Men’s Health
Men’s expectations of psychological therapy (Literature review)
In Australia there are significant differences between men’s and women’s mental health outcomes. Although men and women report similar incidences of mental health disorders in their lifetime (Australian Bureau of Statistics [ABS], 2010), men are dying from suicide at a rate that is three times greater than that of women (ABS, 2017). In response, there has been an increase in public health campaigns targeting men’s mental health (e.g. Man Therapy), with both the American Psychological Association (APA) and the Australian Psychological Society (APS) recently releasing guidelines for specifically working with the male population (APA, 2018; APS, 2017).
Currently, there is a discrepancy between men and women experiencing a mental health disorder and their likeliness to seek the assistance of mental health services, with women at 40.7% and men at 27.5% (ABS, 2010). Moreover, once men are in therapy, treatment adherence is much lower and drop out levels are much higher than women (Pederson & Vogel, 2007; Swift & Greenberg, 2012). Men who have a negative experience in treatment are likely to disengage and not return to therapy (Calear, Griffiths, & Christensen, 2011). Furthermore, a proportionately larger number of men will visit a mental health service within a short period of time prior to death from suicide (Chock, Bommerbach, Geske, & Bostwick, 2015; Cleary, 2016). This suggests that men may wait until a moment of crisis before engaging with a health professional and underscore the importance of not only attracting men to psychological therapy, but the necessity for clinicians to rapidly and effectively engage men during this limited window of opportunity (River, 2018).
Research into understanding mental health issues in the male population, in particular how to engage men in therapy, still remains in its infancy (Seidler, Rice, Ogrodniczuk, Oliffe, & Dhillon, 2018). The literature tends to homogenise male groups, characterising masculinity from a pathological, deficits-based approach (Seidler et al., 2018). Recently, however, a more nuanced approach to this complex problem has developed, acknowledging that men have multiple and context-dependent experiences of masculinity (Seidler, Rice, Oliffe, Fogarty, & Dhillon, 2017). There is a shift towards a strengths-based approach that focuses on the positive aspects of masculinity and re-examines the boundaries of ‘what it is to be a man’ (Kiselica & Englar-Carlson, 2010; Seidler et al., 2017). Initial evidence suggests males prefer this ‘man friendly’ approach (Cole, Petronzi, Singley, & Baglieri, 2018). Moreover, recent APA (2018) guidelines recommend that practitioners promote gender-sensitive psychological services, acknowledging the differences in treatment preferences between genders and the barriers men face when seeking gender-sensitive treatment. These historical trends towards homogenised and deficit-based representations of men evident in the literature may have led to a way of engaging with men that has propagated their fears of being stigmatised (Spendalow, 2015), adding to the cycle of low treatment engagement and adherence. Furthermore, much of the difficulty in understanding how best to engage with men has been due to generic recommendations, following a lack of clinically relevant and psychometrically robust data focussing on men (Seidler et al., 2018).
Although the client is the most powerful agent of change in the therapeutic relationship, there remains limited evidence exploring therapy from a male client’s perspective (Levitt, Pomerville, Surace, 2016; Timulak & Keogh, 2017). Treatment factors, such as client preferences, perceptions, and expectations are considered to have a greater influence on therapeutic outcomes than some theory-driven therapy techniques (Duncan, Miller, Wampold, & Hubble, 2010). Preliminary research into the preferences and perceptions of men highlights preferences for ‘collaboration’ (Brownhill, Wilhelm, Barclay, & Parker, 2002; Richards & Bedi, 2015), ‘goal/action orientation’ (Brownhill et al., 2002; Richards & Bedi, 2015; Rochen et al., 2010; Seidler et al., 2017), ‘skill attainment’ (Seidler et al., 2017), ‘structure’, and ‘practicality’ (Emslie, Ridge, Ziebland & Hunt, 2007; Seidler et al., 2017). Moreover, perceptions of ‘mistrust of practitioner’, ‘pathologising’ (Mahalik, Good, Tager, Levant, & Mackowiak, 2012), ‘stigma’ (Hinton, Zwelfach, Oishi, Tang, & Unutzer, 2006), and ‘loss of control’ (Seidler et al., 2017) highlight the often negative and fearful perception that men have of therapy. This apparent incongruence between preferences and perceptions of psychological therapy provides further evidence of the challenge that exists in engaging men in therapy.
Treatment expectations – the anticipatory beliefs that clients have about therapy (Constantino, Arnkoff, Glass, Ametrano, & Smith, 2011) – are an important factor in psychotherapeutic outcomes (Greenberg, Constantino, & Bruce, 2006; Timulak & Keogh, 2017; Weinberger & Eig, 1999; Westra, Aviram, Barnes, & Angus, 2010). However, there remains a paucity of research examining these expectations from the client’s perspective. The limited research that has been undertaken often fails to use appropriate psychometric measures, and clinical populations are underused (Katerelos et al., 2015).
Current measurement tools for expectations, such as the Milwaukee Psychotherapy Expectations Questionnaire ([MPEQ], Aubuchon-Endsley, 2007; Norberg, Wetterneck, Sass, & Kanter, 2011), explore expectations of psychotherapy as a dichotomous construct, consisting of process and outcome expectations. ‘Process’ refers to what happens within therapy, including the roles of both client and therapist and what the therapeutic process will entail. This consists of expectations of self in therapy – the client’s role in therapy (e.g. “I expect I will work hard to address my problems in therapy”); expectations of therapeutic activities – what techniques and strategies will be used in therapy (e.g. “I will be able to work on my own goals in therapy”); and expectations of alliance – the nature of the relationship with the therapist (e.g. “My therapist will be sincere”). Whereas ‘outcome’ refers to what happens after therapy: how successful the therapy will be for both the presenting problem, and long-term personal change (e.g. “How satisfied do you expect to be with your treatment results?”).
The current literature suggests a relationship between process expectations and treatment outcomes (Katerelos et al., 2015). However, results should be considered with caution. They are often collected from a single time point, not allowing for differentiation between before and after clients participate in therapy (Greenberg et al., 2006; Katerelos et al., 2015). The static and retrospective nature of the reporting renders the majority of findings methodologically flawed (Constantino et al., 2011; Constantino, Visla, Coyne, & Boswell, 2018). Moreover, it appears that managing client’s process expectations may be important in engaging them in the therapeutic process in the first place (Katerelos et al., 2015). Disconfirmation of expectations – when the client’s expectations of what will happen in therapy are not met – can lead to diverse outcomes. If the client has a high expectation of a positive experience in therapy and this expectation is not met, it can lead to a poor outcome (Katerelos et al., 2015). Conversely, if the client has a low expectation of therapy but has a positive experience, the resulting disconfirmation can lead to continued engagement in the process and positive therapeutic outcomes (Westra et al., 2010). This suggests that there may be an optimal level for client expectations that is neither too high nor too low.
Recently, rates of disconfirmation of process expectations in therapy were found to be significantly higher than confirmation of expectations (Button, Norouzian, Westra, Constantino, & Antony, 2018, Westra et al., 2010). This indicates many clients hold a negative expectation of therapy and were ‘pleasantly surprised’ with their therapeutic experience. This research illustrates the apparent disconnect between a client’s expected and actual experience in therapy. It appears that the challenge lies in understanding and managing the expectations of clients in order to both attract them to psychological therapy, and to maintain their adherence once in attendance.
Exploring process expectations from a male perspective, Shaub and Williams (2007) found that men who score higher in gender role conflict – a psychological state in which conforming to rigid gender roles limits men’s well-being – had higher expectations that their therapist would be an expert, and lower expectations of taking personal responsibility in treatment. Bleyen, Vertommen, Vander Steene, and van Auldenhove (2001) found men to have lower expectations of their role with respect to taking verbal initiative and spontaneous self-disclosure. Furthermore, Hardin and Yanico (1983) found that males expected their therapist to be more directive and self-disclosing. These findings provide some indication that men may hold unrealistic expectations about the therapeutic process and their role in it.
Similarly, much of the research suggests a positive relationship between outcome expectations and treatment outcomes. However, similar methodological flaws evident in the literature about process are apparent, and thus findings should be interpreted with caution (Constantino et al., 2011; Constantino et al., 2018; Greenberg et al., 2006; Katerelos et al., 2015). Furthermore, a recent meta-analysis by Constantino et al. (2018) found differences in outcome expectations between men and women to not be significant.
The aim of this study is to better understand the relationship between men’s expectations about therapy and their willingness to seek out and engage in therapy. Current research suggests that men differ from women in their preferences, perceptions, and expectations about what happens in therapy. The present study explores the difference between the experiences men have in therapy, their expectations of therapy, and how this discrepancy may lead to disengagement and drop out. This study will provide data-driven clinical insight to further inform public health education in this domain. The present study uses a community sample of participants who have not previously engaged in psychological therapy to assess whether there is a relationship between men’s expectations of therapy and their willingness to engage in therapy. It is hypothesised that higher expectations of process (but not higher expectations of outcome) predict greater willingness to engage in psychological therapy. The study also examines the process expectations of a clinical population of men involved in psychological therapy. Expectations of therapy will be assessed at the beginning of therapy, and again following either the sixth therapy session or at the termination of therapy (whichever comes first). This will help to identify where the specific differences are between client expectations and their actual experiences in therapy. It is hypothesised that after their experience of therapy, men will have higher process expectations for therapeutic activities, self in therapy, and the therapeutic alliance.
