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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)?