Psychosocial intervention with men.

Many recent studies have stressed the importance of a gender-specific approach to achieve positive results in the mental health field. Nonetheless, the study of men and masculinity is relatively new, particularly with regard to psychotherapeutic interventions. Based on books from Quebec and the United States and the authors' experience in the field, this article summarizes the formulation of an emerging intervention model for therapeutic work with men. The 10-Point Intervention Model is based on the following criteria: concern for gender sensitivity, awareness of invisible biases toward men, and therapist countertransferences. We note that the socialization of men shapes and impairs their help-seeking behavior and therefore therapists must develop a therapeutic model adapted to men. The model proposed in this paper enhances work with men in social service agency settings. It also poses some important challenges for individual therapists and for the mental healthcare profession.

Keywords: men in therapy, intervention model, gender sensitivity, biases toward men, countertranference, help-seeking behavior

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The development of specific approaches with men in counseling settings is relatively recent. In Quebec, the first research projects began in the social-protection field, especially in helping spouses with violent behavior (Guevremont, Lajeunesse, & Rondeau, 1986; Lindsay, 1984). Interventions with violent couples are still studied intensively today. Others (Belanger & L'Heureux, 1993; Dorais, 1988; Tremblay, 1989, 1996) tried to establish a more global vision of social intervention among men, "to propose a number of directions that could serve as the basis for an intervention model that could be qualified as masculinist" and which would no longer be limited to the sole context of conjugal violence (Tremblay 1989, p. 9; authors' translation). More recently, some authors have highlighted the knowledge clinicians have acquired in working with men in recent years (see Brooks & Good, 2001; Dulac, 1997, 2001; Dulac & Groulx, 1999; Home & Kiselica, 1999; Levant & Pollack, 1995; Pollack & Levant, 1998).

These approaches, which began at the end of the 1980s, include more dynamic interactive interventions. An increasingly structured intervention model is beginning to emerge. In this paper, we describe such a model based on the theoretical work of authors from Quebec, English Canada, and the United States as well as our professional experience as therapists and trainers working with a predominantly male clientele. This proposed model is based on 10 constituent principles that are explained below.

BEING AWARE OF GENDER-SPECIFIC ISSUES

Given its anti-oppressive tradition, the field of social work is concerned with the impact of gender on therapeutic interventions. However, this perspective has mostly been applied to interventions with women. It is well known that any efficient intervention strategy must take into account the cultural background of the client, including the influence of gender stereotypes. Otherwise, we will lose key elements of the problem (Longres & Bailey, 1979). Feminist clinicians helped us understand specific issues in counseling women, notably guilt, low self-esteem, and dependency. Working with men requires an effort to understand the effects of male and female socialization not only on the client but also on us as therapists.

Masculinity remains a social construct, a product of history and culture. It is, as Weeks (1991) described, a continuing fiction. Rather than perceiving masculinity as universal, we strongly believe that there is, in fact, a multiplicity of masculinities. All men are different, and each man actively participates in the construction of his gender identity (West & Zimmerman, 1987). Given the diversity of masculinities, we must take into account the diversity of male self-representations (Connell, 1995) by emphasizing the complexity of the male experience (Wilcox & Forrest, 1992). Intervention with men requires attention to nuances since there are many differences within the male population. This does not exclude the fact that men feel a certain pressure to conform to specific gender models.

Our perspective is a postmodern one in which reality is seen as dynamic, multifaceted, socially built, and diversified (Ungar, 2002). Being sensitive to gender dimensions means taking into account male socialization and the diversity of the masculine experience and then adapting our therapeutic intervention accordingly. It also means paying special attention to the power differential in therapeutic relationships with male clients, the language used by the therapist, and the client's unique experiences (Ungar, 2002). Classical intervention models centered on verbalization and expression of emotions may be well suited to more sophisticated men but are far less adequate for traditional men (Bruch, 1978). Moreover, those models must also adapt to the range of realities men experience by taking into account sexual orientation, ethno-cultural origin, age, social class, and other factors.

SEEING MEN AS HUMAN BEINGS

The influence of stereotypes can sometimes lead us to perceive men as living stereotypes, individuals divided from a part of themselves and atrophied beings, rather than as individuals with all their potential. It becomes essential to work outside of these biased visions if we wish to effect therapeutic change.

Some prevalent social notions are based on the idea that masculinity must be perceived and redefined as something fundamentally distinct from femininity (Bly, 1990: Lee, 1993). Others subscribe to the hypothesis that each of us has a feminine side and a masculine side (Corneau, 1989; Lacroix, 1983). From a humanist and constructivist point of view, we believe, on the contrary, that these categories reveal that masculinity and femininity result more from social conditioning than from innate factors in males and females. According to Belanger and L'Heureux (1993, p. 1; authors' translation),

   ... by nature, men are intelligent, creative, tender, exuberant,
   savage, mild, pacific, full of life, marvelous, amusing, fully
   connected to all forms of life (their own and everyone else's)
   on this planet. From the outset, they are honest, just, full of
   dreams and visions, cunning, intuitive, spiritual, sexual, proud,
   wise, captivating, sturdy, warm ... [just as women are.]

Men also possess the necessary mechanisms to discover those qualities in themselves. The effects of socialization are such that men evolved--and conditioned themselves--to express only one part of their human potential. Thus, as Belanger & L'Heureux (1993) state, in dividing all human qualities into masculine and feminine categories, society defines roles appropriate to each gender. This has created problematic views of male-female and male-male relationships.

It is therefore important to apply a new paradigm for intervention with men and understand that men possess important qualities not only for work but also for personal and relational matters. This also means going against popular misconceptions, one of which Dulac (2001) calls the "syndrome of the immoral male and toxic parent" (p. 76, authors' translation).

Over the past 30 years, the women's rights movement rightly succeeded in bringing to public attention and denouncing a number of social problems generally recognized as being primarily acts of men against women: incest, sexual assault, conjugal violence, and sexual harassment, among others. It is not our intention to contest the value of this hard work of denouncing acts that are so damaging to the victims. However, in the quest to change oppressive situations mostly affecting women, two distortions occurred.

First, the term mostly used to describe acts done by men to women became exclusively. Even the Government of Quebec, in spite of the rise in female violence (Statistique Canada, 2000), described the opposite, that is, violent situations with women as perpetrators as being "exceptional" (Ministre de la Sante et des Services sociaux du Quebec, 1995). Speaking of female violence remains taboo (Ruel, 1998). In our opinion, we must denounce all forms of violence, regardless of who is the victim, instead of camouflaging certain situations to defend a particular ideology. Furthermore, some authors have presented violence as being the very essence of masculinity rather than being the result of socialization. Marie-Claire Poirier, in her movie, Mourir a tue-tete, conveyed the message, "Every man is a potential rapist." In some authors' point of view, violence is innate in male biology (Goldberg, 1973), in the male brain (LeVay, 1993), or is a result of the evolution of the male species (Buss, 1994). However, scientific research associates violence more with multi-factor causes (Tremblay, 1999) rather than with the simple fact of being male, even though that constitutes one of the primary risk factors (Cairns & Kroll, 1994) for violent behavior. We should bear in mind that a risk factor is only an epidemiological probability, not an absolute certainty,

PAY SPECIAL ATTENTION TO COUNTERTRANSFERENCE REACTIONS

A whole array of preconceptions about men, most of them negative, are part of our subconscious and shape our perceptions and attitudes. These are prejudices that result from social beliefs and lead us to perceive the client as a potential abuser, a possible incestuous father, or a wife beater long before we see him as a man and an individual in distress. However, we all know male individuals, friends or parents, whom we esteem and think of positively. The social image of the toxic male, however, seems stronger. It is a filter with a powerful biasing effect on the therapeutic relationship. Therefore, the therapist is no longer directly relating with a human being but rather with a behavior to suppress, whether real or imagined.

Often, during training sessions we ask the following question early on, "What is the worst thing you have said or heard about men?" At first, answers are shy and hesitant, "Men have trouble expressing their emotions, they tend to be insensitive with children," and the like. Then other voices are heard, "They have no heart, they cannot change, they are violent, they only think about sex, they think with their penises." The list grows quickly and is often accompanied by laughter. This spontaneous exercise permits identifying the baggage brought by the client as well as by the therapist meeting him. We are all socially impregnated with these social judgments about men. Now, working with a step-by-step scenario, let us see how this can apply to therapeutic interventions.

Step 1

The very ill-at-ease client relates how, the other day, through the partially open bathroom door, he saw his 20-year-old daughter getting out of the shower. He tells of how he got an erection at seeing her naked body.

Probable countertransference from the therapist:

* From a professional point of view: Is there a situation of incest? Has he already touched his daughter? (These are highly pertinent questions.)

* From a personal point of view: What a dirty bastard! Another one who thinks only of sex! The poor girl!

* The therapist takes a deep breath and tries to show understanding even though deep inside, he is judging the client.

Step 2

The client continues to tell his story. His daughter looks a lot like her mother. Her naked body, the shape of her breasts, reminded him of his first night with his wife. It is that memory that excited him. They loved each other so much, and he loves her just as much today.

Probable countertransference:

* Relief, but a question remains: Is he telling the entire truth? Doubts persist.

This is a rather harmless stow: A man recalls his first night of love and gets an erection. There is nothing bad or socially reprehensible in this, only love and a memory of tenderness and sensuality between two lovers, two adults. Still, such an anecdote represents something that is very difficult to tell, and the story can even represent a danger. Will the therapist denounce him? Will his wife react negatively? Socially speaking, the incest taboo raises its head, but even more, in this post-feminist period, his erection fans the flames of certain social judgments against men.

As therapists, we have the duty of social protection. From that will spring expectations, perceptions, attitudes, and behaviors from which sexist biases can result. For example, we can quote a study by the U.S. National Association of Social Workers (NASW) (Fisher, DuLaney, Fazio, Hudak, & Zivo Tofsky, 1976) and another by Hansen and Reekie (1990), reporting that social workers more favorably judge their female clients than male clients. The NASW argues that there is a strong pro-women bias characterizing the clinical judgment of American social workers (Fisher et al., 1976). For example, there is a tendency to rationalize a woman's violence toward her child, "She is exhausted; she is alone to take care of the child." Female violence will be perceived as contextual or accidental. In the case of a man, the tendency will be to perceive violence as being part of him, of his essence, and the professional judgment will be harsher.

We must also have an open mind when counseling men, particularly when we are confronted with situations that would normally meet with social disapproval. More than ever, we must return to the key principles of intervention: differentiate between the person and his behaviors, and accept the individual as an integral whole without judging. Men, like women, are entitled to their emotions and feelings, whatever they may be. Obviously, this does not mean we should stop objecting to inappropriate behavior such as incest and violence. Indeed, it is important to identify clearly our stance on such behaviors.

RECOGNIZING DISCOMFORT IN MEN SEEKING HELP: THE IMPORTANCE OF THE FIRST CONTACT

It is not surprising that very few men ask for help when they are depressed, feel bad, or experience problems. Men hide and deny their symptoms for a long time, no matter how serious the illness or the problem (Charmaz, 1994). In fact, they tend to adopt strategies such as fleeing from their problems to avoid revealing their malaise (Dulac, 1997). They wait for a crisis or strong exterior pressure before consulting (Dulac, 1997; Tremblay, 1989). For Dulac (1997), "Men act downstream, after a crisis" (p. 16, authors' translation). Therefore, the pressure will be so great that they will tend to act out with aggressive behavior, very often directed at their families and friends (Lynch & Kilmartin. 1999).

Recent reflections (Brooks. 1998, p. 44) demonstrate that the processes of assistance go against the prevailing notion of masculinity (see Table 1).

Asking for help requires men to go against the social norms of masculinity, seeming to act as if they are not "real men." The price men pay for admitting helplessness in dealing with or overcoming their own problems may be feeling stigmatized and rejected by their peers (Dulac, 1997). Disease marginalizes men by destabilizing their conception of masculinity. While seeking help may be easier for some who have managed to distance themselves from the male stereotype, it can be much more difficult for other men.

When asking for help more traditional men do so in an unconventional way, sometimes aggressively if they are ill at ease (Dulac, 1997, 1999). Chances are, therefore, that they will encounter a repressive reception or may even be refused access to services. The suffering behind an aggressive attitude will not be identified and will likely not be dealt with. The therapist will have failed in establishing a therapeutic relationship or reaching out to the individual behind the behavior (Dulac, 2001). Even though distinguishing between the individual and the behavior is recognized as one of the basic principles of therapeutic intervention, therapists' own repressions all too often dominate their interventions with men. In many workshops we have offered as well as in some studies (Dulac, 1997, 2001), therapists' discomfort surfaced as a dominant feature of the relationship with men exhibiting disturbing behaviors. Many therapists end up protecting themselves by remaining distant, hiding behind intervention norms and protocols. What is implicit in these attitudes is their preconceptions about men and women: women are fragile, victims and need support, while men are violent and deserve to be punished (Dulac, 1999) ... although yet little is known about the private, intimate lives of traditional men (Dulac, 1999). It is therefore essential to welcome men in spite of the sometimes aggressive or confused stance of their request for help, to decipher the suffering behind the behavior, and to pay special attention to the initial contact.

The therapist must want and decide to establish a therapeutic relationship even though the client's defense mechanisms are such that he avoids that relationship or even provokes rejection. The movie Good Will Hunting illustrates this point. Young Will, having known a hard life, does everything to ensure his therapist will reject him. In spite of that, the therapist believes in him, the relationship is slowly established, and, over the course of their sessions, Will's reluctance wears away.

EMPOWERING AND PROTECTING MALES: DEVELOPING A SENSE OF RESPONSIBILITY

It is important to recognize and use the client's resistance in the counseling itself. Being hindered by the apparent resistance limits our perception of the problem and keeps us from understanding the reasons behind that resistance. Too often, resistance (or tear of resistance) results in problems not being dealt with openly. Both client and therapist end up feeling helpless or even incompetent. We must therefore make an effort to have the client focus on himself and win him over to a process of change. In short, we must break his resistance and develop his sense of responsibility. Hartman and Reynolds (1987) established an intervention sequence according to the paradigm of "confrontation, interpretation and alliance" (CIA) to ensure the active involvement of resistant clients in the process of help (see Table 2). Their method is not exclusively applicable to men; however, it is well-suited for the kind of difficulties encountered with them. Based on Bowlby's theory of attachment and the fear of loss (Bowlby, 1988), the CIA paradigm utilizes alternating between anxiety and relaxation as the basis for developing trust. It also permits the client to feel that he has power over what happens in the counseling process.

We know that male socialization promotes the search for power and control. Traditional men seeking help feel more vulnerable and tend to try to regain control through aggressive attitudes or behavior. To work with such reactions, the therapist can leave power to the client in the form of choices or alternatives. For instance, the client can be helped in exploring the impact of his behavior but is left the choice of whether to reevaluate or cope with his behavior. Another way of working with such reactions is to explore alternative behaviors and attitudes and again let the man decide how and when to make his move. The client must feel that he can influence his destiny, that he is recognized as master of his own life and that we are ready to support him in that sense.

Interpretation enables the therapist to link the individual to his social context. By exploring the cultural context, particularly concerning stereotypes, we can lower tension and anxiety. The client perceives that he is not the only man living with the problem for which he consults, even though his story and circumstances are unique to him. This develops responsibility without creating feelings of guilt.

Developing a sense of responsibility also means helping the client modify inappropriate behavior. It also means assessing risks for suicide and homicide and taking necessary measures to protect individuals. Such acts, rather than disrupting the therapeutic relationship, demonstrate professionalism as well as interest in the client, as the following case study will show.

Case Study 1

Xavier, 35, comes to therapy after a court order due to an episode of severe conjugal violence with his ex-spouse. The couple, recently separated, had been separated previously for short periods over the past few years, which led Xavier to begin psychotherapy. That led to couples therapy with the same therapist, who referred Xavier to the first author because he could not continue to work with both Xavier and his ex-spouse.

The first four interviews were characterized by resistance and even negative attitudes from Xavier. He was excessively anxious, very selective with the information he provided, vented his resentment toward his ex-spouse and women in general, and distrusted the therapist. In short, he did everything he could to provoke rejection and antipathy.

How could this adopted child, who was rejected by his biological mother and later by his adoptive mother, spent time in foster homes, and was now being rejected by his wife and even his former therapist, be able to trust someone again?

The first interviews were devoted to building a therapeutic relationship and managing homicidal and suicidal risk. Xavier was struggling with two very strong internal forces: on the one hand, the fear of being judged, rejected by the therapist, and having his own words used against him in court, and on the other hand a profound anguish and urgent need not to be alone and isolated with his profound malaise. For the therapeutic alliance to develop, the therapist must first not only resist being overwhelmed by the rejection provoked by negative behavior but also identify the client's strengths, which will enable the therapist to believe in him. It is also necessary to accept the client's difficulty in trusting others and to consider that in the interview agenda by negotiating the relationship over periods of time that are acceptable to him. In this sense, it is important to be clear with him about the importance we place on trust and to be honest concerning our professional responsibility regarding social protection in cases of high homicidal or suicidal risk.

PROPOSING A FRAMEWORK FOR INTERVENTION WHILE KEEPING THE EMPHASIS ON EMOTIONS

Therapeutic processes are nebulous and intangible and may be perceived as useless talk by traditional men ("Marlboro Men") (Shay & Maltas, 1998) or John Wayne types (Tremblay, 2001) who are pragmatic and have clear, precise objectives (Dulac, 1999; Shay & Maltas, 1998; Tremblay 1989, 1996; Twohey & Ewing, 1995). These men need to know where they are headed. They need structure and a clear context. This is an important part of the basis for trust (or distrust) felt toward the practitioner, whom the client may or may not see as being an expert. This framework can assume the shape of a clear contract: We will work on such-and-such a topic over X number of meetings, which will be held X number of times per week at such-and-such a time on predefined dates.

Traditional men are centered on doing and acting. They want to feel that the supportive therapeutic relationship is based on practical and concrete change. It is also less threatening not to feel that they are always at the centre of the dialogue. It is advisable to use structured exercises between or during the sessions (Cadsky, Hanson, Crawford, & Lalonde, 1996; Tremblay, 1996) while specifying their purpose. For their part, Cadsky et al. (1996) recommend limiting the use of evaluative means such as questionnaires. However, questionnaires can sometimes be used informally as tools of self-awareness. More dynamic techniques, kinesthetic or others, can help promote self-disclosure, which is compatible with keeping the focus on emotions.

Throughout the process, it is important to "read" men's language and help them find words for their emotions. For example, in a session with a father and his teenage son, it was possible to decode that the father showed love for his son by wanting "to raise him as a good person" while the son expressed his need for his father's presence and affection through his misdemeanors. Thus, love was not absent as both of them thought, but it was expressed in inappropriate ways. Levant (2001) refers to traditional men's difficulty in verbally expressing their emotions as alexithymia. He argues that it is important in therapy to help men develop their emotional vocabulary while assisting them develop mechanisms for better identifying emotions as they arise. For some, a diary can be a useful tool. Other means can be even more useful: genogram, lifeline, storytelling, testing, and interviews with other men conducted by clients.

EMPHASIZING THE CLIENT'S PERSONAL STRENGTHS AND COUNTERING FEELINGS OF SHAME

Too often, counseling with men is based on discussions of their behavior and deficits. The capitalization hypothesis offers another direction (Good & Sherrod, 2001). It states that to be efficient therapy must capitalize on the client's existing strengths rather than directly pointing out his deficits. For example, instead of criticizing men who tend to rationalize everything, the capitalization hypothesis suggests that helping men focus on their desire to understand and their reasoning abilities will also help them develop emotionally.

Capitalizing also offers the advantage of countering the dominant feeling in men--shame. Actually, many men experience having problems or difficulties as equivalent to making them inadequate, no good, bad, or sick. Feminist therapists noted that guilt is the predominant emotion among women and that therapy should therefore be centered on that emotion. This discovery led to progress in work with women. A traditional woman will easily feel guilty about many things, even for the blows a violent spouse may inflict on her. Guilt carries the underlying affirmation: I did something wrong. This feeling leads to self-questioning at many levels. It directly places the woman in the relational sphere, on which the essence of female socialization is based. For men, the dominant emotion is the closely related feeling of shame (Krugman, 1995; Osherson & Krugman, 1990). The Oxford English Dictionary defines shame as "the painful emotion arising from the consciousness of something dishonouring, ridiculous, or indecorous in one's own conduct or circumstances (or in those of others whose honour or disgrace one regards as one's own)" (online at bttp://dictionary.oed.com). Unlike guilt, it implicitly affirms: I am no good. It affects the individual in terms of his right to exist and his core identity (De Gaulejac, 1989). Shame bears the connotation of fear of being judged and disapproved of socially (De Gaulejac, 1989). It leads to a profound malaise that complicates a supportive relation.

It is sometimes more difficult to capitalize on strengths and counter shame in couples therapy when the situation favors negative countertransference toward the man. Often, it is the woman who has pressured her spouse to agree to therapy or even threatened to leave him unless he participates in therapy. The woman arrives with complaints about her partner concerning the lack of emotional sharing in their relationship, his low level of involvement with their children, his tendency to place more emphasis on sexuality rather than intimacy, and so on. In this context, traditional men resist, become defensive, and avoid compromising themselves in discussion for fear of being attacked. For therapists, the greatest danger is to triangulate the therapeutic relationship by showing more empathy and sympathy for the woman, who expresses herself in a way that is much more compatible with traditional interventions, and/or by perceiving her as a victim. In a way, that attitude supports the woman's blame directed at her spouse. It is important for the therapist to remain neutral, to be aware of traditional men's resistances, and to speak out about them if needed in order to ensure that an atmosphere of trust reigns so the man will feel secure in disclosing more of himself in later sessions (Shay & Maltas, 1998) (see Case Study).

Case Study 2

Paul and Mary enter therapy after he confesses to her that he had extramarital affairs for a few months. Tortured by guilt, he decided to reveal the situation. Mary is devastated and goes from confusion to crying bouts to anger. She accuses him of sabotaging their relationship, hurting her deeply, and even putting her health at risk by having unprotected sex with the other women. In her wrath, she has told everything to her children, friends, her family, and even Paul's: Look at what he did to me! Possible countertransference reactions: feeling particularly touched by Mary's pain or seeing Paul as the destroyer of the relationship.

Appropriate reaction: View the extramarital affairs as a symptom of problems within the couple. In fact, Paul only rarely speaks of his needs, while Mary has very strong control of the relationship. Paul does not dare contradict her. Mary's life is centered on the children. The couple's sex life is nearly nonexistent. Paul has complained about it on occasion, but Mary rebuffed him: You're like all the others, you only think about sex! Paul deeply loves Mary. The involvement with other women, whom he recently met, was based on his realization that his sex life did not end at the age of 50 and that life consists of more than just routine. Mary was aware that their relationship was in trouble, but she did nothing. She even refused the sex therapy Paul suggested. She preferred to call him a bastard and heap blame for the situation on him rather than acknowledging her share in responsibility for the failing relationship. Further, after learning of the recent situation, she constantly denigrated Paul and tried to isolate him from nearly all his social contacts.

At the level of language, the more traditional man may not say "I love you" as often as his spouse might like, but his love might very well be expressed in a warm, attentive look, in everything he does for her, or by thinking of pleasing her by performing renovations or other concrete gestures.

Men have feelings and most express them when they feel secure (Gordon & Allen, 1990). However, they sometimes need help in becoming aware of their feelings and improving their often-insufficient emotional vocabulary. Each spouse expresses his or her legitimate needs in a different way. For example, a woman might look for more closeness, which can seem stifling for a traditional man. On the other hand, he may need more solitude, which can leave his spouse with a feeling of being neglected. Both attitudes reflect traditional Western female and male socialization. The situation therefore requires that therapists be aware of the effects of gender socialization, help a couple evolve and find a middle ground, and broaden both partners' horizons, particularly by helping the man to improve his abilities of empathic listening.

BREAKING AFFECTIVE ISOLATION

Although traditional men usually have contacts with many people, they develop very few affective bonds. Their social networks are public, based on concrete activities where expressing emotions and intimacy is forbidden (Dulac, 2001). Too often, their only confidante is their spouse. According to Rubin (1986), 85 percent of men limit their intimate relations to what they share with their spouse. It is therefore not surprising that when a rupture occurs in a relationship many men feel isolated. It is well known that an efficient natural network must have multiple inputs. One person cannot respond to all of an individual's needs. In this sense, it is extremely important to break the affective isolation men create for themselves. This involves helping men learn how to make full use of their social network or participating in various community organizations. By searching more attentively with them, we always end up finding one or two friends who could be approached differently. This experience also enables men to identify their true friends among their acquaintances. In the end, clients thank us because their friendships have changed and deepened.

Group intervention, without being touted as a panacea, often provides a supportive context (Dulac, 2001). The group also favors exchanges between men in a secure climate and permits a break with the tradition of competition typical of their previous relationships with other men. They can learn different ways to be a man and at the same time rid themselves of the hegemonic model of masculinity (Connell, 1995). Being heard and validated by others provides a securing effect and encourages self-questioning while promoting emotional bonds with other men and friendships that go beyond men's usual instrumental mode in interpersonal relations.

ADAPTING SERVICES, ACTING QUICKLY, AND BEING PROACTIVE

Difficulties in intervention are also felt at the service level. There are not enough services suited to men's needs and based on intervention principles that take into account the uniqueness of men's experiences (Dulac, 2001), let alone the times when men are, in fact, excluded. For example, fathers are often neglected in intervention services (Dulac, 1998), particularly fathers without custody of the couple's children after a separation or divorce (Asselin, 1998). Even though research (Amato & Gilbreth, 1999; Lanoue & Cloutier, 1996) shows the father's importance in child development, particularly in situations of behavior problems (Asselin, 1998; Tremblay, 1999), practitioners usually do not attempt to reach out to fathers (Asselin, 1998). In fact, psychosocial intervention often appears to repeat past mistakes, viewing fathers as the secondary parental gender (Dulac, 1993), while seeing women as the partner responsible for the children. Fathers may be forgotten in the intervention or eliminated from the situation as a result of a negative assessment of them by the mother or ex-spouse. Other times, the missing father stereotype keeps us from acknowledging the contributions of traditional fathers to the family's well-being.

Case Study 3

One day, a man steeped in today's popular conception of the absent father (Corneau, 1989) consulted the first author. He was looking for a way to tell his father, who was in the terminal phase of an illness, that he loved him. He told of how his father had always been absent, simultaneously holding two or three jobs. There were seven children in the family, the mother stayed at home, and the family never lacked anything: food, clothes, education. His father had serious heart problems for which he had had to stop working some years earlier. Therapeutic work was essentially directed in helping this man see his father in a different way. Hadn't his father, rather than being completely absent as he described, always, in his own way, devoted himself to work to ensure his children's quality of life? Wasn't that an act of love? Evidently, the situation did not allow the father to respond adequately to the son's emotional needs (and possibly those of the mother and other siblings), but the father responded perfectly to the social expectations of his time by fully assuming his role of provider. The client now had his answer. He had reconciled with his father and, at the same time, became able to tell him, "I love you, go in peace," which he could not do before.

Since men often consult only when they are in crisis, practitioners must often act quickly. Dulac (1999) believes that primary action must occur within the first 24 to 48 hours following contact or at the moment of consultation. It is clear that long waiting lists for services raise the risks of client withdrawal, or worse, of acting out, including suicide. "A delay, even a short one, can hinder the process of assistance; make it more difficult for a man to express his vulnerability or for the practitioner to establish the relationship of trust" (Dulac, 2001, p. 139; authors' translation).

The figures are alarming. Men, more often than women, sink into depression after a breakup and commit suicide four times more often than do women (St-Laurent, 1998). They are also more prone to using psychotropic substances (Tousignant & Payette, 1997). However, it has only been a few years since suicide has been considered as an issue that affects men.

Sometimes we should not wait for a formal call for help. Because traditional men have difficulties asking for help, it is a good idea to develop intervention strategies to reach out to them. This is similar to principles of crisis intervention promoting an "open-arms policy" (Dulac, 2001), for example, when there is a chance of suicidal behavior.

Finally, adapting services to men also means extended working hours, providing waiting rooms with messages for men (screening for testicular and prostate cancer), making available access to specialized services and, above all, training therapists who can adapt their interventions to suit traditional males.

TAKING CARE OF OURSELVES AS PRACTITIONERS

For male therapists, working with men involves constant attention to oneself. It requires questioning many assumption--in short, constant self-questioning. It is therefore important to pay particular attention to taking care of ourselves as practitioners and seeking the necessary support in difficult situations. Such a support network can provide reassurance and lead to improvement as a therapist (Dulac, 2001). Organizations and institutions must also be able to provide training and professional supervision to facilitate the integration of new ways of intervening with men.

CONCLUSION

We have attempted to explain what we have observed over the past few years as an emerging model for intervention with traditional men. We have summarized it in terms of taking gender issues into account, becoming aware of our own counter-transference reactions, and recognizing that males' socialization influences and handicaps their seeking help. The model is based on a clear and structured context, an approach consisting of both confrontation and support, and relying on men's strengths to counter the inhibiting effects of shame. Attempting to break men's affective isolation and reaching out to them in a proactive manner are key elements of the model. This approach forces us, individually and collectively, to adapt services and work on our own therapeutic relationships with men, which will necessarily be challenging if we commit ourselves to this perspective.

Beyond these thoughts, a constant that will remain is that any effective intervention must be adapted to the type of man seeking help, whether he is traditional or in a process of change; gay, bisexual, or heterosexual; rich or poor; highly educated or less so; or from a minority ethno-cultural background. There are many ways to be a man or a woman. It is advisable for us, as therapists, to keep that in mind.

Table 1
Contradictory Demands (Brooks, 1998)

Typical Psychotherapy Demands          Masculinity Demands

Self-disclosure                        Hiding private life
Renouncing control                     Maintaining control
Nonsexual intimacy                     Sexualizing intimacy
Revealing one's weaknesses             Showing strengths
Feeling shame                          Expressing pride
Being vulnerable                       Being invincible
Seeking help                           Being self-reliant
Expressing emotions                    Being stoic
Being introspective                    Taking action
Addressing relationship conflicts      Avoiding conflicts
Confronting pain, suffering            Denying pain, suffering
Recognizing failures,                  Persisting indefinitely,
   admitting ignorance                    feigning omni-science

Table 2
Confrontation-Interpretation-Alliance Paradigm (Hartman &
Reynolds, 1987)

Intervention                           Client's responses and feelings

Confrontation: Words that confront     Anger, need for help, surprise,
  resistances and which are related    anxiety, fear, weeping and
  to the client's idiosyncratic        remorse, fleeing.
  dynamic. These words must be
  direct, concise and to the point.

Transition: switch rapidly to:

* Interpretation: Interpret responses  Relief because the therapist
  or feelings expressed; encourage     understands; intensified anger
  the expression of emotions; speak    at being "found out"; fear of
  of an overt manifestation of         what will happen; fear of losing
  feelings underlying the need         the therapist's affection;
  for help; establish a link between   fleeing; desire to take cover,
  the current response and previous    to defend or protect himself;
  responses and feelings of anxiety    denial; desire to please,
  and fear; use the "here and now."    submission, better perception
                                       of his own anger.

Transition: Change in posture, to:

* Alliance: Express warmth, support,   Surprise and relief that
  and interest; use mild non-verbal    somebody accepts him even
  means of expression; be empathic;    though he showed his
  put the other at ease; show          inferiority; assurance that
  confidence in the client; share      someone shared his distress to
  his distress.                        help him overcome obstacles;
                                       feeling of being closer to
                                       and trusting the therapist.

* Result: Focus on relational work;    Trust; security; feeling that
  stability; trust; confrontation      someone is taking care of and
  when necessary; goal achieved:       accepts him; needs of dependence
  growth; autonomy; decision making.   met; goal achieved: growth
                                       and autonomy.

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GILLES TREMBLAY

Universite Laval (Quebec)

PIERRE L'HEUREUX

CLSC Simonne-Monet-Chartrand (Quebec)

Correspondence concerning this article should be sent to Gilles Tremblay, School of Social Work, Universite Laval, Quebec, QC G1K 7P4. Electronic mail: [e-mail].