Building the Therapeutic Alliance with Men – blog

Nathan
May 14, 2020

Why men don’t seek help. The importance of having a gendered approach to mental health services.

Simon Tyler – B. Psych. Sci. (First Class Hons), MS. Psychology, PhD Candidate Mental Health and Suicide Prevention Research Group and Alison Milner Memorial Scholarship Recipient

Building the Therapeutic Alliance with Men - Simon Tyler
Simon Tyler

There are significant issues when it comes to men and seeking support for mental health difficulties. Research suggests a stark gender disparity and indicates that in comparison to women, men are significantly less likely to see a psychologist (Spendelow, 2015). Furthermore, research also suggests men have greater drop-out rates than that of women, with men regularly opting to not continue treatment following initial consultation (Pederson & Vogel, 2007). Understandably, this is of great concern as while research shows the prevalence of mental health conditions in men is not as prolific as that for women, many serious outcomes that are associated with mental health difficulties are significantly higher in men, such as suicide, drug and alcohol dependence and violence (Mahalik & Rochlen, 2006). Fundamentally, this suggests that while there may not be as many diagnoses of mental health conditions in men, presence may be far greater than currently understood and men may be choosing to deal with their mental health difficulties by themselves rather than seeking professional help.

This information highlights the need for better understanding of what psychologists can do to get men to access, and continue, treatment services. However, many suggestions for why men do not seek psychological help are directed at an individual level and their failures in this space, rather than what psychologists can do to change this narrative (Seidler et al, 2016). For example, regular professional commentary focuses on men’s adherence to traditional masculine norms such as self-reliance and stoicism, as reasons for why they do not seek psychological support when they are experiencing mental health challenges (Addis & Mahalik, 2003). Furthermore, men regularly shoulder the blame for not continuing treatment with suggestion that their preference for treatment methods that do not align with traditional approaches their issue rather than that of the psychologist (Mahalik et al., 2012). Despite this narrative, there is a simple but significant area that psychologists can and need to improve to ensure men to uptake and upkeep psychological support.
The therapeutic alliance can be defined as the “collaborative relationship between patient and therapist in the common fight to overcome the patient’s suffering and self-destructive behaviour” (Bordin, 1979). The importance of the working relationship between a psychologist and client has long been understood with early psychotherapists outlining its significance in obtaining positive treatment outcomes (Rogers, 1951). More recently empirical evidence has further highlighted the importance of the therapeutic alliance with studies demonstrating an effective therapeutic alliance may be as, or more, valuable to positive client outcomes than the treatment modality used during sessions (Ardito & Rabellino, 2011). There three key components to the therapeutic alliance being 1) goals of the treatment 2) agreement on the tasks 3) development of a personal bond made up of reciprocal positive feelings (Ardito & Rabellino, 2011). However, despite the long term understanding of the importance of developing and maintaining an effective working relationship between a psychologist and client it would seem some principals central to its development are discounted by psychologists when dealing with male clients.

A major component of the therapeutic alliance is collaboration with a need for significant focus on the mutual agreement on treatment methods and subsequent outcomes. Unfortunately, it is often reported by men that this does not occur for them with regular dismissal of their desires for the direction of their treatment. For example, men display a preference for psychotherapy methods that place significant focus on action and overall goals as opposed to therapy of an emotional disclosure format (Seidler et al., 2018a). Men regularly report that talking and disclosing emotions often makes them more frustrated and doesn’t help with day to day coping (Kingerlee, 2004). While research suggests that men and women may experience similar positive outcomes from emotional disclosure therapies, to develop an effective therapeutic alliance, psychologists should consult with their clients about what treatment methods are desired and they are willing to engage in. Therefore, by not understanding that many men may prefer a more practical form of assistance with focus being placed on the development of action based coping strategies, as opposed to therapeutic approaches heavily focuses on emotional vulnerability and empathic communication, psychologists may be compromising their ability to form an therapeutic alliance and hindering client access and retention (Johnson et al., 2012).

In addition to the above the formation of an effective therapeutic alliance with male clients is dependent on the development of a working relationship that has attributes of trust and positivity. The need to create an environment that feels safe and non-judgmental is vital however it has been commented that often psychologists fail in this when dealing with male clients with both settings and the language used not facilitating this feeling (Bedi & Richards, 2011; Englar‐Carlson, 2006). It has been suggested that psychologists need to utilise a more casual environment and approach, breaking the elitist stereotypes that are often associated with psychologists (Seidler et al., 2018a). Furthermore, there has been suggestion that trust can be developed in men through ensuring they are treated like individuals rather than just a number or tick box exercise. Men often report that they do not develop effective therapeutic alliances due the feelings that they are not recognised and understood as individuals (Seidler et al., 2016). Psychologists who focus on and remember personal details and topics that are important to the client are suggested to develop stronger working relationships with male clients and increase likelihood of treatment continuance, fundamentally developing an effective therapeutic alliance (Seidler et al., 2018a).

In short, the need to develop effective and long-term therapeutic alliances with men who seek psychological services is a necessity. However, there is a significant need for clinicians to self-reflect on their approaches to developing the working relationship with men in this space and change the narrative that men are the main contributor to the issues faced in men accessing and continuing psychological treatment. Clinicians being aware of male clients preferences and desires for treatment goals and outcomes, as well as ensuring they modify their traditional approaches to settings and language, will inevitably lead to better therapeutic alliances positively influencing male client retention and treatment efficacy.

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References

Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. The American Psychologist58(1), 5–14. 

Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology2, 270. https://doi.org/10.3389/fpsyg.2011.00270

Bedi, R. P., & Richards, M. (2011). What a man wants: The male perspective on therapeutic alliance formation. Psychotherapy48(4), 381–390.

Bordin E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy (Chic.) 16, 252–260

Englar‐Carlson, M. (2006). Masculine norms and the therapy process. In M. Englar‐Carlson & M. A. Stevens (Eds.), In the room with men: A casebook of therapeutic change. (pp. 13–47)

Johnson, J. L., Oliffe, J. L., Kelly, M. T., Galdas, P., & Ogrodniczuk, J. S. (2012). Men’s discourses of help‐seeking in the context of depression. Sociology of Health & Illness34(3), 345–361.

Kingerlee, R., Precious, D., Sullivan, L., & Barry, J. A. (2014). Engaging with the emotional lives of men: Designing and promoting male‐specific services and interventions. The Psychologist24, 418–421.

Mahalik, J. R. and Rochlen, A. B. (2006). Men’s likely coping responses to clinical depression: What are they and do masculinity norms predict them? Sex Roles 55(9):659-667

Mahalik, J. R., Good, G. E., Tager, D., Levant, R. F., & Mackowiak, C. (2012). Developing a taxonomy of helpful and harmful practices for clinical work with boys and men. Journal of Counseling Psychology59(4), 591–603. https://doi.org/10.1037/a0030130 

Pederson, E. L., & Vogel, D. L. (2007). Male gender role conflict and willingness to seek counseling: Testing a mediation model on college‐aged men. Journal of Counseling Psychology54(4), 373–384.  

Rogers C. R. (1951). Client-Centered Therapy. Boston: Houghton Mifflin

Seidler Z. E., Dawes A. J., Rice S. M., Oliffe J. L., Dhillon H. M. (2016). The role of masculinity in men’s help-seeking for depression: A systematic review. Clinical Psychology Review, 49, 106–118.

Seidler, Z. E., Rice, S. M., Ogrodniczuk, J. S., Oliffe, J. L., & Dhillon, H. M. (2018a). Engaging Men in Psychological Treatment: A Scoping Review. American journal of men’s health12(6), 1882–1900. https://doi.org/10.1177/1557988318792157

Seidler, Z.E., Rice, S.M., Oliffe, J.L., Fogarty, A.S. and Dhillon, H.M. (2018b). Men In and Out of Treatment for Depression: Strategies for Improved Engagement. Aust Psychol, 53: 405-415. doi:10.1111/ap.12331

Spendelow J. S. (2015). Cognitive–behavioral treatment of depression in men: Tailoring treatment and directions for future research. American Journal of Men’s Health, 9(2), 94–102