see Why Men Barbecue), We’d best not forget that masculine development is part of human development and survival. This doesn’t mean that masculinity doesn’t also have its fragilities, as millions of failing men prove. As Paul Nathanson has pointed out in Replacing Misandry, to be accused by otherwise smart people, like the mavens of the APA Guidelines, of crimes you have not committed, to survive and thrive when those ostensibly caring for them, from academics and businesses to communities and schools, treat their very existence as shameful, can only lead to the very self-hatred that is the most dangerous force in our culture.

I am a straight white male. I’m not sorry. I do applaud many of the changes encouraged by the #me, too movement, but I am also wary of its excesses, and the damage to reputations and careers brought about by a culture of shaming, of guilt by accusation, too often resembling an Inquisition. We too easily forget the McCarthyism of my own childhood, and you do not need to go to the Rock and Roll Hall of Fame to remember the “evils” of Rock. Happily, I also remember the role of rock music, not only in the cultural upheaval of 50 years ago, a pendulum which is now swinging back, but the velvet revolution in the Czech Republic in 1989.

Michael Gurian already embodies the sorts of applications the guidelines almost patronizingly suggest and describes counseling a prepubescent boy by first going on a shoulder-to-shoulder walk, as the male brain is often cerebellum dependent (needing physical movement) to connect words and feelings to memories. He then uses ball-tossing with his young client, as cerebellar and spatial involvement helps the male brain communicate between limbic system and frontal cortex (between emotional and cognitive centers). There is a burgeoning literature on embodied cognition which I once summarized for Zygon: Journal of Religion and Science (and overview on my blog of 6.20.2018 on “Knowing Ourselves Bodily”), of which the APA Guidelines seem entirely unaware. I have already pointed out some of the logic of the evolutionary biology of sex differences that the Guidelines leave unconsidered.

Gurian emphasizes a science-based application of neuroscience, another area of study that does not appear in the Guidelines, to male nurturance in schools, homes, and communities. APA is supposed to be a science-based organization, but much of what is presented in the Guidelines is ideology masquerading as science, and not very hard science, for that matter. Sadly, when the more scientifically minded American psychologists formed an alternate Association for Psychological Science in 1988, the APA renewed its attention to science, but perhaps it has not sustained it. Empirically speaking, few women need walking, movement or visuo-spatial stimulation to help access memories, emotions, and feelings, and can do it sitting still, having language centers on both sides of the brain, where men’s are mainly on the left. I’ve already talked about the maturational differences of language development that also make contributions to deeply rooted differences in the biological sexes.

As I have said, men are far less likely to say “let’s talk,” or sit down over coffee just for exploring feelings, though they might be perfectly comfortable saying “let’s go shoot some pool, " or “ go have a beer,” or even “let’s play some chess,” but it tends to include doing something. The prototypic therapeutic practice of sitting down and talking face-to-face about feelings is already a hugely female-biased mode of communication, perhaps no surprise when 85% of new counselors are female, and their clients skew to almost 80% female, males often being dragged in by moms or spouses, unequipped for this form of communication. Even the social psychology of nonverbal communication suggests that personal space differences mean that women find a face-to-face approach trustworthy, versus someone sidling up to them; men find face-to-face encounters more threatening, and often prefer the kind of side-to-side conversations which might occur when engaged in a joint task.

Gurian celebrates the attention paid by the Guidelines to male developmental needs and crises in our culture, but he believes that they then fall into an “ideological swamp.” If one claims that socialization to the “traditional masculinity” marked by stoicism, competitiveness, dominance, and aggression, is what damages male development, how can one eliminate these male sins without also eliminating their virtues? Gurian asks: “How much longer can our society and its professionals pretend we are developing a saner society by condemning the very parts of males that help them succeed, heal and grow?” I confess to being one of the “testosterone poisoned,” but is the real solution emasculation? Gurian presents himself as an example case: Sexually abused in boyhood, this sensitive boy spent ten years healing from this abuse, which came as much from tapping into masculine strengths as it did expanding his sense of self to the feminine. It’s not zero-sum, both are good, but he does not think he could have healed without masculinity.

It is difficult to see why a man, even the average mensch, would seek out any therapist operating by the Guidelines. Isn’t the APA self-destructing? Now, perhaps the new APA Guidelines are not likely to be anything more than another symptom of the problems with the culture and ideology within which they were formulated. Is the average male, most of whom were socialized under “traditional masculine ideology,” which has “held sway over large segments of the population,” now to be considered dysfunctional? One might legitimately ask “by whom, and on what basis?” The overwhelming majority of both psychotherapists and their clients are female. I suppose there are many women who would happily agree. But then, maybe sitting down with someone for a face-to-face chat is not men’s preferred way to resolve problems.

Maybe it shouldn’t be. Kenneth Gergen warned over a decade ago about the growing inflation of categories of dysfunction and the correlated narrowing of definitions of what might constitute “normality,” such that most people might well be categorized as outside this range on one characteristic or another. I regularly joke that I would have been categorized as suffering from Attention Deficit Disorder, even if my characteristics were common for males of my generation, were the criteria for appropriate behavior in schools and other institutional settings the same as those employed for Millennials. Happily, I was self-reliant enough to self-medicate with caffeine instead of Ritalin, and to organize workspaces for multiple tasks, instead of relying on special education to shape my life.

It is also the case, as others have commented, that psychotherapy, spottily funded by insurance companies, is still considered an expensive oddity for the poor. Mental health treatment in this country is “broken,” to use the word used by Tim Insel, the director of the NIMH until 2015. The system reaches only a fraction of those suffering from mental disorders, who are either discouraged by cost, social stigma, or ineffectiveness (which, even according to the Guidelines, may be differentially felt across the gender spectrum). Just under forty-three thousand Americans commit suicide year (more than the number dying from breast cancer or auto accidents, and 70% of completed suicides are male), but only half of those have ever gotten any treatment from the mental health system. Half of incarcerated criminals (93% of whom are men) have mental health problems, 60% of federal inmates are incarcerated for drug offenses. Calling it “broken” hardly seems harsh.

Let’s not even talk about the American Psychiatric Association’s bible, the DSM-5, heavily funded by the pharmaceutical industry, such that even iatrogenic disorders resulting from the use of medications can have their own category. Have a look at Gary Greenberg’s (2013) The Book of Woe: The DSM and the Unmaking of Psychiatry, for a useful discussion of the politics and other flaws of the DSM-5. Despite the same funding rapidly supporting the immediate revision of psychology textbooks to include it, the DSM hasn’t been used by the military for over a decade, the NIMH has proscribed it, and even most third party insurance payees will only accept DSM-5 diagnoses that overlap with the DSM-IV, or the ICD-10, the International Classification of Diseases used by the World Health Organization. But then, psychotherapists have been called “shrinks” (short for “headshrinkers”) for generations. When I lectured students about the DSM, I always illustrated it with a beautiful color image of the Malleus Malleficarum.

Still, while the application of the Guidelines may be mitigated by the judgement of competent therapists, they do reflect the cultural misandry of the #me,too era. Please, do not think for a moment that I do not support and even applaud the attention to very real and all too common cases of sexual abuse, sexual discrimination, and sexual harassment, just the overuse and dangerous over-extension of “sexual harassment,” which can cause the serious damage of guilt by accusation. And this is to say nothing of an emasculated generation, where most millennial men think that asking to buy a woman a drink constitutes an act of sexual harassment. Apparently “consent by internet” is now a prerequisite to what used to be merely considered “flirtation.” Men, beware: the same behavior may be categorized as either flirtatious or harassing, depending on the woman’s response, and it is up to her to decide. I suspect that this may also be true across the wider gender spectrum. In any case, 51% of Americans from 18-34 say they don’t have a steady romantic partner, up from 45% in 2016, and 33% in 2004, a precipitous decline.

The problem is that, according to the APA Guidelines, “traditional masculinity ideology” is itself the source of a lot of the dysfunction of boys and men, putatively in comparison to girls and women, but it leaves “the complex interplay of biology and environment” almost entirely unaddressed. Moreover, we are left wondering what the ideal would or should be, and based on what empirical evidence, aside from ideological assertion. Is that also up to women to decide? Or just therapists? So, a problem is being diagnosed, on very soft empirical grounds, certainly up to not only scientific interpretation but ideological slant. Am I now to seek out the very persons who are asserting this diagnosis, and then pay them to work through it? Why on earth would I want to do that? What virtues must I surrender for my sins to be redeemed? Much like the logic of the Inquisition, once we are "Called to the Question," the answer is already known, and it is only by convincing your inquisitor of the honesty of your confession that you get the garrote before the auto da fe. No thank you. And until and unless the Civil Authority requires my presence, my preference is to turn and walk the other way. If this is the sort of foundation on which it is built, good luck with your profession. Perhaps Noam Chomsky is right, that we will probably “always learn more about human life and human personality from novels than from scientific psychology.” Or even from the poetry of blues lyrics?

I don’t need no doctor, ‘cause I know what’s ailin’ me ---Ashford & Simpson

My favorite version was sung by Beth Hartat the Paradiso in Amsterdam in 2013.