Why guys are reluctant to lie on the therapist’s couch
The Globe and Mail
From the deer head hanging on the wall in his virtual study to the fresh-caught trout he may produce from an icebox and clean with his pocket knife if you fail to click a link soon enough, Dr. Rich Mahogany is a guy’s guy.
Paunchy, with a rusty mustache and a comforting timbre to his voice, Dr. Mahogany is a fictional therapist, a focus-group creation who packs every good-ol’-boy stereotype into one website – making your all-knowing but profanity-prone uncle the spokesman for why a man needs to talk about his emotions.
“Here we won’t be complaining, whining and moping about,” he says, closing his chainsaw manual. “We’ll be getting off our keisters and form-tackling feelings like anger, stress and sadness.”
Dr. Mahogany is the comic face of Mantherapy.org, an online mental-health-awareness campaign produced in Colorado after two years of research and released this week. It is definitely an innovative alternative to more traditional campaigns featuring fierce-looking firemen and optimistic slogans. Instead, Dr. Mahogany demonstrates man-yoga in shiny blue athletic shorts from a cringe-worthy camera angle; at opportune moments, he points to the red phone in the corner that, with one click, produces a suicide-hotline number.
Humour and mental health is a tricky combination, but studies show that many men soon forget why the fireman was on the bus poster, if they noticed him at all. And men are far less likely than women to tackle problems by getting off their keisters and seeking a real doctor for help.
The cultural bias is that strong men keep it together and don’t lie on couches and spill their guts, unless they are HBO television characters. Meanwhile, experts are predicting that male joblessness and fragile work environments will increase depression and anxiety among men, and make them even less likely to tell their bosses if they’re in trouble. Middle-aged men already have the highest rates of suicide in the Western world, and there is evidence that those numbers are rising.
Dr. Mahogany represents an increasing awareness that there’s a gender element to mental health – and health in general – that has been overlooked when it comes to providing services, and ignored in research that has clumped the sexes together.
It’s not only that men and women tend to have different attitudes about mental health. Their symptoms are often not the same, and the forms of therapy that succeed with them, as well their responses to medication, may be different.
The shortage of male therapists hasn’t helped – all but a small fraction of graduates in psychology and social work are women. Even trivial design decisions, such as the pastel walls and women’s magazines that are the mainstay of many doctor’s offices, send a message, as one researcher put it, that “this is not a man’s space.”
But gender bias ripples throughout the entire health-care system, from cardiac care to cancer treatment, influencing how quickly patients get help and how seriously their symptoms are interpreted. Women having heart attacks have been sent home because their chest pain was interpreted as anxiety; men have died from suicide after their depression was misread as mere stress.
This week, President Barack Obama signed a law that requires the Food and Drug Administration to report gender differences in clinical trials – a move long advocated by women’s groups. A similar directive, requiring gender to be a consideration in studies, was issued by the Canadian Institutes of Health Research (CIHR) in December, 2010.
“We have a gender blindness when it comes to thinking about treatment and outcomes,” says Joy Johnson, the scientific director for the CIHR’s Institute of Gender and Health.
“How we began thinking about depression really came out of studying women. … Sometimes there are no differences, and that’s fine, but we are not paying attention. There are a lot of unanswered questions.”
Fifteen years ago, feeling overwhelmed and anxious at work, Robert, a Toronto-area lawyer, found himself in a therapist’s office. “It was the kind of therapy where you go in, and they sit there and wait for you to speak,” the 45-year-old recalls.
He continued off and on for about 10 years, treating therapy, he says, like a gym workout for his mind. It was helpful, to a point. “There was this whole idea that an epiphany was going to happen, and all of a sudden whatever was lurking in the back of my mind that was making me anxious would be released and then I would be cured.” That never really happened.
More recently, he decided to try cognitive behavioural therapy, in which a therapist guides a patient through strategies to deal with his problem; he went for several months, and found he preferred it. He learned to see his physiological responses to anxiety as temporary, and understood more clearly why alcohol or tranquillizers only masked the symptoms, without alleviating them.
“I felt like there were techniques being taught that I could use to cope, in a practical way,” he says.
Robert is not alone. Men who attend therapy report satisfaction levels similar to women, but studies have found that they may respond better to certain approaches. John Ogrodniczuk, director of the psychotherapy program at the University of British Columbia, says his research has found that men-only groups are popular and effective; when men are put in mixed groups, where they are often outnumbered by women, their active participation drops significantly.
The men in Dr. Ogrodniczuk’s studies responded best to short-term, individual therapy that focused on practical solutions as opposed to supportive therapy that reassures or sympathizes with the patients. The opposite was true for women.
As well, interviews with men dealing with mental-health issues have found that they valued therapy well above medication. They reported that taking drugs made them feel powerless to help themselves, whereas therapy was a form of self-management, says John Oliffe, an associate professor at the School of Nursing at the University of British Columbia who specializes in men’s health.
Other research has found that men appreciate the reciprocal nature of a group – the sense that they are actively helping others, a strategy employed in Alcoholic Anonymous, which gets more male participants than women.
Australia has responded to this pattern by developing a network of neighbourhood “sheds” (garages) that serve as physical spaces for men to meet. In Britain, public awareness campaigns have targeted players and spectators at soccer games.
But even the messaging in those campaigns, Dr. Oliffe suggests, has inadvertently fostered stereotypes. While men do visit the doctor less often than women, he says, emphasizing this statistic may make men less likely to change this habit.
Men tend to seek medical attention in emergency rooms, which are not designed for long-term evaluation and care, especially for mental-health issues.
Some gender patterns in mental health are well known – for instance, males are more likely to be diagnosed with schizophrenia. But there is currently a debate over whether to recognize a disorder of “male depressive syndrome.” And Dr. Johnson, among others, proposes that all diagnostic categories should be studied for gender differences.
Women are diagnosed for depression and anxiety at far greater rates than men. Researchers are not sure how much this is due to biology, gender expectations or overlooking male cases.
But the male suicide rate, which is four times higher than the female, clearly suggests something is wrong, Dr. Oliffe said. “We are missing them, and then the point we pick them up is in the judicial system, or in addictions treatment.”
Many people seeking help for mental-health issues have difficulty getting proper diagnoses, and the men in Dr. Oliffe’s studies reported being turned away about three times before help is offered – a major deterrent for already-ambivalent patients.
Because men tend to report feeling “stressed” more than “sad,” family physicians prescribe rest instead of therapy. Even nationwide surveys on mental health pose questions in a way that might leave male depression underreported – Dr. Johnson points to one that asks people if they cry frequently.
Women are more likely to fall into the stereotypical profile: internalizing their emotions, self-criticizing. Men are more likely to be aggressive or irritable, and turn to alcohol and drug abuse. Instead of sleeping more, as in the classic depression profile, they may spend more time at work.
In a study published in June, Dr. Oliffe interviewed male university students diagnosed with depression. He found they masked symptoms with anger, drinking too much at parties, or brooding in solitary – actions that could be considered “regular guy” behaviour (though Dr. Oliffe quickly points out that not every life of the party is depressed).
Other patterns might be useful in guiding education and public awareness: While girls more often first reveal depression or anxiety to a friend, boys are more likely to tell a family member.
According to Statistics Canada, divorced or separated men are six times more likely to experience depression than men who are married, and twice as likely as women who’ve had a marriage breakdown, a pattern for doctors and family members to note.
Women and men often differ in their knowledge of mental health, or in recognition of their symptoms. A high-profile New Zealand television campaign involved rugby star John Kirwan discussing his experience with depression; in surveys afterward, only 26 per cent of men recalled that his point was that mental illness was nothing to be ashamed of; women were twice as likely to remember it. (On the other hand, targeting women makes some sense, since wives and girlfriends are often the strongest influence behind men seeking help.)
If misconceptions about therapy are deterring men, says Boadie Dunlop, director of the Mood and Anxiety Program at Emory University in Atlanta, then public education has to go beyond vague notions of seeking “help” to more specifics about what happens behind the doors of a psychologist’s office.
“We can do all sorts of ad campaigns,” Dr. Dunlop says. “But it needs to be incorporated into a man’s psyche that you can still be tough and strong and get depressed, and treatment will help you.”
These were the reasons that Brett Zachman, 41, a financial consultant in Denver who was an adviser on the Mantherapy campaign, resisted getting help when he began to feel lonely and overwhelmed following his divorce.
“My initial approach was the machismo route,” he says. “I didn’t need anything. I didn’t need anyone. I could be a lone wolf and solve it on my own.”
Finally, a severe panic attack led him to a group divorce seminar, and eventually individual therapy. Talking to other men helped the most, he says. “It normalized the emotional response to divorce.”
Ultimately, this is the aim of the Dr. Mahogany campaign (Mr. Zachman likens it to a beer commercial, as opposed to a public-service message) – to promote mental-health problems as a common experience of everyday guys, which might not be like the gals’ version.
As for whether those variations are biological or cultural, Dr. Dunlop points out that a natural experiment on the issue may be under way. In a recent editorial in the British Journal of Psychiatry, he predicted rising depression rates over the next decade for men who have seen their family roles shift or their jobs downgraded or lost.
He compares it to the experience of 1950s and 1960s women who were university-educated, only to be confined to the kitchen. “That thwarted sense of development in the work force, or feeling trapped at home – if that’s a force for women, why shouldn’t it be a force for men?”
If Dr. Dunlop’s warning is right, it’s all the more vital that something like Dr. Mahogany’s message of “gentlemental” health reaches all those displaced males: “Being open and honest – that is one of the least unmanly things a man can do,” he barks. “So share away, gentlemen.”