I'm Dr. David Stifler, and on behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar, which is the second in this academic year hosted by the, or in what we're calling the Advanced Addiction Psychotherapy Curriculum. This is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty, and this is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today, and we will continue to offer you these live trainings that will be held the second Wednesday of each month from 5.30 p.m. to 7.00 p.m. Eastern Time. Today's presentation on working with men with substance use disorders will be the first of three talks in a series that we're calling Gender-Aware Care, and this will also include talks on working with women by Dr. Shelly Greenfield and also with transgender patients with Dr. Kevin Johnson, and those will both be later in this academic year. The next presentation, meaning next month, will be Wednesday, October 11th, and that will be Dr. Christine Berkman discussing trauma psychotherapy. Please check the AAAP website for updates on all the other upcoming talks and speakers. A few housekeeping items before we get started. Please feel free to ask questions any time during the presentation. You can use the chat box on your control panel, and you can also submit questions to be asked at the end through the Q&A option, and we're going to reserve 10 to 15 minutes at the end, so there'll be plenty of time for questions. And then finally, after the session, you can claim your credit by logging into your AAAP account and accessing this course, and please complete the evaluation and follow the prompts provided to claim credit. I'll turn it over to you, Dr. Blazes. Yes. Hi, everybody. Thanks for joining, and I'm Chris Blazes from Oregon Health and Science University, and today we're very excited about having Dr. Sam Wan, PhD, come to speak with us about psychotherapy with men. He's the director of the training for the clinical psychology postdoctoral residency training program at the San Francisco VA healthcare system and the clinical supervisor with the substance abuse and PTSD clinic. He's also associate clinical professor of psychiatry at UCSF School of Medicine. For the rest of the long bio, you can check the website, but we're really excited for him to talk about this. He's been speaking on this topic for some years now, and I first heard his lecture some years back when I was a fellow at UCSF, and he has a great perspective on this complex and interesting and important topic. So thank you, Sam, for agreeing to speak with us, and I'll pass it over to you. Well, thank you, Chris and David, for inviting me and for having me join you this afternoon or evening, wherever you are. I will be looking at mostly our hosts and my slides, so unfortunately, I don't get to see your reactions or faces, but I do love interaction, and so please use the chat liberally or get my attention through these mechanisms virtually along the way. If you're watching this as a recording, feel free to reach out to me once this is over and if you have any questions. But this is a very beloved topic for me. It is something that I've been thinking about and certainly working on from an academic perspective since I was a graduate student about 20 years ago at this point, and my academic advisor and dissertation chair was heavily involved in this field and still is, and so he also had a really wonderful kind of connecting role for me into this particular area of knowledge, but also then eventually of practice. So I could put a couple of images here. One, as we were talking about before I started here, was Band of Brothers. I happen to work at a VA. I know that many healthcare professionals do get trained in VAs. I'm a training director of psychologists as well, but I certainly know that not all of those who might be listening to this work in VAs, but VAs tend to be very male-centric as our Department of Defense and military branches are, which is where the VA population mostly stems from, but of course now there are lots of female veterans also, but primarily you will still see a lot of men and do a lot of psychotherapy with men there. I included this image that refers to toxic masculinity, and I will talk a little bit about this during the presentation, but only because it has been really equated with this discussion about both men and masculinity, and generally speaking, I'm not going to be taking this as the summation of this topic, partly because I think it does the topic a disservice by overly categorizing everything about men and masculinity as kind of a negative or toxic paradigm. So anyway, but it is certainly in our culture and wanted to pay acknowledgement to that, and another acknowledgement, or well, a couple of things I wanted to kind of highlight in the outline. One is that we'll go through some terms, we'll talk about the construct and constructs, the biological bases, which I will not linger on whatsoever, but there is an element of acknowledging that. Then we'll move into roles and norms and how they play into our understanding of the way that men live in society and in our population. Areas of extremism that exist, both in real life and in the virtual world, and many online platforms are filled with some of these groups. We'll talk more about intersectionality and how multiple identities play into this. We'll talk about assessment and measurement, intervention and treatment, and we'll try to summarize with some questions and answers with perhaps a little vignette, and again, along the way, your questions. So a couple of acknowledgements. A lot of what I also continue to be a part of is this division in the American Psychological Association, Division 51, which is the Society for the Psychological Study of Men and Masculinity. It actually has updated itself to men and masculinities, but it is one of the main communities of researchers and clinicians focused on trying to understand who are we as both academicians and clinicians, but also how do we work with boys and men? Again, I've been talking about men, but of course, there's a world of providers out there treating boys as well as men. The division also is a companion and was an early outgrowth of the Division for the Society for the Psychology of Women in the 70s, and so Division 35 was really the forerunner for this division. So I'm going to move into some terms, and perhaps these are terms that you are very familiar with, so I'm not going to belabor them, but these are meant to level set where we are with some of our discussion. So sex is usually assigned at birth and is based on the appearance of appearance of external anatomy. It's typically assigned and categorized as male, female, or intersex. Intersex is a general term covering a variety of conditions in which a person's sex characteristics, including chromosomes, gonads, or genitals, are not distinct to either a male or female. Gender, the behavioral, cultural, or psychological traits associated with one's sex, which can vary widely depending on time and place. It's widely held that sex and gender are not the same. Essentialist thinking is the belief that familiar categories, for example, dogs and cats, space and time, emotions and thought, each have an underlying essence that makes them what they are. This belief is a key barrier, though, to scientific understanding and progress. It's an element of ideology based upon the argument that this one thing is different fundamentally from the other thing. Non-essentialism refutes this, though. Each factor that contributes to one's composition, such as an identity of race or class and gender, helps to create a more different individual. Benevolent sexism refers to complementing a person of another gender based on various stereotypes. For example, when it comes to women, you're treating them based on the fact that the stereotype is that a woman is nurturing or compassionate, and neither. When you're so-called being benevolent towards them, the challenge is that it's still treating somebody based on a stereotype. Feminism, which is not an easy term to define, but it's the advocacy of women's rights on the basis of the equality of the sexes, and gender identity is your internal knowledge of your own gender. For many, it aligns with the sex they were assigned at birth, but for others, they may identify with neither or multiple genders. Non-binary is a term used by people whose gender identity or expression does not neatly align with male or female. Okay, transgender describes someone whose gender identity differs from the sex they were assigned at birth. Cisgender describes someone whose gender identity lines up with the sex they were assigned at birth. Gender expression is how you present your gender outwardly, including through behavior, mannerisms, clothing, name, pronouns, and more. Gender transition, the multi-layered process of aligning one's life with one's gender identity. This can include medical, social, cultural, and legal changes. Gender dysphoria, a medical term for the psychological and physical distress that happens when one's sex assigned at birth does not align with their gender. And last, gender euphoria, the satisfaction and happiness people feel when their gender is affirmed. All right, so going to this question here, what does it mean to be masculine or what does masculinity mean? Here's a couple of images from pop culture or some recent ads, and although I can't have a discussion with those of you online right now, if I were to imagine what you might say, you know, we also have some of these things about clearly strength. So this man is hanging from the cliff with one arm and clearly has a very muscular physique, drinking milk. And of course, this guy with the tie is lifting a car to help this young boy retrieve his soccer ball. So clearly there's an association with strength. And of course, in the military, I talked about this a little bit, there's various images we might have of strength and or power or authority related to the military. So masculinity is often kind of associated with the culture in the military. There are other things that are often associated with masculinity, such as, for example, in my work, substance use disorders and either using substances or how one uses substances, how much they can tolerate those substances, for example. And also maybe the prevalence of how, which people are susceptible to substance use disorders. Other things about masculine, what masculine means in our culture. This is something I just thought I'd add, you know, the term mansplaining, something that I learned about not too long ago. And it's meant to be kind of a comical take on it, but I think this is a real phenomenon that people really refer to these days. So important to at least acknowledge that masculinity often involves many things. So there are also, and I'm not going to click on links to go to YouTube or go to certain specifics, but if you're looking for men and masculinity images or portrayals, you're going to find them very easily in the media, both in the press and in, of course, our entertainment world. And lots of ways to think about what men are either like in this day and age or are expected to be like. Fascinating NPR series called Men in America. This is several years old now, but it was called The New American Man Doesn't Look Like His Father. And TED Talks, you can find those as well. As well. So there's all sorts of ways to think about masculinity and various characteristics of that. Some of which I'll be going into that are kind of agreed upon and others that maybe you have thoughts about yourself. Okay. Now, just to go back to basics, and even if this is not necessarily, this might be straightforward and simple, but at times, it may not be either. But when we look at kind of the biological basis, of course, boys are defined by their genetics, biology, chromosomes, genitals, hormones, neurotransmitters, and glands. And boys develop secondary sex characteristics based on those hormones that affect their hair, their muscle tone, their aggression, their libido. And that also, as we have that other image, does determine, generally speaking, one's body type overall. But the perception of what is masculine for that body type does evolve with time and evolve with society's views on that. So for example, Superman. Everyone probably knows this character. And in the early versions of the TV show, this was kind of the ultimate image of what Superman, I'm emphasizing the man part, but Superman, would look like if you were to think of somebody who's super. Of course, this is a more recent version of him and stark contrast in terms of then versus now, in terms of what people would think of as the ultimate image of Superman. But there are idealized body image aspects that we would consider as part of the zeitgeist around masculinity. Number one, that you're tall, that you're muscular, that you have wide or broad shoulders, that you have large biceps, hefty chest, narrow waist, or the inguinal crease called the moneymaker. And of course, we have a couple of very famous idealized men. Got The Rock up here and Bruce Lee down here. And both of them represent idealized body images over time, but also across different groups. But then what about this one? I think there's also now this phenomenon of the dad bod also being part of this body image and that it is something that's very, I don't know if it's embraced, but it's accepted as normative. And even the new Ken dolls have different variations on men and their image. There's a man bun Ken or a mixed race Ken, shorter but not in a way that makes him any less of a man Ken. And then there's a dad bod Ken. So these Ken dolls, just riffing on the phenomenon of Barbie over this last summer, there are images that are in our pop culture. But moving beyond nature, talking a little bit about nurture, which is more the crux of what we're going to spend our time on today, is what are masculinities in the United States? What does it mean to be a man in the United States? What do men do to make themselves feel like men? Important questions that we ask ourselves when we're thinking about how do men become who they are over time? And then how do they end up who they are when they arrive to us as providers? And what are we encountering? Of course, we're encountering the accumulation of multiple factors in one's life. And when it comes to gender identity, these are the ones that I think of when I'm thinking about who's in front of me, and their ideas about being a man. There are processes of socialization. That's the first thing to understand, of course, that we're all socialized into what it means to be fill in the blank. A provider, in my case, a psychologist, a father, a husband, a son, a boy, a man. So there's processes of socialization. And there are certainly over time, lots of texts one can refer to. And I know you're going to get all these slides, so no one has to write anything down. But there's lots of authors looking at, for example, the rites of passage in masculinity. What are those? Or normative alexithymia by Ron Levant, 2005. I'm going to talk a little bit more about alexithymia or what he defines as normative alexithymia, which is restrictive emotion, and other problems like empathy deficits. There are some commonalities with traditional male ideology or traditional masculine ideology, which I'm going to talk about in a moment. But there's a few other terms that you've probably heard about, but if you haven't, there's hegemonic masculinity. Actually, did I skip a slide here? Yes, I did skip a slide. Okay. So there's a hierarchy of masculinities by Connell, which was a very seminal work about masculinity. There was a book in 1995 that he wrote called Masculinity. And he defines these four aspects of the hierarchy of masculinities. One is that hegemonic masculinity is defined as the dominant form of masculinity in our society. It's culturally valued the most. Its qualities include, excuse me, heterosexuality, whiteness, physical strength, suppression of emotions. It's a theory coined by him that describes the social pressures and expectations men face to be the perfect expression of masculinity. It's the stereotype that our society sells us as the normal and exalted version of true masculinity. There's complicit masculinity, where a man doesn't fit the characteristics of hegemonic masculinity, but also doesn't challenge them. He often admires the characteristics of hegemonic masculinity. There's marginalized masculinity, where a man doesn't or cannot fit into the hegemonic version because of certain characteristics like race. One still subscribes to norms of hegemonic masculinity like physical strength and aggression. Folks who might fit this category might be men of color or men with disabilities. Subordinate masculinity. This man exhibits qualities that are the opposite of those values in hegemonic masculinity. He may exhibit physical weakness or be very expressive with emotions, sometimes considered the effeminate male. But what this hierarchy of masculinities has in common are that they are narrow, non-flexible definitions that are also gender role specific. They often characterize a person as hyper-masculine, that that's what really is values. And when I included work on Bruce Lee in my dissertation, thinking about him as one of the kind of central figures for Asian men, especially from the 70s, I wanted to think about introducing to more of a Western media and to think about what are the characteristics of him and how he became very popular for many reasons, but also became then a bit of a defining image for many Asian men in US society. Of course, he had a very hyper-masculine presentation. Then of course, we have the toxic masculinity term that I talked about briefly and precarious masculinity, but these are terms that all do involve a very narrow understanding of what it means to be a man. They're very inflexible and they certainly are gender role specific. And here's the other piece about the reason I mentioned at the very beginning of the talk, the image about toxic masculinity and kind of my thoughts on it. Number one is that it certainly does identify things that we don't want men to be restricted by and constrained by. And also we want to identify all the negatives that are associated with masculinity that has a very negative impact on both men and women and all people in our world. Certainly the Me Too movement, these kind of coincided in terms of their emergence into the pop culture language, but the Me Too movement certainly evidence of the ways that masculinity borne out is very negative. So masculinity ideology is the main phrase that has been used to define men's acceptance or internalization of a culture's definition of masculinity and beliefs about adherence to culturally defined standards of male behavior. The masculine man in the trait approach, this is one who possesses particular personality traits. The traditional man in the ideology normative approach is one who endorses the ideology that men should have sex specific characteristics and male role norms and gender role strain paradigms were developed as two main constructs used to better understand and operationalize masculinity. So masculinity ideology is what is referred to in understanding various standards of what it means or what our society believes it means to be a man. Sometimes we think of it as men have traits that these are their specific traits that they embody. And there's also the moving to traditional masculinity ideology. One of the things that we really think about when we're talking about ways that men are constrained is to think about it from the traditional perspective, which includes standards such as anti-femininity, achievement, issue of the appearance of weakness and adventure, risk and violence. So the one that's been most examined within the literature is the traditional masculinity ideology affectionately known as TMI. And I don't know if I should be pausing for any questions that might be popping up. So I'm just gonna ask that in case there's something that people are asking. No, right now we haven't been getting any questions. Sometimes they kind of trickle in at the end, but nothing so far. Okay. I guess for the audience, just, I guess, keep in mind, maybe you're gonna pause and ask if there's been any questions. So if anybody wants to type any in, Chris and I would be happy to kind of triage those. I'm happy to pause whenever. I'll insert a few just, number one, it's not easy to just keep running on, but also be nice to be able to address your questions as they're coming up. So we're still within the realm of understanding ideology about masculinity in society. And the primary problem with our ideology around men is that it's restricted and that men feel that there is no way to not conform to these things and that there are consequences for not conforming, which we're gonna talk about in a minute as well. But that's sort of the take-home message is that traditional masculinity ideology is very prescribed. And not conforming, it has its consequences. And so there is a certain perpetuation of this by both men raising boys, as perhaps even women raising boys as well. I think we do have a question coming in. Is it okay if I allow the- Please. Okay. Jennifer, if you still have your question, I tried to unmute you. I think I'm unmuted now. There you go. Hello. Okay. I don't know about my camera, but... Yeah, I don't think the camera turns on. I think it just allows you to speak. Okay. Okay, hello. Hi. So I'm a psychiatrist and a child psychiatrist. And one of the things that I think I was taught years ago and kind of believe in is that there's a case to be made for boys to be brought up in all boys' schools. And some of that is because in co-ed schools, boys can often sort of be discriminated against because they're more rambunctious and more physical and more impulsive. And they don't get chosen to do the special jobs like the teacher's helper with this and that, or to be the hall monitor or the messenger, that girls sort of, by default, get this sort of preferential treatment. And that in an all boys' school, the boys have to do those jobs. Somebody has to play the violin in the orchestra. So I was wondering what your reactions are to hearing about this. Well, that's a good question. I do think that at some level, in mixed gender environments, there is more, there's the potential for restriction, more narrowly defined roles. And I'm gonna talk a little bit more about gender role in a moment. But I think at some level, maybe what you're referring to is the argument that in the same-sex, same-gender school, that that single gender does have more ability to not have to only conform to one particular definition because, as you said, there's more need for an expansive definition of what it means to be a boy in this case. And so there's potential for expansion of that. And, yeah, I wonder if that's part of what is at the basis for that. I certainly am aware of same-gender schools. And I think there's a case to be made pro and con for those at a certain time of raising children, not that they are the only way to educate, not that it's the only kind of best environment, perhaps. It is one choice one can make. Thank you. Perhaps some of what I get into later might spur some more thoughts about it, but thank you for the question. Others, or should I move on? Oh, it looks like you can move on. Thanks for- Okay, all right. Thank you. All right, so again, we're just kind of focusing a bit on ideology that we all live and breathe, even if we probably haven't thought too much about it so far. So dominant masculine ideologies from, at least captured in the literature from when this field began, roughly 30 or 40, well, actually now it's 50 years old, white American ideological standards, four ideals. This is where it started. And there's been an evolution as you could probably imagine since, but the sturdy oak, stoicism or not sharing pain, the big wheel or somebody who's achieved a lot of status and power, the give them hell ideology that you're a person with daring and bravado and a love for violence even, or no sissy stuff, the condemnation of the expression of dependent or warm feelings or urges seen as feminine. So these were earlier standards identified. Perhaps you agree with them. Perhaps there's some things that you disagree with, but those were the ones identified early in the literature. And then O'Neill defined other aspects of masculinity in the literature around, against stoicism, restrictive emotionality. You'll probably hear that being over and over again. And surely that's one of the challenges we have as providers as well. Healthcare problems because of kind of the value for independence and bravado, obsession with achievement and success, restricted sexual and affectionate behavior, socialized concerns for power, competition and control as well as homophobia. But then over time, there was Plec who defined the myth of masculinity to look at this further, where there's understanding that there's a shift in the psychology of gender that refocused the conceptualization of gender away from the individual and what lives within the individual, for example, and more onto the experience of the majority and to a normative perspective through paradigms such as gender role strain. We're gonna talk about that here. Gender role strain is defined by appropriate gender roles are determined by the prevailing gender ideology, some of which we've talked about already and are imposed on the developing child by cultural transmitters. For example, parents, teachers, or peers who subscribe to the prevailing gender ideology. And the gender role strain piece here is referring to the conflict that boys can have where no one can really live up to all the expectations of that ideology. There are even contradictory expectations for boys that they don't cry, but also that they are supposed to be emotionally expressive in other ways. And living up to these expectations often leads to stress and conflict. The masculine socialization towards stoicism, interpersonal dominance, self-reliance, resistance toward vulnerability is also another aspect of conflict. And there's often more comfort with doing versus being and having a hard time sitting with affect. So something to be concerned about or to be aware of and at times concerned about is really how does gender role conflict present within the people that you're working with, boys or men? One of the ways that gender role ideology, masculinity ideology is reinforced and socialized in boys is around the utility of shame. Oftentimes shame is the signature tool for shaping behavior and avoiding shame almost at all costs is usually what boys and men are trying to do by enacting particular roles. And the signature of shame in trying to enact particular roles is secrecy and hiding. So when boys are crying, for example, the way that they are trying to, often they want to hide that behavior and other boys might tease them, for example, and this is where the shaming comes in and then they restrict that. So the mechanism for shaping these behaviors over time are often shame based behaviors. Okay, I'm gonna talk a little bit about extremism because this is where it goes off the rails but it exists and it's important to at least start to understand it exists in a particular way and it may be lurking with some of the folks that you work with at times if they reveal it to you. We're talking a little bit about things like the online, it's called the Manosphere, that was a newer term to me several years ago but the online platforms where a lot of these blogs and a lot of these rooms are held, dark web, if you will. And there are groups called the Men's Movement, the Men's Rights Movement or the Men's Rights Activists where these are movements really thinking about how do we understand men's, prominence and sort of diminishing prominence in society, current society. Some rights groups can be categorized as being part of a hate ideology where some might be focused on some legitimate grievances. Other groups are called men going their own way or pickup artists or father's rights groups. Maybe some of you have heard of the term incels or involuntary celibates, men who feel that they're only not having sex because of the way that women treat or see men and it's an involuntary state. And then there's the terminology of the blue pill, the red pill, the black pill, if any of you have heard of this but the blue pill refers to a just world fallacy. There's folks who have had the blue pill in this particular way of sorting men and where these men have a preference of believing in comforting or convenient tropes, especially when it concerns a person's worldview with emphasis on the pretense or opinion that goes contrary to the research suggesting physical attraction is utmost in social or sexual situations. Blue pilling is banned from incels. So blue pill folks are the ones who kind of think about women and the world in a less than negative way that there's more of a just world out there. And that's in contrast to folks who have had the red pill and I believe that this does come from the movie, The Matrix. So if you've ever seen that particular movie there is a decision point in that movie with the main character about which pill to take to really see the world as it is. The red pill is informed by the belief that society is gynocentric and discriminates against men rather than women as well as valuing male gender traits over female gender traits. The belief that those who lost the genetic lottery face shallowness and unfairness but this can be overcome through self-improvement particularly looks maxing. So these are various concepts, ideas or beliefs that are operating within these particular groups. And I think the main thing to kind of think about is kind of the narrowness as well as the stubbornness of these particular beliefs that are very inflexible. The black pill talks about feminism, technology, modernity have unleashed female sexuality and created a shallow locus and hypergamous dating sphere which is destroying the social fabric of modern civilization. It's over for insults with poor looks and low social status or other flaws that is that they have next to no chance of ascending or attaining sexual and social fulfillment. Those who are in this camp of the black pill probably have the most pessimistic viewpoint about the ways that men are viewed in society and what their chances are in society. And the hypergamy image that I have here if you're not familiar with this particular term is about kind of this idea that on the left side maybe there was this thought that, well, there's somebody for everybody. Doesn't really matter if you're good looking or if you're interesting, whatever your traits are, whatever your characteristics are, there's probably somebody out there for you. That's the looks matching kind of ideology. Whereas the hypergamy ideology is that essentially the act of marrying or forming a relationship with a person is really only based on whether or not they are superior or have a superior sociological or educational background. That there's really only a certain segment of women that most women are only drawn to a certain segment of men in the population. So the women figures are on the left and the male figures on the right. And essentially all the men below the arrows have no chance of being matched with anyone who's interesting or good looking. So I am not diving a ton into the extremist viewpoints which these pills represent, but they are out there and they can be very formidable when you're dealing with folks who espouse these particular beliefs. Okay, did I need to bring back my... I'm still sharing and I've lost people's faces here. Sorry, there we are, there we are, okay. Okay, I'm gonna move on to intersectionality to move on to the idea that men who don't fit the traditional masculinity ideology have multiple identities. And that's something to also be aware of and thinking about with the folks that you're working with. So there's lots of literature out there, but masculinity is among African-American men and intersectional perspective by Dr. Rogers, Sperry and Levant looks at the ways that African-American men have a very particular experience of masculinity in society. There's also other ways that I was talking a little bit about this earlier where certain races may not be able to conform with traditional masculinity ideology. There was this details magazine several years ago that had this page in it. And you can kind of see the tension here where this is bringing up something very painful for Asian men, because the question here is about, is he gay or is he Asian? And really just for particular appearance. So intersectionality is a way to understand that men inhabit various and multiple identities based on class, race, ethnic groups, sexual orientations, life stages, or historical eras. And often men of color do not share or measure up to the same construction or social construction of masculinity as the majority group. Socialization for men of color can be, I'll use the word traumatizing, but it can be very negative and amplified for boys of color due to the experience of racism. Acculturation or conforming to the majority or dominant group can be a form of race-based trauma as well. And internalizing racism can stem from an internalizing of white masculine standards and expectations. So what are some of the costs of this socialization for intersectional identities? Well, there can be a sense of corrupted boyhood that they're not able to be the boys that they want to be. They can be socialized to violence. And although lots of violence is perpetrated by boys and men, the majority of boys and men are not violent. Male sexual misconduct as a group norm. So it can be that this particular norm of sexual misconduct is something that is a part of men's masculinity ideology. And it is one of the costs of the way that men are socialized. And I would put it in, again, I'm not using toxic masculinity as a summary statement, but I will put it in that negative camp of things that men adhere to rigidly and have negative consequences. Substance misuse, substance use disorders higher in men, high risk behaviors, absent fathering, homelessness and vacancy. Men's health can be at risk, work and chronic stress and lacking male friendships and homophobia. So these are things that are the negatives of traditional masculinity ideology that we want to address and we want to correct in the boys and men that we work with. Social psychology does give us particular thoughts about how we understand what the rules and norms are that boys and men are expected to adhere to. Social psychology gives us these terms of descriptive, injunctive and cohesive norms to understand what people see in their environment, what they work to live up to in their environment. Descriptive norms are norms where you're seeing what most others do. They describe what people should wear or what people's haircuts should be, what length of hair they should be, different things that they should enjoy, whether they should dress in blue or dark colors versus pink and bright colors. Injunctive norms are ones where they tell us what one should do. These are injunctions in society that sort of give the message that you should be doing this if you're being masculine. So you should be strong if you're a real man drinking milk. Those are injunctive norms. Cohesive norms are really based on what important others do. So these are the role modeling norms. So when you choose any role model, fill in the blank, when that person is doing that and you think of that as a masculine or see that as a particular way of being in the world that you wanna emulate, that is a cohesive norm. And advertising obviously uses this to a high degree, using celebrities to tell you, well, if you wanted to smell this way, you would use this soap or shampoo, things like that. So cohesive norms are about looking at role models and what other important others do. Now, when we're looking at social psychology, we're also thinking about the term conformity and non-conformity. And we're gonna talk about that in a second. But when I talk about some of these cohesive norms, for example, when you think about a role model for dad in popular culture, that changes over time. You can see in the 50s and 60s in TV shows, you might've had folks who look like this and emulating a particular image like this. And as the 70s came around, maybe you had your image of dad was more like Charles Ingalls on that TV show. Or the Brady Bunch. As you move into the 2000s, you have different various father images in the TV shows that are out there. And then relatively, I put now here, relatively to capture a number of different figures, but you have sort of mixed characters. They're not unidimensional, they're more diverse racially and sexual orientation. So I think that there are ways that we as humans change and we should recognize them. And we also wanna be intentional about understanding what our influences are and what people are conforming to or non-conforming to. So moving towards assessment, there are some measures in our field that we can use. I'm just putting up an alphabet soup here, but conformity to masculine norms inventory, for example, the CMNI or the gender role conflict scale, the GRCS. There's several of these that I have references to and are in the presentation, but there are measures out there that help people to position themselves on these spectrums of masculinity. When we're thinking about conformity, we're also thinking about ways that conforming both benefits oneself, as well as contributes to stress in your life, in your relationships, your work, your health. So conformity is meeting societal expectations for what constitutes masculinity in one's public or private life. And non-conformity is about not meeting those expectations in one's public or private life. Some of the aspects in the norms inventory for men or for masculinity are these, 11, winning, having emotional control, risk-taking, violence, having power over women, being dominant, being a playboy, sexual alliance, primacy of work, disdain for homosexuals or pursuit of status. And the idea here is that you're trying to locate whoever's responding to the inventory is locating themselves along the continuum of these particular gender role norms. And the subsequent conversations, if you have the data, if you have the information, number one, sparks the discussion around, well, what are these norms and what do you think of these and how do you live by them? And as well as, how much do you conform? It's a question of not whether or not it's good or bad that you are, it's about, do you recognize that you're living by these norms and how do you intentionally conform or not conform? And what are the costs for you? And there's a companionate femininity norms inventory as well. But that's an important, it's one measure, I think that can be very helpful. I'll say one more for now, which is the male role norms inventory, the MRNI, which also has avoidance of femininity, fear and hatred of homosexuality, extreme self-reliance, aggression, dominance, non-relational sexuality, restrictive emotionality. So more so putting yourself on the continuing, where do you conform or not conform with any of these particular norms? Again, I'll just pause in case anything has come through. Oh, sorry, go ahead, Chris. Now, there was one question that came through in regard to the preference of men towards doing versus being. I wonder if the mindfulness techniques often used in therapy are provoking intolerable discomfort for certain men. I'm curious how I can assess who might benefit from these coping skills versus who isn't ready. Also curious about reframing these skills in a way that may resonate more with men with normative alexithymia. That's a great question. It's a big one. Determining who is ready or who is not, I'm not familiar with anything academic, for example, in the literature that you might give to men. I'll be using my experience to try to start with an answer here, of course, not definitive. I think that I've been surprised, to be honest, by men who have been willing to... Mindfulness exercises are certainly more prevalent now in our psychotherapies and in our approaches, whether it's ACT or other approaches. And I have personally been surprised by the receptivity of most veterans that I work with who are male who have wanted to do mindfulness exercises. At first, to be honest, I'll be perfectly honest, I thought that maybe they wouldn't like this because it does invoke a more attentive state to how one is feeling. And based on some of these norms of restrictive emotionality would potentially conclude that they would want to avoid that. However, for whatever reason, I think some of the men I've worked with have been very receptive. The only thing that I personally work on is whether or not, or use as a gauge, would be whether or not there's more of a trauma history or a known history of more avoidance of emotionality. In that case, I might ask a little bit more along those lines before embarking on exercises like that. I don't unfortunately have anything that I'm aware of that you would use as an instrument to gauge that better other than to try to at least be aware of it, which you are, and to really think to ask about it in a way that would help you gauge their readiness and perhaps invite versus assume that they would want to do it right away. Now, I do think that there is a doing aspect of mindfulness also, that perhaps that might be some of the reason why some of the men have somewhat surprised me by being receptive to mindfulness exercises. Yeah, it brings up the idea of wei wu wei, which is action without action, and you can get into old philosophy. But I think there was another question. From Jennifer, I unmuted her. So Jennifer, welcome. Yeah. Hi again. Hello. Okay, so when I'm looking at these gender role conformity, Norms. I'm thinking these have to have had some role in evolution. And I'm wondering if like after the women's movement, the accessibility of birth control turned the tides so that these qualities became sort of like obsolete caricatures of something that used to be useful. What do you think about that? Well, that brings to mind what you're referring to, sort of the evolution of the usefulness of our socialization. Whether or not you're talking about from an evolutionary biological standpoint, I'm not certain. But from a socialization standpoint, I do think what we expect of each other in society, both men and women, continues to change. Our needs as a society changes based on the resources and technologies we have. So yes, I do think that gender roles have changed quite a bit as you have already referred to. Women, once they entered the workforce, which was a part of when you're referring to birth control, that certainly made that possible. And so the world of work on its own and how we understand men and women in that world nowadays versus 50 years ago, 60 years ago, I think is tremendous. And so I do think that whether or not our attitudes though have caught up is a different question, which I think is where some of these norms really are working is on our attitudes. Some of these attitudes and norms have been stubborn and difficult to do away with in many ways. So if that helps, I agree with you that the world has changed and the way we express ourselves and live in the world has changed. But our attitudes towards what we think of as an optimal masculine man, sometimes those images are stubborn. Thank you. Thank you for the question. Please continue to comment if you have any other thoughts. All right. Well, and Chris, there was a second half to that first question I was talking about with the mindfulness and readiness. Was there a second half? Yeah. I don't know if we can archive it. Okay. It was, perhaps she can put it back in there, the second half and we'll get to it afterwards. All right. So again, just focusing on gender role again, from the 70s, there was the idea that from Sandra Bem's sex role inventory, for example, this was the idea that the roles were within us and the way we thought about these things were within us. We were the good providers. We were the attentive lovers. But I think that the evolution of the theory has moved towards more understanding what society expects of people and whether or not men are trying to conform or choosing to not conform, but understanding what those costs and benefits are. Okay, I'm gonna move towards that. So just a couple of concepts, just discrepancy strain, dysfunctional strain or traumatic strain. Discrepancy strain is when one fails to live up to one's internalized manhood ideals or dysfunctional strain is when one fulfills the requirements of the male code and these characteristics have negative side effects. So when that strain results in dysfunction or trauma strain, experiences with gender role strain that are thought to be particularly harsh and inherently traumatic. So I'm gonna move forward. So just to highlight that gender role strain thought is important to really use in your thinking when you are working with your individuals to understand how are people locating themselves along these continuums. And what kind of strain are they experiencing if they are and likely they are in some particular way. Okay, moving past a couple of these pieces. So let's talk a little bit about interventions. I think that's why we're here. We're all interested in what do we do here? And of course, I just in the last hour pretty much breezed through volumes of literature and volumes of ways that we could be talking about this and hopefully in our Q&A, we can get further into that. But interventions, as I was talking about, here were some of the things that we can think of as the cost on boys and men's lives. The corruption of their boyhood, not having a boyhood, for example, or childhood, if you will. Violence, sexual assault, sexual harassment, sexual misconduct, substance misuse, risky behaviors, not being fathers and attentive to their responsibilities. Men's, their focus on their own health, their work and their relationship to work. What is the status of their male friendships and also homophobia, internalized or externalized. And then we think about, well, what about the approaches that we do have? Why do men want to be involved in counseling and psychotherapy? And there are some reasons why they may not like to be in counseling or psychotherapy, maybe because of their stereotypes they have of psychotherapy. These are not necessarily even unique to men, but these may be some of the reasons. The social construction of masculinity, as we talked about in terms of what their ideas of what it is to be restrictive in emotion and sturdy and the stoic. Political power and triangulations in terms of who's involved in the relationships and the way therapists in the past have potentially treated a particular man. And when you think about some of the things that we ask of the quote unquote ideal patient, we ask for them to do things like self-disclose, relinquish control, express feelings, experience vulnerability, and be introspective, confront relationship issues, admit when they don't know something or when they failed, and manage their non-sexual intimate relationships. Whereas sometimes quote-unquote real men, they want to hide their private experience. They don't want others to know what they're feeling. They're looking to maintain control and stoicism of their emotions. They present themselves as invincible or powerful. They're men of action, not being as we talked about, or feeling. They avoid relationship conflicts and they know what to do when it comes to sex. And so those are some of the discrepancies that we might think of as to when we're thinking about the psychotherapeutic situation, why sometimes they're reluctant to be involved in that. I would like to point out some resources that do exist. I have a copy of this where I work, but the Handbook of Men and Masculinities and APA's relatively new guidelines for psychological practice with boys and men. The book obviously you'd have to purchase, but these guidelines are free to download to take a look at. I'm going to go through 10 of their guidelines and there's several more pages you can read through on your own. But the 10 guidelines are psychologists, in particular, this is for psychologists, but I think it's relevant for many of us as providers. Psychologists strive to recognize that masculinities are constructed based on social, cultural, and contextual norms. They strive to recognize that boys and men integrate multiple aspects to their social identities across the lifespan. They understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others. And they strive to develop a comprehensive understanding of the factors that influence the interpersonal relationship of boys and men. They strive to encourage positive father involvement and healthy family relationships, to support educational efforts that are responsive to the needs of boys and men, to reduce the high rates of problems they face and act out in their lives, such as aggression, violence, substance abuse, and suicide. They strive to help boys and men engage in health-related behaviors. They strive to build and promote gender-sensitive psychological services and psychologists understand the strive to change institutional, cultural, and systemic problems that affect boys and men through advocacy, prevention, and education. So those are the 10 guidelines in the American Psychological Association's guidelines for working with boys and men. There are criticisms of those guidelines out there, and you can find them when you look for them. Some of them include that they're reifying or reinforcing masculinity norms, which I think also there's a criticism for that, but also that maybe kind of the reaction that I refer to around toxic masculinity, kind of in that same camp, that some people are upset that they are framing masculinity as a negative, and that it's not, they don't appreciate that masculinity is villainized in a particular way. And just kind of putting out there, in case you don't know who Jordan Peterson is, a clinical psychologist in Canada, you know, he also has his particular critique of the APA guidelines on men and boys. You can certainly YouTube that if you'd like. Now, there are, when we're looking at multicultural competence in the ways that we work, the three pillars are awareness, knowledge, and skills. Awareness and knowledge is what we're here for for this hour and a half, and skills are what we will develop over time when we're working in a competent way. And we're also important, it's also very important to think about common issues for men of color, the impact of racism and oppression, their racial and cultural identity issues, understanding that there is historical underutilization of services as well. Something to consider would be maybe the all-male therapy group. I'm not sure if anybody here has ever had experience with that, but I think that that does have its utility, where there is some centering, or sorry, countering men's emotional isolation from other men, so bringing folks together in a group by nature helps people to not feel alone. In fact, that's the very words that a veteran of mine said in a group yesterday, I'm so glad I'm here because I don't feel alone. And it sounds very cliche in many ways, but it can be very true and profound as well. It can help decentralized women in their lives for that moment, or for that hour, or longer. It can help enhance communication skills, it can help them discover emotional interconnections, it can help instill hope and initiate mutual empowerment. Another intervention, maybe beyond the all-male therapy group, again, I mentioned this alexithymia, normative alexithymia concept by Ron LeBond. He has a treatment called the alexithymia reduction treatment, it's available from his website, you can ask him for it and he'll grant you access to it, there's no fee. It involves successions, and there's a particular scale that is called the normative male alexithymia scale, there's some items on it, let me show you the sample items, for example, if I am upset or worried, I don't like to show it for fear that I will be seen as weak, you know, so you take that item, they'll rate on this Likert scale, and other particular things, like I find it's very hard to cry, so you would score it and get a sense for where they are with their expression of emotion. But the goals of the therapy would be learning to read the emotions of others, emotional empathy, having an emotional response log, addressing shame, and how to move forward. So that's another resource available to you, here's a sample of the emotional response log, where if a person is trying to understand their emotions and they don't have good words for them, this is a way to develop that vocabulary and understand what's going on and be more attuned to what happened, what's happening in their context or circumstances, and then translating what they're feeling or what their sensations are, say in their gut, for example, or in their chest, and what words they would use to describe that. Gender-sensitive approaches are informed by knowledge of masculinities, attuned to power issues, informed by experiences of intersectionality, and demanding of therapists' self-awareness, and involve some activity-based interventions. I mention surfing here only because I happen to work, Chris Blazes knows this colleague of ours, Dr. Strasnik, is here in San Francisco, who's a very big proponent of surfing and has, not just as an activity, not just as a recreational activity, but as kind of a connection to community, a connection to developing, in this case, veterans who surf and building bonds that lead to more connection and also lead to potentially even more treatment and willingness to be engaged in treatment. Okay, I think I'm getting close to the end here and I'm not going to do everything that I've planned. I'm seeing the time. There are other things to think about when you're not in the office, and if you're somebody who does have an interest in ways to address these systemic issues by being involved in violence prevention programs, addressing pornography, healthy sexuality, and sexual violence awareness, ways to foster resilience overall, and developing emotional intelligence, so primary prevention for boys and male adolescents. I suppose, Dr. Leong, if these are things that those single gender schools for boys are focusing on, there may be utility to that. Not that you couldn't do this in a mixed gender school, but potentially if there's a culture around focusing on some of these issues, maybe there's a chance for that. All right, in summary, men are not born, growing from infants through boyhood to manhood to follow a predetermined biological imperative encoded in their physical organization. To be a man is to participate in social life as a man, as a gendered being. Men are not born, they are made, and men make themselves actively constructing their masculinities within a social and historical context. I thought that was a very insightful way to think about this and gives us a chance to develop and to change from what we are. And it's a fluid construct that bends to fit the current cultural values of a society, rather than static biological trait that is consistent across cultures. The roles we have for gender can also be considered culturally specific templates that are applied to individuals of a specific sex by the culture in which they live. And one's gender identity is largely defined by the extent to which he, she, or they conforms to the acceptable templates of gendered behavior. And in terms of content, I'm going to end there with content. I do have some aspects of a vignette potentially for discussion, but I again want to pause there just given the time in case there are questions that we might also discuss instead. Well, I was going to ask a question about, maybe it's not so much of a question as a comment. It just seems that men and boys are not doing great in the modern Western world, right? There's the increased rate of suicide, and I think there's recent data that there's not as many men who are going to college or graduating from college or buying houses. And it seems like it's a suffering demographic that probably could benefit from some psychotherapy and attention to get back on track a little bit. What are your thoughts? Well, I would agree. I mean, I think the issue that I see from a larger lens is that I think we're spending time here on men today. We will be, the series involves spending time on understanding women, understanding transgendered individuals. So I think that men are suffering. And unfortunately, some of what we've covered today really contributes to the reasons why men are not flexible in the way they address an adapting world or they are not adapting to a changing world rather. And some of the traditional behaviors really have a high cost. So men are not doing well and they continue just to struggle. And the question is, how do you change that at a societal level, first of all, but then when they're, you know, certainly in our day to days, we're doing that on most individual level, maybe a group level if in group psychotherapy and how to turn the tide there. So I personally, I think of it more as a social problem, but of course it's why I'm interested as well. But when I encounter these themes in my everyday work, I'm pleasantly kind of satisfied by having this greater context in mind. So this is why I stay very interested in this particular field. And bringing it to an individual level, I, you know, maybe I'm doing something wrong here and I'm curious about your opinion, but obviously establishing rapport is critical in terms of working towards the therapeutic alliance and increasing the efficacy of both medications and other interventions. And I find myself that oftentimes with men who I might stereotype as more masculine, I might talk about football or something like that, just to kind of like work towards establishing a rapport. Do you have any thoughts or ideas about, you know, better ways to establish rapport? Is that appropriate? What do you think? Well, I hear that question as a challenge of how much do I use our understanding of masculinity as a way to bond versus not perpetuating these things that might actually be harmful. Those micro moments, I think are probably more about building rapport than they are reinforcing, only reinforcing rigid gender roles. But it's a good question. I think it of course would have to depend on the situation and the person. There is an article that I can send about kind of this question of do we reconstruct masculinity and try to change it in certain ways that are helpful and positive, or do we really need to blow it up somehow as a society and deconstruct it altogether? And so I think that's an important question, a fundamental one, as they put it here about what to do with this. And I saw a hand that went away, but did you want to? Hi, I'm Hillary. I'm the addiction psych fellow working with Dr. Blazes. I actually had a very timely case right before this that brought up a lot of questions around the stuff you were talking about with the normative roles that men play. And so my question is that I have found that there have been a handful of cases during the fellowship where men in particular have responded to a more paternalistic touch to motivational interviewing. It's kind of like this point that we get to in the interview where I'm saying things like, hey, man, this is what I would recommend for you as your doctor. And these are my strong recommendations as opposed to maybe a more patient-guided plan. And then what's been surprising to me is that these patients have actually responded very positively to this. Even today, I had a guy who he says was fueled kind of out of spite for his provider of I stopped drinking for 16 days just to tell my doctor to screw off so that I could prove it to him. And that response was, I think I expected men to maybe respond better to an approach that helped where I was supporting them as being the big decision maker. And it's been interesting to me that this more paternalistic approach has actually worked better for certain people. And I'm curious regarding your thoughts on that. I appreciate that commentary and just your active case that highlights these challenges, which is how much do we sing their song and play their tunes? Because I think sometimes that's part of why we are trying to understand men is so that we can work with them. And sometimes that's an important thing in the moment to do, which is to really understand where they're coming from and what they're responsive to. So we can't necessarily come at this with our own agenda, expecting that because we have this greater understanding somehow that they're going to respond to us with this deeper level of intervention, that somehow they must want to be empowered and want to be shown that they have the agency. And then they're going to take on the behavior that we're expecting or hoping they will take on. Whereas in the example that you're giving, no, actually maybe his paradigm for authority is to really listen to authority and to really know when he needs to comply. And therefore it works for him. So I think that that's kind of a little bit of the song that I hear. You're singing his song is how I think of it. And at times I think, yes, if we have a longer term relationship, if we have a chance to dig deeper into ways that some of this perhaps discrepancy strain, maybe if we're looking at it from that terminology or dysfunction strain, if we're able to identify ways that his definitions of masculinity don't work for him, we can challenge them and then perhaps suggest interventions or enact interventions that work better. We have a chance over time, but sometimes in the moment we do what works for the moment. And it sounds like you found one. So I think that's a win. And I want to put in another shout out for John Strasnikas and his kind of surfing interventions, because I think that there's really something here with these activities-based interventions that some men are more willing to kind of open up and to slowly open up through kinship and activities where it's not just sitting in an isolated room across from one other person. And the vulnerability has more of an opportunity to come out in the setting of something else. Yeah. And I think that's at some level, no matter what we believe should be the end game here for men and how they really should evolve to be better men, more functional, more adaptive to current times and sensitive to others and themselves. I think it can be functional to also recognize where a particular man or boy is in their own development and adherence or conformity or non-conformity with these norms and then intervene in that way or work with them at that point. So I think activity-based interventions have a place certainly for lots of men. But I think a lot of talk-based therapy can also be very important for a lot of men, depends on where they're at. Right. Just having a sensitivity to the person who's in front of you and having ideas of multiple different options, I think is critical in this situation rather than just pigeonholing these patients into one paradigm. Personally, what I've found valuable in these theories, and I have not exhausted my attempts at trying to understand them, but they give me a way to start with understanding where these men are coming from. I often hear that from colleagues, often female colleagues, how do I understand this guy? Where is he coming from? What do I not get here? And some of that, and of course, I asked that myself. So these approaches and theories can give us a starting point. And then there are people who think deeply about interventions and ways to really address this, like the alexithymia reduction technique or other interventions. So it's a way to understand, and hopefully we can all come together over time and develop new ways that are very important and helpful and effective. Well, thank you very much, Dr. Wan. We're at the hour. And just to remind everybody, we are the second Wednesday of every month at 2.30 Pacific time. We have another session. Next month is Dr. Chris Burke been talking about trauma and substance use disorders. And today's session was the first of a series of three. The next sessions are with Dr. Shelly Greenfield in February, talking about psychotherapy with women. And then Dr. Kevin Johnson, I believe in May, talking about psychotherapy in the transgender population. So thank you again, Dr. Wan. We appreciate your time for this great lecture. Thank you for having me and for the wonderful questions. Bye. Thank you. Bye, everyone. See you next month.

masculinity

traditional ideology

gender role strain

shame

socialization

extremism

manosphere

intersectionality

African American men

inclusive understanding

mental health

societal perceptions

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Dr. Sam Wan

gender roles

men's mental health

traditional masculinity ideology

online subcultures

socialization costs

interventions

gender-sensitive approaches

substance use disorders