Recommendations for male-friendly counselling with adolescent males

In this Papers Podcast, clinical psychologist Micah Boerma discusses his CAMH journal Review paper ‘Review: Recommendations for male-friendly counselling with adolescent males: A qualitative systematic literature review‘ (doi.org/10.1111/camh.12633).

Micah is the first author of the paper.

There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include;

• The importance of focusing on the experiences of young males receiving psychological treatment.
• Why young males are so reluctant to engage in professional help-seeking and also quick to discontinue treatment compared to females.
• What emerged in terms of therapists’ assumptions or biases or any views they had about the specific challenges of working with young men.
• Did the biases apply equally regardless of the gender of the therapist?
• What is male friendly counselling and what recommendations are there for therapists to adapt their practice to better engage this population?
• Recommendations and resources for therapists/practitioners who want to become more gender-informed in their practices.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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Micah Boerma is a clinical psychologist at the University of Southern Queensland, originally from regional Australia, working with adolescents and young people in Sydney. Having worked across the age spectrum, Micah’s interest is in working with young men and adolescent males in particular and their complex relationship with counselling and psychotherapy; which has led him to undertake a PhD in this area.

Other resources

• Featured paper ‘Review: Recommendations for male-friendly counselling with adolescent males: A qualitative systematic literature review’, Micah Boerma, Nathan Beel, Carla Jeffries, Jesse Ruse
• The Mask You Live In
• Research article ‘Developing a taxonomy of helpful and harmful practices for clinical work with boys and men’, Mahalik, James R. et al.
• APA GUIDELINES for Psychological Practice with Boys and Men
• New BPS briefing paper on practising therapy with men

Transcript

[00:00:01.380] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. In this series we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.

Today I’m interviewing Clinical Psychologist, Micah Boerma, of the School of Psychology and Wellbeing at the University of Southern Queensland in Australia. Micah is the first author of the review, “Recommendations for Male-Friendly Counselling with Adolescent Males: A Qualitative Systematic Literature Review,” recently published in CAMH. This will be the focus of today’s podcast.

If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.

Micah, welcome, thank you for joining me. Can you start with an introduction about who you are and what you do?

[00:01:12.430] Micah Boerma: Yeah, absolutely. So, my name is Micah Boerma. I’m a Clinical Psychologist originally from regional Australia and now I’m working with adolescents and young people in Sydney. Although I’ve worked across the age spectrum, I’d say I have a real interest in working with young men and adolescent males, in particular. Their relationship with counselling and psychotherapy I think can be complex and this, as a consequence, has led me to undertake a PhD in the area, which I’m doing with Dr Nathan Beel and Dr Carla Jeffries.

[00:01:38.810] Jo Carlowe: Brilliant, thank you. Today we’re going to look at your review, “Recommendations for Male-Friendly Counselling with Adolescent Males: A Qualitative Systematic Literature Review,” recently published in CAMH. Micah, can you start with an overview to set the scene for us? What is included in your review?

[00:01:55.280] Micah Boerma: As the name suggests, what’s included in this review is a systematic synthesis of a body of academic literature that focuses specifically on adolescent males and counselling and their relationship between those. So, the ultimate purpose of this review was to provide a spotlight, really, on counselling with this population, with the reason being that young men seek out an engage in counselling the least across the lifespan and when they do engage, they appear to drop out sooner than their female peers and also before the Treating Clinician deems appropriate to do so or deems them ready.

So, when this occurs, we know for men, that negative experiences of counselling in the past can impact their willingness to use mental health services again in the future, so it’s really important to do. But when exploring previous literature, we found that adolescent males have historically either been situated in one of two camps. So the first being research examining counselling with adolescents as a group, including males and females, and other research examining counselling with adult males, and then is just suggestive in extending their recommendations for counselling young men. So, we thought it quite pertinent and timely to complete a systematic review focusing just on them.

[00:03:02.390] Jo Carlowe: You’ve already touched on this in part, but can you say a bit more about why it is so important to focus on the experiences of young males receiving psychological treatment?

[00:03:12.030] Micah Boerma: Yes, there’s some really good research that’s come out recently, particularly around the health disparities that are very clear, the young men in contrast to other populations. And I guess if you took Australia as a, kind of, example or context, suicide in Australia is a leading cause of death for young men, so around age 15-44 and about a third of deaths in males aged 15-24 are death by suicide. But when we look at population statistics and, kind of, self-report statistics, young adolescent females present more and have higher rates of psychological distress and mental disorders, but males in Australia are three times more likely to die by suicide. And this is what we call the, kind of, gender paradox of mental health, where in Western countries there’s higher rates of, and prevalence for females, but more suicides for males.

This has, kind of, led to further research looking at are we assessing men well for their mental health when they typically present with more anger and irritability, rather than, kind of, the classic depression symptoms? And also looking at masculinity as a determinate of their, kind of, use of mental health services. So, they’re really key things that have come out around these disparities, but there’s really clear intention that more work needs to be done.

[00:04:19.199] Jo Carlowe: Thank you. Just going back to the review, can you tell us a little more about the methodology used for the paper?

[00:04:25.370] Micah Boerma: Yeah, so we wanted to create a really specific research question to guide the systematic review and analysis and that question is, “What are the thematic recommendations in the existing literature for adapting counselling to the needs of adolescent males?” And we chose this in particular, mainly because gender sensitive practices for working with adolescent males has, kind of, been placed somewhat in specialist bodies of research, whether that be with teen fathers, people of certain kind of racial groups or other types of groups, as well. And those, kind of, male-friendly practices have been put in there, but when we’re doing a review, it’s hard to, kind of, see what data is relevant and what’s not and what is useful for generalisation or, you know, what’s inaccurate in distinguishing that data relevance?

So, we really wanted to be broad, and the inclusion criteria was based around working with adolescent males in individual face-to-face counselling context and recommendations for doing so. So, myself and another author, Jesse Ruse, we systematically searched the data and completed quality appraisals using JBI’s critical appraisal checklist, and then we used thematic analysis, traditionally following Braun and Clarke’s, kind of, general procedure.

[00:05:30.919] Jo Carlowe: And what are the key findings that you’d like to share?

[00:05:33.860] Micah Boerma: Yeah, so, from the analysis, there was three overarching themes. The first thing that Therapists should be aware and have a knowledge of masculinity and gender socialisation and male relational styles. And when we looked into this deeper, the context of masculinity was really a central organising concept in the literature for males and their relationship with contacting mental health services and engaging in mental health services.

In addition to this, adolescence is really considered a key developmental period where masculinity is developing and identity formation and male socialisation is forming, and Therapists really need to be aware of this because it could also come into how they assess, provide treatment planning and interventions for young men. And also, more broadly, to reframe any resistance to therapy or discussions of emotions and issues that they may experience in therapy, based upon masculinity and traditional masculine norms of strength and stoicism. So, this knowledge is really key.

The second was Therapists to actually address masculinity in a therapeutic space if it’s impacting therapy, so both within themselves and together with their clients, as well. In response to this knowledge and awareness, we need to know how young men are socialised to restrict and, kind of, avoid emotionality. And so, a key task in therapy with men, actually becomes to developing their capacity to identify and articulate emotions, and subsequently expand that range of emotional expression that he deems acceptable.

And finally, a third theme is to actually fit therapy and the conventional styles of therapy to the relational styles of young men. So, young men build intimacy and trust in relationships broadly, but the dynamics of those relationships can be less personalised. So, that trust and familiarity can come through sport or shared activity and that type of thing. So, we really want to, in this review, look at what’s conventional counselling requirements and expectations for Therapists and their clients, but what needs to be changed to be more relatable to young men?

[00:07:25.729] Jo Carlowe: And you already described earlier that young men are less likely to engage in treatment and therapy in the first place, but what are your views as to why young males are so reluctant to engage in professional help seeking and also quick to discontinue treatment compared to females?

[00:07:41.990] Micah Boerma: So, broadly, we know that young males, on the whole, with research, recognise mental health problems and mental health disorders more poorly than females. This has been found both in themselves and also in case vignette examples and this also then extends to their knowledge of existing services, but also accessing those existing services. There was also a trend that they preferred to either cope by themselves or access informal supports much more readily than females, who tend to go to more formal supports more quickly. And this, kind of, appears to be related to those traditional masculine norms and ideals of self-reliance and independence that have been – young males are trying to, you know, achieve.

They also hold more negative views towards therapy, and again linking it to weakness and vulnerability, and the norms of, like, stoicism and strength can really impact that. So, they’re more broadly, in the literature. I guess when they do attend counselling, both anecdotally and it’s been highlighted in past literature, the conventional counselling requirements and environment and task of therapy not well suited to them, so prioritising activity together, whether that be cards, Lego, ping-pong, something like that shared activity, really lessens the pressure and unease that they feel.

And another thing, finally, as well, is control and autonomy, I think very important to young people in counselling, particularly for young men, when we know that most are referred by the concerns or worry of someone else, and they come to counselling as a response of someone else’s concerns and worries. So, many Therapists start really an uphill battle when they’re working with young men, because they might not necessarily want to be there. So, through the process, from onboarding to the end of counselling, there can be barriers to, you know, achieving that trust with young men.

[00:09:21.310] Jo Carlowe: And in your paper, you say, “Therapists were encouraged to critically reflect upon their own assumptions of masculinity.” What emerged in terms of Therapists’ assumptions or biases, or any views they had about the specific challenges of working with young men?

[00:09:36.810] Micah Boerma: So, one of the subthemes that we had, and the literature highlighted and emphasised, was the Therapists remain gendered beings, in the sense that their own gender socialisation and the cultural socialisation they come from and their – to a large extent, their relationship with masculinity, as well, brings with them an experience towards the therapy space and how they approach young men. So, they might have biases that if they go unchecked can impact their opinion. Some of those biases could be around the actual capacity for young men to succeed in therapy, for them to – actually wanting to be there, the ability for the Therapist and the male to do deep emotional work with, you know, a lot of substance around the emotionality of men and being more shallow than females. And so, really, some of these biases and stereotypes, if they go unchecked, they can actually impact the therapeutic stance and commitment Therapists have towards young men, which can then easily stymy therapy or any effective work with young men.

So, Therapists were readily encouraged to explore, whether in supervision or through reading and learning about masculinity and that process, to explore their views and assumptions that they might bring and to take a unconditional positive regard towards working with young men.

[00:10:50.580] Jo Carlowe: The biases you just mentioned, did that apply equally, regardless of the gender of the Therapist?

[00:10:56.130] Micah Boerma: Yeah, so in the research, there wasn’t as much done regarding the gender of the Therapist from the Therapist’s perspective. More research is highlighting most young men there’s a preference. So, most don’t care if their Therapist is male or female. A small portion, I think about 30%, do care and the rest would prefer a male or female. So, there’s less on the Therapist, their gender, and more around the client’s perspective.

[00:11:19.769] Jo Carlowe: Hmmm hmm. A theme captured across literature in your review was the need for Therapists to adapt counselling practices to engage adolescent males, and you’ve already touched on this. Can you go into the detail? What is male-friendly counselling and how do you recommend Therapists adapt their practice to better engage this population?

[00:11:38.639] Micah Boerma: I guess, broadly, the main aim is to fit counselling, how it’s done, what it involves, how information is communicated, into ways that appeal to young men, and this is both in approach and belief as well. So, rather than coming from a stance of blaming young men for not accessing mental health services sooner, or being reluctant to engage, and rather than insisting that the young men change to fit the service, the Therapist and the service changes the way that they work with people to fit the young man and to give the young man the help themselves.

So, this is done by appealing to archetypal, kind of, masculine interests, you know, their current cultural interests as well as young people. The norms and the roles that they experience and also their cultural context within school and their friendship groups and discussing those interests at length. But it also acknowledges the diversity and, kind of, the dynamic nature of masculinity as well, where we’re wanting to affirm positive strengths and positive aspects of masculinity while not affirming negative and restrictive types of masculinity.

So, in our review, we suggest practices that could be considered either “masculinity aligning” or those that are “masculinity extending,” and they’re just words we used, but masculinity aligning is more around tailoring therapy to the interest of the young man, to appeal to them. That could be the physical therapy space, with magazines and Lego and toys. That could also be communicating in more of a casual, friendly way, that, kind of, get through to those, you know, power hierarchies in therapy. Could be more discussion of interests, it could be using humour, self-disclosure, metaphors and just having a transparent and collaborative relationship really aligns with, kind of, that approach.

The other is masculinity extending, which we talk about in our discussion, where we create a safe space for young men to consider their masculinity in relation to their psychological distress and whether some restrictive masculine norms that they try and uphold actually are a barrier than doing deeper work or, kind of, contacting that emotional side, or asking for help or support from the Therapist or others. So, Therapists are really afforded a rare opportunity with young men to engage in a discussion about those restrictive masculine norms and can really create with them, kind of, new codes of manhood that are healthy and positive for them.

[00:13:49.870] Jo Carlowe: Micah, your review highlights the need for practitioners to be both gender-informed and to take developmental considerations into account when working with adolescent males. I’m wondering how confident Therapists feel, practitioners feel. Do you have any recommendations or suggested resources for our listeners who want to become more gender-informed in their practice?

[00:14:10.990] Micah Boerma: Interestingly, there’s been a recent burst of literature on this scene, in the sense of both Australia and in Western, kind of, research groups, as well. Probably the key article to read is one by James Mahalik, and it’s, I think, called “Taxonomy of Helpful and Harmful Practices.” This was the first perspective looking at what is useful and helpful in therapy with men and what’s not useful and not helpful. More broadly, the APA has also recently released guidelines for working with men, the British Psychological Society as well, looking at male-friendly practices. These are good starting points for practitioners.

There’s also a new training out in Australia called “Men in Mind,” which is more for adult males, but looking at, kind of like, gender socialisation in therapy, as well. So, kind of, more popular media. The YouTube documentary, I think “The Mask that You Live In,” is a really excellent understanding for male development and adolescent development for – and the gender socialisation processes that happen at that phase. I think any of those are good starting points.

[00:15:05.680] Jo Carlowe: Micah, is there anything else in the paper that you’d like to highlight?

[00:15:10.100] Micah Boerma: So, notably, a finding for us was when we specifically look at how adolescent males engage in therapy, this is a very small research area and not as much has been done on the experiences of young men in therapy themselves and the challenges that them and Therapists face. So, it’s actually quite a small field, still, and more research need to be undertaken, both with Therapist’s experiences and young men’s experiences.

[00:15:32.410] Jo Carlowe: And are you planning any follow-up research, or is there anything else in the pipeline that you would like to share with us?

[00:15:39.600] Micah Boerma: So, this paper, for us, is part of a larger body of research where we’re trying to collate and synthesise multiple perspectives on what makes counselling more engaging for men and young men, with the ultimate aim of providing mental health practitioners with broad based, yet intentional, information and recommendations. We want to also look at practices and perspectives of current Therapists and mental health practitioners, their, kind of, challenges they face and also their recommendations in their experience in the work they do. And we’re also going to try and capture the experiences of families and adolescent males, as well, that have received counselling, to get their perspective on what’s helpful and not helpful, and then synthesise that together.

[00:16:16.519] Jo Carlowe: Finally, Micah, what is your take home message for our listeners?

[00:16:20.589] Micah Boerma: Just an encouragement, you know, from the review, is that for listeners and practitioners to approach their practice with adolescent males, I guess, with a spirit of awareness, curiosity and greater understanding for how they relate to the world and others, and in therapy, and their respective masculinities. And rather than try and get them to do traditional experiences and conventional practices in therapy, we make it appeal to them and fit for them. We know that young men are not forthcoming with seeking professional support, so when they do, we really need to make sure that we are working with them in a way that increases engagement and therapeutic rapport and ultimately, retention.

[00:16:57.800] Jo Carlowe: Fantastic. Thank you so much. For more details on Micah Boerma, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform. Let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.