A Five Stage Model for Counselling Men

IntroductionSad man

This year I was honoured to be a panelist at the “Healing Journeys: Violence and Trauma Conference Focusing on Male Victims” by the Canadian Centre for Men and Families. I sat in on a panel discussing the needs of men, and had an opportunity to discuss the influence of men and suicide. It was a wonderful learning and networking opportunity.

We know that men have smaller social circles than women (McPherson, Smith-Lovin & Brashears, 2006) and they seek help less often (Courtenay, 2011; p. 13). Finding male therapists is also difficult (Carey, 2011), which can complicate things for men experiencing current or historical intimate partner or sexual violence.

Below is a model for counselling men from the second chapter of “Counselling Fathers from a Strength-Based Perspective” in Counselling Fathers (Oren, et. al., 2010; p.30.) Although this model was originally designed for working with fathers I believe it is equally applicable to working with men who are not fathers.

Five Stage Model for Counselling Men
Five Stage Model for Counselling Men

The five stages are:

  1. Rapport and Therapeutic Alliance
  2. Assessment
  3. Identification of strengths
  4. Interventions
  5. Resiliency and Termination

Each of these will be reviewed below.

Rapport and Therapeutic Alliance

The first element of any therapy or counselling is establishing a strong therapeutic relationship. The SOLER elements of active listening (Egan, 2007) can be useful, although with a change noted below. There are also some things that can be used to establish rapport when counselling men or boys (Kiselica, 2003), including:

  • Displaying magazines relevant to men’s issues (sports, hunting/fishing, men’s health and fitness)
  • Flexible scheduling for appointments (shorter or longer to allow time for building rapport without getting tiring)
  • Using humour and self-disclosure
  • Sitting side-by-side rather than across from each other
  • Setting goals and working collaboratively
  • Using client-centered language

Kiselica also notes that traditional models of engaging with clients (especially young boys) may be ineffective, and that a more instrumental, active or group-based process may be useful.

Assessment for Counselling Men

A strength-based assessment (Graybeal, 2001) acknowledges the overlooked assets that men bring into the counselling relationship, rather than focusing on problems or challenges. This continues into the next stage (identification of strengths). In addition to identifying strengths, the concept of gender role conflict should be explored.

Gender role conflict (O’Neil, 2008) is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others” and involves six elements (O’Neil, 1981) that have commonly be forced upon men:

  1. Restrictive emotionality – The inability of men to express their emotions (often because of society or familial prohibition)
  2. Health care problems – Men are less likely to seek help for their physical or mental health problems
  3. Obsession with achievement and success
  4. Restrictive sexual and affectionate behavior – Related to restrictive emotionality, men are sometimes prohibited from being affectionate with other men
  5. Socialized control, power, and competition issues – Men are socialized to pursue control, power and achievement at any cost, while men who choose a different path (for instance, by parenting) are considered weak or un-masculine
  6. Homophobia – Men who fear being called gay may be less likely to pursue heterosexual friends

By developing a deep understanding of the conflicts your client is experiencing you will be better able to identify strengths and plan appropriate interventions in the next stages.

Identification of Strengths

Identifying strengths is paramount to a positive therapeutic environment when counselling men, especially for men who have been rejected by therapists in the past. Some positive male qualities include (Oren, et. al., 2010; p.59):

  • Altruism
  • Courage
  • Generativity (Slater, 2003) – the concept of leaving your mark
  • Perseverance
  • Protection of others
  • Responsibility
  • Service

These and other values (self-sufficiency, achievement, efficiency, loyalty, and pride) can help build often-fragile male self esteem and provide a framework for intervening.

Interventions for Counselling Men

Now that you’ve performed a comprehensive assessment and you have an understanding of your client’s values, strengths, and what gender role conflict they may be experiencing you are ready to begin planning effective interventions while counselling.

Exploring times in the client’s past when they were able to cope with the problems they’re experiencing now and allowing them to narrate the stories in their life. (Smith, 2006)

Employment is often an area where men succeed, even as they are challenged in their personal life. Using work as a metaphor, men can apply the attitudes of being assertive, prioritizing, building relationships, and so on. Applying these lessons and potentially hidden skills to their personal life can help men improve their ability to deal with problems at home.

Mahalik (1999) used the concept of gender role strain – the idea that men are not living up to their gender or masculinity requirements – to help assessing and working through cognitive distortions. He suggested some strategies for changing cognitive distortions:

  1. Explore how men experience cognitive distortions as adaptive or positive instead of negative; for example, a man who values hard work in their career over everything else may experience positive career and financial benefits at the expense of their relationships with their family
  2. Examine the connection between gender role and these cognitive distortions
  3. Practice experiments to confirm or deny the accuracy of these distortions
  4. Provide more accurate beliefs to replace the distorted ones

Throughout the counselling process it’s important to recognize the impact that gender roles has on someone’s behaviour. Gently challenging these and other beliefs (like those around social support or emotional expression) and encouraging new ways of men expressing themselves are ways of working through the intervention stage. (Oren, et. al., 2010; p.145)

Resiliency and Termination

The final stage in counselling men is resiliency and termination. This starts with identification of male-positive resources or institutions such as programs to promote healthy marriages or healthy children (Oren, et. al., 2010; p.38) and finding other more informal supports in the client’s life such as friends, family, coworkers and professionals like doctors, coaches and clergy.

Finally, modelling elements of good termination in general counselling can help the client terminate other relationships (such as with partners) in their personal life more effectively. These elements include (Hardy & Woodhouse, 2008):

  • Highlighting the positives of ending sessions
  • Providing an open discussion
  • Ensuring both client and therapist are prepared for the end of therapy

References

Carey, B. (2011, May 21) “Need therapy? A good man is hard to find” Retrieved on October 22, 2016 from http://www.nytimes.com/2011/05/22/health/22therapists.html?_r=2

Courtenay, W.H. (2011) Dying To Be Men: Psychosocial, Environmental and Biobehavioral Directions in Promoting the Health of Men and Boys. Routledge: New York, NY.

Egan, G. (2007) The Skilled Helper: A Problem Management Approach to Helping. 8th ed. Thomson Brooks/Cole: Belmont, CA.

Graybeal, C. (2001). Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm. Families In Society,82(3), 233-242.

Hardy, J. A. & Woodhouse, S. S. (2008, April). How We Say Goodbye: Research on Psychotherapy Termination.  [Web article]. Retrived from http://societyforpsychotherapy.org/say-goodbye-research-psychotherapy-termination

Kiselica, M. S. (2003). Transforming psychotherapy in order to succeed with adolescent boys: Male-friendly practices. Journal of Clinical Psychology, 59(11), 1225–1236.

Mahalik, J. R. (1999). Incorporating a gender role strain perspective in assessing and treating men’s cognitive distortions.Professional Psychology: Research And Practice, 30(4), 333-340. doi:10.1037/0735-7028.30.4.333

McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).

O’Neil, J. M. (1981). Patterns of gender role confl ict and strain: Sexism and fear of femininity in men’s lives. Personnel and Guidance Journal, 60 , 203–210.

O’Neil, J. M. (2008). Summarizing 25 years of research on men’s gender role confl ict using the gender role conflict scale: New research paradigms and clinical implications. The Counseling Psychologist, 36 (3), 358–445.

Slater, C.L. Journal of Adult Development (2003) 10: 53. doi:10.1023/A:1020790820868

Smith, E. J. (2006). The strength-based counseling model: A paradigm shift in psychology. Counseling Psychologist, 34(1), 13-79.

Oren, C.Z., Englar-Carson, M., Stevens, M.A. & Oren, D.C. (2010) Counselling Fathers. Routledge: New York, NY.

Cite this article as: MacDonald, D.K., (2016), "A Five Stage Model for Counselling Men," retrieved on January 23, 2018 from http://dustinkmacdonald.com/five-stage-model-counselling-men/.
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Alleged Gender Bias and Family Court

One issue that comes up very commonly in the “men’s issues” movement is an alleged bias in the Family Court system. Some men maintain that women are awarded custody, alimony/spousal support and/or child support more often and in higher amounts than themselves for no good reason.

Custody

A Bias in the Law?

The Department of Justice, in their 2002 report “Putting Children First” noted their opinion that there was no bias on the part of the legislation itself, while also conceding “while the law may be gender neutral, in a majority of cases the mother is a sole custodian or, in a joint custody arrangement, she is the primary caregiver with the father having the role of an access parent.”

This report goes on to state “There is no reason to believe that this gender differentiation is a result of systemic bias in the Canadian courts. It is more likely that in the vast majority of cases the parties have themselves agreed on this arrangement. The social realities or parents’ perceptions regarding parenting roles may be responsible.”

As the “tender years” doctrine (which stated that mothers should be the sole breadwinners) has fallen out of favour in place of the “best interests of the child” doctrine, at least on paper, one can assume that there is no de jure bias in the laws as written. As judges still have control over awards, however, bias may still exist.

Prevalence of Sole Mother Custody

The most common point brought up is that women are often chosen as the custodial parent when a relationship dissolves. The research seems to indicate that this is true.

A research report by Le Bourdais, Juby & Marcil-Gratton (1999) notes the following breakdown of custody:

  • 81 percent sole mother
  • 7 percent sole father
  • 13 percent shared custody

This suggests that while the majority of the time the woman is awarded custody, there is no information provided about the way that custody was determined. For that information, we turn to the National Longitudinal Survey of Children and Youth (NLSCY).

The NLSCY, recorded in a Department of Justice report (2000) notes that in 1995, slightly more than half of relationships (52%) where custody was established did not involve a court order. This may suggest that men are choosing to give up custody voluntarily. The same report, however, also notes that in cases where a court order did exist, almost 80% of the time a court order was established, the mother was granted sole custody.

The large mother sole custody number drops slightly (but still substantially) when the child gets older, with 80.6% of mothers of children 0-5 being given sole custody, while only 74% of mothers of children 6-11 did.

Another interesting element from this survey is that contact with fathers drops the longer the relationship has been broken up. I won’t speculate on the reasons for this.

Two questions that I don’t believe have existing data to answer them include whether men apply for custody less often, and whether men win custody more often when they apply for it.

One argument is that men are counselled by family lawyer they are unlikely to win if they do apply, and secondly that only those with so-called “slam dunk” cases will even bother. This could explain some of the disparities claimed in other countries where men who ask for custody are more likely to win than women — but where men simply don’t contest custody.

Alimony / Spousal Support and Child Support

Alimony or spousal support is money that is paid to a spouse (an ex-husband or ex-wife) after a divorce. It is usually time-limited, and designed to compensate the spouse who gave up earning power during the marriage (often to raise children.)

Kelly (2013), using data from the 2011 General Social Survey noted that 96% of spousal and child support awards in Canada were paid by the father to the mother. This is interesting when you consider that according to the US Bureau of Labour Statistics (2013), 38% of women outearned their husbands. Similar numbers are reported in Canada (Sussman & Bonnell, 2006) and England. (Ben-Galim & Thompson, 2013)

Despite men being eligible for spousal support, it is awarded less often. It’s unclear from the research whether this is the result of men not applying for alimony or spousal support – or whether judges, who have significant discretion over awards, are choosing not to give it to men.

Bibliography

Ben-Galim, D., Thompson, S. (2013) Who’s Breadwinning? Working Mothers and the New Face of Family Support. Institute for Public Policy Research.

Labor Force Statistics from the Current Population Survey. Bureau of Labour Statistics. (2013) Accessed electronically on Nov  2, 2015 from http://www.bls.gov/cps/wives_earn_more.htm

Selected Statistics on Canadian Families and Family Law: Second Edition. (2000) Department of Justice. Accessed electronically on Nov 2, 2015 from http://www.justice.gc.ca/eng/rp-pr/fl-lf/famil/stat2000/index.html

Final Federal-Provincial-Territorial Report on Custody and Access and Child Support: .Putting Children First. (2002) Department of Justice. Accessed electronically from http://justice.gc.ca/eng/rp-pr/fl-lf/famil/flc2002/pdf/flc2002.pdf.

Kelly, M.B. (2013) Payment patterns of child and spousal support. Juristat. Accessed electronically on Nov 2 2015 from http://www.statcan.gc.ca/pub/85-002-x/2013001/article/11780-eng.htm.

Le Bourdais, C., Juby, H., Marcil-Gratton, N. Keeping Contact with Children: Assessing the Father/Child Post-separation Relationship from the Male Perspective (1999) Department of Justice. Accessed electronically on October 21 from http://www.justice.gc.ca/eng/rp-pr/fl-lf/divorce/2000_3/pdf/2000_3.pdf.

Sussman, D., Bonnell, S. (2006) Wives as primary breadwinners. Perspectives on Labour and Income. 7(8)

Cite this article as: MacDonald, D.K., (2015), "Alleged Gender Bias and Family Court," retrieved on January 23, 2018 from http://dustinkmacdonald.com/alleged-gender-bias-and-family-court/.

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Understanding and Preventing Male Suicide

Introduction

Suicide is a significant public health issue in most countries. Suicide rates have been constant in the US and Canada, with some age and risk categories experiencing reduced suicide rates while increased suicide rates in other age groups and risk categories have made up the difference.

Male suicide has been commonly overlooked as suicide has not been seen as a gendered issue. Unfortunately, as more men than women die in virtually every country where the World Health Organization publishes data (2012) there exist the potential for significant reductions to be made in the suicide rate by interventions targeted specifically at men.

Suicide Statistics: A Comparison

Suicide rates are presented here for Canada, broken down by age range and gender.

Age Range Male Female Total Male % of Total
10 to 14 12 17 29 41.38%
15 to 19 140 58 198 70.71%
20 to 24 224 77 301 74.42%
25 to 29 198 63 261 75.86%
30 to 34 212 71 283 74.91%
35 to 39 220 68 288 76.39%
40 to 44 267 87 354 75.42%
45 to 49 318 114 432 73.61%
50 to 54 322 121 443 72.69%
55 to 59 273 102 375 72.80%
60 to 64 186 59 245 75.92%
65 to 69 117 33 150 78.00%
70 to 74 107 21 128 83.59%
75 to 79 78 23 101 77.23%
80 to 84 60 16 76 78.95%
85 to 89 36 13 49 73.47%
90 and older 10 3 13 76.92%
Total 2780 946 3726

As you can see, male suicides make up the majority of suicides in every age range except the 10-14 rate, where girls outnumbered boys. That is certainly worthy of further research by child suicide prevention specialists.

In Canada, suicide rates peak for men around 45-54, which contrasts with other countries where suicide rates increase with age after 30 and suicide rates in the elderly are the fastest growing group.

Suicide Methods

The most common method of suicide in the United States is firearms, accounting for 51% of the suicides in the US (Barber & Miller, 2014), followed by suffocation/hanging (25%), overdose/poisoning (17%) and other methods at 7.6%. (Centers for Disease Control and Prevention, 2013)

Because 85% of firearm suicide attempts result in death while only 2% of overdoses do (Vyrostek,  Annest, & Ryan, 2004), and because men most often choose methods like firearm and hanging over overdosing (Callanan & Davis, 2012), reducing access to firearms can significantly reduce the amount of male suicide.

Theories of Suicidal Behaviour

There are a number of theories that attempt to explain suicidal behaviour. These include the Interpersonal Theory of Suicide, the Stress-Diathesis Model, and the Integrated Motivational-Volitional Model. The interpersonal theory is detailed below.

The Interpersonal Theory of Suicide suggests that you need three elements for suicide to take place:

  • Thwarted Belongingness
  • Perceived Burdensomeness
  • Acquired Suicide Capability

Thwarted belongingness involves feeling like you have no social support or that you do not belong in your peer group. This can also be called “alienation.” Men are known to have smaller social circles (McPherson, Smith-Lovin & Brashears, 2006) and fewer access to social support when they are distressed.

Perceived burdensomeness refers to the idea that you feel like a burden on those around you. For men, this can present as being unable to be a provider or support their family.

Finally, acquired suicide capability refers to events that give you the capability to die by suicide. This includes exposure to war, physical abuse, fighting, self-injurious behaviour (cutting, etc.), or other elements that desensitize you to painful or fear-inducing experiences.

Men are more likely than women to be victims and perpetrators of violence (Statistics Canada, 2006), they make up the majority of occupational injuries (Bureau of Labour Statistics, 2013) and sufferers of substance abuse (Cotto, 2010). All of these items can increase men’s suicidality.

Additionally, suicidal intent (desire to die) has been associated with use of more lethal suicide methods. What this means is that although women attempt suicide at a rate of 3x men do, they don’t intend to die. The goal of attempting suicide is to accomplish other means. Update Nov-1/15 This is in fact incorrect and there is research support to the idea that women have similar levels of suicide intent as men (Denning, Conwell, King & Cox, 2000).

Player et. al. (2015) suggest that male coping strategies are responsible. While women increase their social support and look outward when they are feeling suicidal, men often wall themselves off from others to avoid being a burden. This only amplifies their systems and increases their distress, which can prevent an interruption in the suicidal process that may happen with women.

Clinical Interventions to Reduce Male Suicide

Interventions for suicide that can help individual men include:

Counseling on Access to Lethal Means. By reducing access to lethal means like firearms you can reduce an individual’s chance of dying by suicide. Many suicide attempts are made impulsively and having a gun makes a suicide attempt much more lethal.

Treatment for substance abuse.  Many suicides involve drugs and alcohol and so getting off drugs and alcohol can reduce a person’s reason and ability to attempt suicide, both because of the impact of substance abuse on a person’s ability to function in their day-to-day life (especially as it relates to relationships) but also because drugs and alcohol can make people — young men especially — more impulsive.

Increasing social circles. The average man has a social circle smaller than women. This lack of close friends means that men are not able to express themselves emotionally.

Self-esteem training. This can be a part of counselling or therapy or an initiative on it’s own. Group environments in particular provide an opportunity to both build a man’s social skills and his self-esteem. The benefit of high self esteem is that it can reduce a man’s perception that he is a burden, one of the key elements for suicide.

Public Health Strategies to Reduce Male Suicide

From a public health perspective, there are a few interventions we can help reduce male suicide.

Getting more men in front of family doctors. Men have poor records of going to the doctor when they need to, or even for regular checkups. Because physical health issues can prevent men from working or otherwise providing for themselves (creating the feeling of burdensomeness), physical health care is an important element to reducing suicidal ideation.

Screening for suicide and substance abuse by family doctors. Once men are in front of their physician, it’s important that they’re able to recognize the signs and symptoms of suicidal ideation and substance abuse. It has been noted that mental health professionals are less likely to diagnose depression in men and this is also an area for exploration.

Improved services for sexual violence. With as many as 1 in 6 men experiencing sexual abuse/assault in their lifetime (Dube, Anda & Whitfield, 2005) and a lack of services like rape crisis centres that provide service to men, suicide as a result of the after-effects of abuse will continue to be a devastating issue.

Areas for Additional Research

Areas for additional research include whether men respond differently to standard treatments for depression or substance abuse, or if there are any ways to intervene with men experiencing suicidal ideation that are particularly effective.

Bibliography

Barber, C.W., Miller, M.J. (2014) Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A Research Agenda. American Journal of Preventive Medicine. 47(3S2):S264–S272

Centers for Disease Control and Prevention. (2013) Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed Jun 21 2015 from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html

Denning, D.G., Conwell, Y., King, D., Cox, C. (2000) Method choice, intent, and gender in completed suicide. Journal of Suicide and Life Threatening Behaviour. 30(3). 282-288

Dube, S.R., Anda, R.F. & Whitfield, C.L., et al. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28, 430-438.

Callanan, V.J., Davis, M.S. Gender differences in suicide methods. (2012). Social Psychiatry and Psychiatric Epidemiology. 47:857–869 DOI 10.1007/s00127-011-0393-5

Cotto, J.H. et al. (2010) Gender effects on drug use, abuse, and dependence: An analysis of results from the National Survey on Drug Use and Health. Gender Medicine. 7(5):402-413

“Fatal occupational injuries in 2013.” Bureau of Labour Statistics. (2013). Accessed from http://www.bls.gov/iif/oshwc/cfoi/cfch0012.pdf on Sep 5 2015.

Global Health Observatory Data Repository. (2012) World Health Organization. Accessed from http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en on Sep 1 2015.

McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).

Player MJ, Proudfoot J, Fogarty A, Whittle E, Spurrier M, Shand F, et al. (2015) What Interrupts Suicide Attempts in Men: A Qualitative Study. PLoS ONE 10(6): e0128180. doi:10.1371/journal.pone.0128180

Vaillancourt, R. 2010. Gender differences in police-reported violent crime in Canada, 2008. Catalogue no. 85F0033M, no. 24. Ottawa: Statistics Canada.

Vyrostek S.B., Annest, J.L, & Ryan, G.W. Surveillance for fatal and nonfatal injuries–United States, 2001. Morbidity and Mortality Weekly Report. 2004:53(SS07);1-57.

Cite this article as: MacDonald, D.K., (2015), "Understanding and Preventing Male Suicide," retrieved on January 23, 2018 from http://dustinkmacdonald.com/understanding-and-preventing-male-suicide/.
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