Men, Addiction, and Intimacy

Strengthening Recovery by Fostering the Emotional Development of Boys and Men

Mark S. Woodford

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781135197698
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In the substance abuse and addiction treatment realm, males outnumber females two to one. While gender-issues are seen as a key element of women's treatment, the acknowledgement that males are "gendered beings" who have lived lives full of male-specific developmental challenges is often overlooked. This text takes a developmental lifespan approach to examine the neurobiological and psychosocial factors associated with substance use disorders for males, specifically in relation to emotional growth and awareness, and how these areas, in turn, affect the development of healthy relationships. Theoretical concepts from the field of interpersonal neurobiology, the psychology of boys and men, and the substance abuse and addiction literature are interwoven with practical clinical examples to help elucidate how the notion of fostering emotional development can strengthen the treatment and recovery processes with boys and men. Relevant case examples are included that illustrate work with males of all ages and address a variety of factors associated with culture, ethnicity, race, religion, and sexual orientation. Mental health practitioners will find this a valuable guide to understanding male development in relation to substance use and abuse and providing more comprehensive, gender-responsive counseling and assessment practices.

CHAPTER

1

Substance Abuse Counseling with Boys and Men
Gender and Development Matters

First the man took a drink. Then the drink took a drink. Then the drink took the man.

—Chinese Proverb

Common sense will tell you that the progression described in this proverb does not happen to every man who “takes a drink.” However, there are men for whom the wisdom of this ancient saying, in its simplicity, captures the essence of their lived experiences. As they reflect back upon their own personal process of initiation and use of substances, they can see how the consequences of their substance abuse have left them feeling that somehow “the drink took the man” that they had hoped to be. And yet who is this “man” that they had hoped to become?

Even though it is not a common occurrence that men openly discuss what it means to “be a man” in society, most boys and men have an implicit sense of how they are expected to act as males in their culture. Whether it is conscious or not, males know from their gender socialization process as boys and men—that is, through the influence of family members, peers, and the media—that there are certain ways of being that are more “masculine” than others. Importantly, there are physical, social, and emotional consequences for males who rigidly subscribe to and act out (or outside) of traditional male gender roles (e.g., emotional restrictiveness and an intense emphasis on self-reliance and success, power, and competition), such as physical health problems, depression, anxiety, stress, and mental health issues (O’Neil, 2006), including substance use disorders.

The acknowledgement that males are “gendered beings” who have lived lives full of male-specific developmental challenges is having a positive influence on the way that counseling and psychotherapy is being conceptualized with boys (Horne & Kiselica, 1999; Kiselica, Englar-Carlson, & Horne, 2008) and men (Brooks, 2010; Brooks & Good, 2001a, b; Levant & Pollack, 1995; Pollack & Levant, 1998). Mental health professionals and the clients they serve can benefit greatly from seeing boys and men as being more than simply “generic human beings” (Kilmartin, 2007, p. xi). Nowhere is this statement truer than in the substance abuse and addiction treatment realm where the number of males outnumbers females two to one.

SUBSTANCE ABUSE COUNSELING WITH MALES: GENDER MATTERS

The 2008 National Survey on Drug Use and Health indicated that males (age 12 or older) were twice as likely to be classified with substance abuse and dependence as females and more than twice as likely as females to receive treatment for an alcohol and/or illicit drug use problem in the last year (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009a). Similarly, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Episode Data Set (TEDS) indicated that twice as many males were admitted for substance abuse treatment than females in 2007 (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009b). Of particular concern is the subpopulation of adolescent male substance abusers. The Monitoring The Future study, a national survey conducted annually of secondary students, found that adolescent males were more likely than females to drink large quantities of alcohol in a single sitting, were more involved with illicit drug use than adolescent females (in most categories of illicit drug use), and reported higher rates of frequent use than females, resulting in significant costs to themselves and to society (Johnston, O’Malley, Bachman, & Schulenberg, 2010). Additionally, findings gathered by SAMHSA regarding adolescent admissions rates for substance abuse treatment services indicated that school-age adolescent admissions were 70% more likely to be males than females (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009c). Arguably more disturbing are the rates of substance abuse reported among later adolescent males (ages 18 to 25). This group, moving through the transition phase from late adolescence into young adulthood, has the highest rates of substance abuse among all age groups in the United States (Park, Mulye, Adams, Brindis, & Irwin, 2006). These statistics further indicate that males (and particularly adolescent males) tend to abuse substances at a higher rate and with greater consequences than females (Johnston, O’Malley, Bachman, & Schulenberg, 2006) and that this trend appears to continue into adulthood for males across the lifespan (Office of Applied Studies, 2004).

With higher numbers of males being admitted into substance abuse treatment programs, one might make the basic assumption that there must be a genetic and/or environmental causal link between being male and the development of substance use disorders in boys and men. However, making an assertion that male socialization processes somehow explain substance abuse and addiction in men would be both overly simplistic and inaccurate (and not the purpose of this book). Rather, pointing to the fact that two thirds of the individuals in treatment for substance abuse and addiction are males serves a more practical purpose. That is, if we know from the psychology of boys and men that male gender roles are “a salient organizing variable of client’s lives and experiences” (Englar-Carlson, 2006, p. 28), then highlighting the salient features of the male socialization process can help us to identify how traditional male gender roles (and the resultant behaviors that we can observe in treatment) might be either barriers to effective treatment or, as appropriate, resources for successful treatment and recovery. Importantly, understanding how the male socialization process may affect boys and men’s willingness to receive help for their substance abuse issues will increase our ability to have empathy, understanding, and nonjudgmental acceptance (key factors in the healing process) as our male clients struggle with ambivalent thoughts, feelings, and behaviors related to asking for help from others.

For example, men’s literature related to gender role conflict (O’Neil, 2008; O’Neil, Good, & Holmes, 1995; O’Neil, Helm, Gable, David, & Wrightsman, 1986;) and gender role strain (Pleck, 1981) highlights the potential that boys and men may be struggling to live out traditional male role norms such as avoidance of femininity, restrictive emotionality, seeking achievement and status, self-reliance, aggression, fear and hatred of homosexuals, and non-relational attitudes towards sexuality (Levant et al., 1992). Gender role strain occurs when males find that they cannot live up to the gender role expectations (stereotypes, rigid standards, and norms) of their ethno-cultural background. Similarly, the concept of gender role conflict (O’Neil, 1981) entails a broad look at the behavioral, cognitive, and emotional problems that arise in various situational contexts, such as when males:

(a) deviate from or violate gender role norms (Pleck, 1981); (b) try to meet or fail to meet gender role norms of masculinity; (c) experience discrepancies between their real and ideal self-concepts, based on gender role stereotypes (Garnets & Pleck, 1979); (d) personally devalue, restrict, or violate themselves (O’Neil, Good, & Holmes, 1995); (e) experience personal devaluations, restrictions, or violations from others; and (f) personally devalue, restrict, or violate others because of gender role stereotypes. (O’Neil et al., 1995; Englar-Carlson, 2006, p. 19)

As boys and men will come into treatment from a variety of ethnocultural backgrounds and differing developmental levels across the lifespan, these male-specific challenges will have great variability within each individual client’s lived experiences. Specific examples of how these male socialization processes play out in the substance abuse assessment and treatment process are provided throughout the developmental case studies in chapters 4 through 8.

Of particular importance are the emotional and relational issues and challenges that these males will face as they enter substance abuse counseling and proceed through treatment and into recovery. For example, imagine how the following gender role patterns might play out in an addiction treatment setting for men: (a) having an emphasis on success, power, and competition; (b) restrictive emotionality; (c) restrictive affectionate behavior between men; and (d) conflicts between work and family relations (O’Neil et al., 1986; as cited in Englar-Carlson, 2006). These internalized gender-based expectations would have an effect on a man’s receptivity to the counseling process. Will he be preoccupied with comparing himself to other men? If he is approached by another man in a physically affectionate way, how will he respond (e.g., with anger, disgust, or shame)? Will he have a desire to understand the impact of his emotional life (e.g., his mood and general affective states) on his relationships, specifically his choices about emotional expression around others (and especially around other boys and men)? Additionally, the combination of the traditional male value of intense self-reliance with the often mandated status of substance abuse sets the stage for a “perfect storm” of prohibitions about asking for help in general and specifically in seeking out help in a counseling setting to address substance-related challenges.

Substance abuse counseling clients rarely arrive in treatment with an eager enthusiasm to change. At best, they are often ambivalent about changing their behaviors (Miller & Rollnick, 2002). Having mixed feelings and/or ambivalent thoughts about whether they need to be in the counseling process at that point in their lives leaves them sitting on the proverbial fence. And, at worst, they are adamant that they do not belong in treatment. Perhaps their attendance has been legally mandated by the court system, or it may be the case that they have been challenged by doctors, family members, and/or a boss to take a look at their drinking or drug use. If they have been told that they had “better get help” for their problem “or there will be consequences,” then we are faced with the dual challenge of mandated status in counseling (Wallace, 2005) plus the possibility that gender-based messages have contributed to a negative attitude about seeking professional help (Englar-Carlson, 2006). Without understanding how boys and men may choose to face these challenges (based on their individual male socialization processes and their particular early life histories), we may be left baffled by either an intense anger (fight), chronic silence (freeze), and/ or potential early departure from treatment (flight) in the initial phase of counseling.

The substance abuse professional trained in contemporary addiction counseling strategies will recognize their client’s bewilderment and/or their ambivalence about being in counseling as characteristic of either the pre-contemplation stage of change (not seeing a problem) or the contemplation stage of change (seeing a problem and considering whether to act) (Prochaska, DiClemente, & Norcross, 1992). Seeing these stages of change from a heuristic perspective, the professional will very likely choose to use some version of motivational enhancement strategies, or specifically motivation interviewing (MI), to try to elicit intrinsic motivation from their clients to make changes in their behavior. A detailed description about MI principles and practices is beyond the scope of this book; however, there are several excellent resources available on this approach (Miller & Rollnick, 2002; Naar-King & Suarez, 2011; SAMHSA, 2002). Importantly, there is evidence that MI enhances the potential for individuals to engage in the substance abuse treatment process.

Rapport-building with boys and men in the initial phases of counseling can be enhanced by using motivational interviewing strategies that are contextually appropriate and meet each client where he is in terms of his stage of change. For example, the MI approach at the pre-contemplation stage emphasizes normalizing ambivalence and raising awareness about the client’s substance-using patterns by providing personalized feedback from any relevant assessment findings, by exploring the pros and cons of substance use, and by offering factual information about the risks of substance use (SAMHSA, 2002). In providing these opportunities for client self-exploration and information gathering, counselors can use a decisional balance worksheet (to examine the costs and benefits of changing or not) and begin to observe any discrepancies between their client’s and other people’s perceptions about their behaviors. Importantly, this process should enlighten both counselor and client about how the client’s personal values and experiences have influenced his decision to make changes in his life. What internal and external pressures, for example, might he identify as weighing heavily upon his past and future decisions about change?

Additionally, in the spirit of meeting these male clients at the stage they are in during this initial rapport-building phase, the MI strategies of emphasizing a client’s autonomy, responsibility, and self-efficacy for change (Miller & Rollnick, 2002) can work in tandem with traditional male socialization processes related to being self-reliant, such as using one’s own resources to overcome adversity (Kiselica, 2011). Although this may seem contrary to an approach that hopes to foster emotional development and an appreciation for the importance of interpersonal processes (e.g., asking for help) in recovery, this is an instance where we may be able to use a traditional gender expectation as a means to an end in engaging a male in exploring his personal values in relation to changing his behaviors in this beginning phase of the treatment process. Alternatively, in this same instance, it may be the case that gender role strain related to living out the value of self-reliance may make it difficult for this man to have a sense of self-efficacy, because his hope and his belief in himself as a man that he can change may have dwindled long before he entered treatment, particularly if he has had repeated “failures” at addressing his substance abuse issues. A gender-responsive approach would recognize both of these possibilities and respond unequivocally with the MI principles of expressing empathy, avoiding argumentation, and rolling with resistance (Miller & Rollnick, 2002). As we will see in chapter 2, these processes of therapeutic engagement change brain connectivity patterns and encourage new neural connections between the emotional (e.g., amygdala) and the executive (prefrontal cortex) areas in the brain, which in turn enhances capacity for self-regulation. Importantly, as we work in a male-responsive way, we can develop empathy for how this man may be viewing himself as inseparable from his behaviors that occurred while he was under the influence of alcohol and other drugs. For example, the consequences of these behaviors, including how he may see himself as a man, and how others view his behaviors as fitting their expectations of him as a man, are likely to be inextricably linked to the reasons that propelled him into treatment. Similar examples of how MI strategies can match male-specific needs in the rapport-building phase of treatment are provided in the developmental case study chapters that follow in the latter half of the book.

In summary, the psychology of boys and men (Brooks & Good, 2001a, b) emphasizes the sociocultural and developmental influences on males. In addition to outlining various mental health challenges that men face, such as alcohol and drug abuse, depression, anxiety and stress, and antisocial behavior and violence (Brooks & Good, 2001a; Cochran, 2005), this literature has taught us that developmental factors related to the male socialization process have an impact on how we can provide counseling service for males. With knowledge specific to male development (e.g., gender role conflict; O’Neil, Good, & Holmes, 1995), we can cultivate greater empathy and, in turn, be more effective in engaging males who may be reluctant to seek professional help in counseling (Vogel, Wade, Wester, Larson, & Hackler, 2007). Having a basic understanding of male-specific developmental issues provides an evidence base for our clinical work with boys and men (Cochran, 2005) at each phase of the counseling process; not only at the engagement, rapport-building, and assessment phase of treatment, but also in strengthening long-term stability and recovery from substance abuse. Importantly, as we will see in chapter 2, with increased understanding and empathy, we can deepen our level of responsiveness to our male client’s developmental and emotional needs, which will ultimately create a counseling environment that will be essential to building the regulatory structures in the brain that can help to make relapse less likely in the short- and long-term.

SUBSTANCE ABUSE COUNSELING WITH MALES: DEVELOPMENT MATTERS

Neuroscientists, physiologists, developmental researchers, and clinicians in the emerging field of interpersonal neurobiology Cozolino, 2006; Siegel, 1999) have contributed a key conception about human development as it relates to mental health; namely, that our sense of well-being throughout our lifespan is mutually influenced by (a) our biological “hardware” (the body-brain connections), (b) our mental “software” (the mind and the sense of self), and (c) our relationships, specifically those that involve meaningful and emotional attachments to others. These relational connections help to give us both a sense of self and a sense of belonging (Siegel, 2001, 2010).

The term “interpersonal neurobiology” (IPNB) was introduced in 1999 by Daniel Siegel in his seminal book The Developing Mind (1999). IPNB is an emerging interdisciplinary field that bridges biological and social sciences and includes concepts from writings on attachment, genetics, comparative anatomy, psychoanalysis, constructivism, and evolutionary studies Cozolino, 2006. Although deeply rooted in neurobiology, IPNB is not a “branch of neuroscience,” but rather a field that is an “open forum for all ways of understanding reality, the human mind, and well-being” (Siegel, 2010, p. 279). Most importantly, it explores the connections between the development of the human ...

Table of contents

• Cover
• Men, Addiction, and Intimacy
• The Routledge Series on Counseling and Psychotherapy with Boys and Men
• Full Title
• Copyright
• Contents
• Series Editor’s Foreword
• Preface
• Acknowledgments
• 1 Substance Abuse Counseling with Boys and Men: Gender and Development Matters
• 2 Educating Boys and Men about Substance Abuse and the Developing Brain
• 3 Strengthening Recovery by Fostering Emotional Intimacy in Males
• 4 Substance Abuse Counseling with Early Adolescent Males (Ages 12 to 18)
• 5 Substance Abuse Counseling with Later Adolescent Males (Ages 18 to 24)
• 6 Substance Abuse Counseling with Males in Early Adulthood (Ages 24 to 34)
• 7 Substance Abuse Counseling with Males in Middle Adulthood (Ages 34 to 60)
• 8 Substance Abuse Counseling with Older Adult Males (Ages 60 and above)
• References
• Appendix A
• Appendix B
• Appendix C
• Appendix D
• Appendix E
• Index