Why do men leave therapy?
Why do men leave therapy?
I am writing this piece based on my experiences as a psychotherapist in private practise. The theme is one I have been considering over a number of years as I have noticed men seem to experience specific difficulties in therapy, difficulties that can cause them to leave prematurely. This important topic is both complex and multi-layered and these thoughts have been abbreviated here into digestible chunks for the reader.
Initially, I think it is useful to present some contextual thoughts on cultural and inherited pressures experienced by men. These are both conscious and unconscious pressures belonging to historical definitions of cultural and inherited gender roles and found commonly within social and family structures. These pressures appear culturally through common narratives and platitudes such as ‘you’ll be head of the house one day’, ‘be strong’, ‘show no emotions’, or more historically ’real men don’t cry, etc. At the same time boys and men have a range of uniquely design gender biased insults woven culturally into their lives, for example, ‘don’t be weak’, ‘don’t be a wuss’ or ‘stop crying like a girl’, etc. We can see how such judgmental and sexist insults are aimed to separate men from their ‘more emotional’ counterparts as if this is a weakness. I believe such derogatory comments belong to men globally and although I see clients in the UK – but not exclusively – such attacks on males and their masculinity seem worldwide. I also feel it important to add that while such negative gender-based speech may be experienced by many men, not all men suffer as a result. If suffering is experienced as a result, I think the insults add too or touch upon something psychologically deeper. By way of example, I have had many men arriving in therapy presenting with depression or anxiety, but as therapists I believe we should not make assumptions that we ‘know’ what this means to any individual.
In my experience people seek therapy due to problems experienced in early life when their needs were not sufficiently met. These problems may include deprivation or mistreatment of an emotional and/or physical nature and may also be clinically linked to neglect, trauma, abuse, or abandonment etc. Such deprivations when experienced as an infant or child can be extremely upsetting and difficult to manage and form long-term pathological problems. In such cases children manage emotionally by developing rigid defences and the feelings experienced during these difficult times of early life become frozen and repressed. Once repressed they remain as part of life throughout childhood, into adolescence and then into adulthood. Children who have encountered such difficulties enter primary school years with some emotional development already affected or arrested. By this I mean that if inadequate care, nurture, kindness, love, and attention has not been received it can affect emotional development. So, while I quite often hear men speaking of their primary school years as being manageable or good - and while I believe this to be the conscious truth - I also wonder if this might point to a defence mechanism. By this I mean a protective psychological coping mechanism of something already experienced is already in place to manage difficult feelings from early years. Psychodynamically, this defence mechanism is called splitting. It is a common psychological defensive phenomena where experiences of early traumas become buried away so while I might hear men describing early life as good, they are speaking to one part of their experiences and not the parts split off.
As mentioned earlier, I have heard many male clients speaking to expectations put upon them to keep their vulnerable feelings hidden. This reflects cultural narratives where boys who were told not to cry or show emotions, arrive at school already disadvantaged. This can shape life for a schoolboy and in particular secondary school and during the time of puberty. Here, peers copying role models seek ‘weakness’ in others to boost their own developing ego’s by hunting out scapegoats. Bullying and psychological abuse during secondary school is a wide and common problem for many children but from my observations it also seems that boys who have attended private, or all boys’ schools, can experience significantly more abuse than others.
During adolescence boys watch and copy their male roles models, internalising their behaviour and imagining this to be the type of person they are ‘supposed’ to be. These behaviours are often interpreted (or misinterpreted) and form unconscious understandings of themselves and relationships. Often these distorted interpretations lead to thoughts and feelings which themselves become confused or redirected back at themselves. A classic example of these dynamics is with anger where bullied boys can hate themselves rather than those doing the bullying. Often these self-attacks happen because of a deep fear to speak out against the attacker. It is often during adolescence that earlier repressed feelings also begin to re-appear. More school children in greater numbers than ever are reporting emotional problems such as anxiety, depression, fear, guilt, self-loathing, shame, and anger etc. Mental efforts to hide or avoid such feelings is a physically draining and exhausting task. Once repressed such emotions can feel like a dark swell, of shaming, frightening thoughts and opinions trying to flow over and overwhelm the unconscious defensive wall. This can be experienced literally in all sorts of confusing forms such as dreams, nightmares, projections, or other believable fantasies. It is understandable without help how such disturbing thoughts can turn into common physical, emotional, and mental health problems.
Such critical, persecutory views of oneself are punishing to live with and boys, believing such feelings should be avoided, turn into men believing the same. One such illusion is the fantasy of the external world as being an uninterested or unsafe place and this can unconsciously drive the urge to keep pretending all is fine. Meanwhile another part – the more vulnerable, needy part - is desperate to be seen and heard but if this has never been experienced, why trust the world now? As I mentioned I think of such coping mechanisms as denial, splitting, or disassociation, etc., and the symptoms commonly reveal themselves through social anxiety, depression, anger, behavioural, or sexual problems etc. The shame of such feelings can create a powerful resistance to accepting help. Indeed, I believe it is often an act of real bravery for men to contact a therapist; an act, that needs acknowledgement.
One of the main benefits of psychotherapy is how a psychotherapist can help put words to thoughts, feelings, or fantasies mulling around the mind. Such thoughts may have languished unspoken for years or even decades so to hear empathy, or compassion for the first time in therapy can feel wonderfully cathartic. But this may take a while, for therapy is a process, a journey, and that in essence touches upon the major theme of this paper for the task of conveying oneself to a therapist – initially a stranger – can be difficult.
Embarking upon therapy can feel uncomfortable and for some people, particularly early in the work, prove to be a complicated and anxious period of time. These anxieties can be provoked by the regularity and consistency of the sessions – the frame - and the attention received, particularly if care early in life was the opposite. On paper meeting and speaking to someone who we rationally know is there to help also exposes the hidden internal thoughts mentioned earlier. This exposure - difficult and shaming for the client – is carefully attended by the therapist who listens, reflects, or interprets back what they hear. For the client and the boy - within the adult - who had not previously received ‘good enough’ maternal care this can feel very uncomfortable. They may have always wanted and needed such attention, but to receive it now in therapy is not easy. Some of this discomfort comes from the differences. Where parents may have failed or made mistakes, now internalised and unconsciously the norm, the therapist begins to take their place. And simultaneously unconscious assumptions and expectations silently inform the client of old familiar dangers and fears repeating. It is a phantasy, not real, but to the client it seems and feels very real.
Over time the therapist, this stranger, will become someone more familiar. But this does not make exposing the secret internal parts easier for it involves shifting such unconscious parts to a conscious position. This shift can provoke feelings of vulnerability and as you may remember, if the male assumption is to show no weakness or vulnerability, then doing so can be experienced as appearing weak. This can involve projections onto the therapist – he see me as weak - although I (the therapist) do not think this. Quite the opposite for I see speaking hidden thoughts out loud as true strength and bravery. But my knowing and thinking this does not mean my male client thinks the same, or even believe me when I share this thought with him.
For the client, dynamics created when forming a therapeutic relationship can also create an internal power struggle: speak or keep silent. This struggle is often played out within the therapeutic relationship. One part of the struggle is to shift from an old familiar position where keeping parts of oneself hidden – i.e., unspoken - is felt as potent and powerful. Simultaneously, his primal urges to link and attach – as the baby does with mother - causes great conflict for such urges provokes a deep, visceral need to connect. In the client such conflicts can emerge through real physical discomforts i.e., somatised body responses, such as disturbed sleep patterns, stomach problems, hypertension etc. These somatised expressions of emotions can be unpleasant and stressful and, in an effort, to avoid them the client can ‘act out’, by missing sessions, or payments, taking sudden breaks or by just leaving. I respect these acts and see them as communications of psychic disturbances caused by therapy and recognise in some people they can feel too much. In particular for those clients who have suffered childhood abuse or traumas I always have a profound sense of sadness when they leave. But I also understand why and hope, that from their time in therapy with me they have experienced something positive from our sessions. This process is called internalising. It happens naturally through relationships and clinically maybe partly why psychotherapy can change people’s lives for the better.
In conclusion: Men may leave therapy early due to the resistance of lowering defences, formed in early life to manage the absence of care, and challenged when forming the therapeutic relationship. If so, this resistance many feel unbearable and leaving therapy felt as more manageable than staying and becoming curious about the feelings that arise. I acknowledge and understandable the power of re-emerging feelings can overwhelm but also trust those who leave prematurely may take some positive effects with them.
Blog written by our counsellor Martin.