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Among its many impacts, COVID-19 has been widely expected to bring major negative effects on mental health, although the more catastrophising predictions of spiralling mental crisis have generally been balanced by research showing rapid recovery and a general level of resilience across the UK population when lockdowns have been lifted. Certainly, predictions about spiralling suicide rates have so far been shown in the data to be misplaced.

However, as we (hopefully) move towards greater normality in our social and working lives and the death rates fall, there are repeated warnings that the economic impacts of the pandemic are likely to take a longer-lasting toll. And, say Samaritans, we should be very alert to the potential for rising suicides among the group already known to be most at risk 鈥� middle-aged men. In a recent coronavirus briefing,¹ Samaritans points out that the common risk factors for men in this age group have all been exacerbated by the pandemic. The main themes emerging in calls to the helpline from men during the height of the pandemic have been loneliness and social isolation, in part due to the closure of so many traditionally masculine opportunities for social contact such as sporting events and venues; feeling that they should be able to 鈥榩ut on a brave face鈥� in the face of the pandemic; fear and uncertainty about job and income loss and its implications, and relationship breakdown due to the lockdown pressures.

With male suicides already returned to levels not seen since the early 2000s, according to the latest (pre-COVID) ONS data,² is it time for the counselling profession to ask itself searching questions about what it needs to do if men still aren鈥檛 availing themselves of what it offers?

Not a 鈥榤an thing鈥�

It is a paradox that, despite the fact that psychotherapy and counselling have largely been theorised and developed as therapeutic practices by men, men are least likely to seek their help. And it鈥檚 another paradox that what should make men more in need of talking therapies is (arguably) what stops them seeking them 鈥� essentially, the fact that they are men. Whether you subscribe to the biological, environmental or cultural explanations (or all three), what bring men to the point where they need such help and what stop them reaching the counselling room are the very attitudes, values, beliefs and behaviours that we, certainly in the industrialised West, generally associate with being male and traditional norms masculinity.

These are issues with which psychologists have been tussling since the 1980s, and most recently following the publication in 2018 by the American Psychological Association (APA) of its Guidelines for Psychological Practice with Boys and Men.³ The guidelines have proved highly controversial within the psychology profession and the controversy revolves precisely around this central issue of whether and in what ways masculinity is pathological, or 鈥榯oxic鈥� 鈥� are the chief elements of what it is to be a man in and of themselves psychologically dysfunctional and in need of intervention and treatment?

This, argues John Barry, currently Chair of the British Psychological Society鈥檚 Male Psychology Section, co-author of the recently published Perspectives in Male Psychology (Wiley, 2021) and co-founder of the Male Psychology Network, is exactly what the guidelines do. The guidelines are, he believes, far too influenced by sociological constructs of masculinity that essentially regard masculine attributes and how they impact on men and those around them as negative and harmful. 鈥楾hey鈥檙e useful if your interpretation of masculinity is just a social construct or that it鈥檚 all about men鈥檚 power over women and being competitive,鈥� he says. Guidelines one and three particularly provoke his criticism: guideline one with its injunction that 鈥楶sychologists [should] strive to recognise听that masculinities are constructed based on social, cultural, and contextual norms,鈥� and guideline three, which recommends that, 鈥楶sychologists understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others.鈥�

鈥業 think these guidelines are just a really poor advert for therapy and won鈥檛 encourage men to seek help,鈥� he believes. 鈥楶eople get very entrenched in the nature/nurture debate when it comes to masculinity and it鈥檚 not only very unhelpful, it鈥檚 wrong, because it鈥檚 not one thing or another, it鈥檚 both 鈥� there are some aspects of masculinity that are to do with biology or evolutionary psychology and some to do with enculturalisation and socialisation 鈥� both sides have something to bring.鈥�

He says the import of ideas from sociology have 鈥榥ot landed well鈥� when imported wholesale into psychology, 鈥榓nd especially in the therapy room鈥�. 鈥榃hen men lose their job and get depressed, to say it鈥檚 because they have lost their role as the family patriarch is probably the least useful avenue to explore in therapy 鈥� there鈥檚 a lot of things that might help him but trying to get him to see himself as a fallen patriarch isn鈥檛 going to help him in any productive way. These things don鈥檛 have much use scientifically or clinically. We should always strive to use evidence-based therapy, and we just don鈥檛 have enough research. These guidelines would make a lot of men run for the hills and we already have a problem with men seeking help for psychological problems.鈥�

There are he argues, many benign evolutionary and biological characteristics of masculinity that get ignored: stoicism, for example 鈥� men鈥檚 capacity for enduring unendurable circumstances, like warfare and dangerous jobs such as mining. 鈥榊ou can鈥檛 be sitting in the trenches talking about your feelings because probably everyone would panic and run away,鈥� he says. He agrees that some expressions of 鈥榯raditional masculine attributes鈥� can be harmful, both to men and to those around them, 鈥榖ut you have to be careful not to pathologise them. We need to normalise them, see them in their context, not simply say this is a problematic part of being a man鈥�. That, he says, 鈥榠s a psychological dead-end鈥�.

Psychotherapist Sue Parker Hall agrees. She is a staunch defender of what she calls traditional masculinity, in relation both to characteristics and roles. 鈥楩or example, the APA guidelines are quite critical of such things as achieving and competing; they talk about men鈥檚 power as oppressive, whereas I would think about men鈥檚 strength, how they welcome being a supportive partner, enjoy being a dad, like being a provider, take a pride in those roles of fathering providing and protecting. That has been very attacked, particularly by radical feminist idealogues, and I think the APA guidelines have politicised it. I am only willing to say masculinity can be bad for men and women if we say femininity can be bad for women and men.鈥�

She argues that counselling and psychotherapy try to force men into a particular mould, a way of being in the world and relating, where they innately do not fit. 鈥業 think there is a danger of feminising men, making them more like women. People say men need to learn to express their feelings but I say there are three ways of being in the world: one is thinking, one is feeling and one is behaving. A lot of men would more comfortably negotiate the world quite adequately through using their behaving and thinking; their feelings don鈥檛 have a big role. The same is true for some women too. So this push to get men into 鈥渢raditional鈥� therapy is misguided.鈥�

Power imbalance

Counselling psychologist Dr Michael Beattie takes a different view of masculinity as it plays out in men鈥檚 thinking and behaviours. 鈥楽o much of the discussions around the idea of masculinity is that there鈥檚 nothing good about it and it needs to be overhauled. I think it鈥檚 not masculinity but some aspects of patriarchy that need to be overhauled. Masculinity wouldn鈥檛 be a problem if there weren鈥檛 imbalances of power, or imbalances of privilege between sexes and between different masculine positions 鈥� men dominating women, white men dominating people of colour, or cis-men dominating non-cis men and so forth. If we are to make value judgments, I would say what is problematic about masculinity, what is 鈥渢oxic鈥�, are some of the norms around how to be male, because they make life difficult for men and women.鈥�

He points to research by Mahalik and colleagues⁴ that identifies the 鈥榥orms鈥� necessary (for men or women) to 鈥榞ain access to the tribe of men鈥�: attributes such as winning, emotional control, risk-taking, violence, dominance, primacy of work, power over women, disdain for homosexuals, physical toughness and pursuit of status. Being masculine is, Beattie argues, essentially a social performance that is all about getting to the top of the power pyramid 鈥� and then fighting the competition to stay there, because having achieved the pinnacle, you have to defend it. 鈥業t鈥檚 exhausting for men,鈥� Beattie says.

He acknowledges the view of fellow psychologists and counsellors like John Barry and Sue Parker Hall but finds plenty evidence to challenge their argument that men鈥檚 ways of being in the world are 鈥榥ormal for men鈥� and shaped by their biology. 鈥楾here is research that little boys are very emotionally labile and that testosterone is a very irritable hormone 鈥� that little boys in fact are not naturally less emotional; they are socialised into this. I prefer to think about the value of emotions at a very basic level: they exist so we can connect with what we need. We have nerve endings so we don鈥檛 stand too close to the fire and get burned; we feel hunger so we know to eat; we have thirst so we know we need to drink; we feel loneliness so we know to seek company; we feel anger so we know to set boundaries 鈥� they are all feelings that connect us to what we need, and I think the problems arise when we get emotionally stunted or cut off. For me, one of the principal goals when working with men is enabling them to allow a certain amount of emotional discovery or reconnection. I am not saying all men or only men do this, but it does seem there is a lot more compartmentalisation of affect in men 鈥� putting things in boxes and hoping they will just go away 鈥� and that can come home to roost at a certain point.鈥�

You can, he argues, see how this plays out in the suicide statistics. 鈥楪enerally men act out feelings and generally they are socialised and encouraged to do so. It鈥檚 not biological destiny. Notions of toxicity grab headlines but I do think there are aspects of gender role socialisation that we could be helping our children with more. As things are, what comes from denying feelings and doing masculinity well is you get rewards, you get privilege, right from a very early age, as research with primary school children show. If you didn鈥檛 get rewards, you wouldn鈥檛 want to do it, because there is a cost.鈥�

Doing emotions differently

Paul Atkinson grew up in a working-class family in Nottingham and is now a practising psychotherapist, co-founder of the Free Psychotherapy Network. His father was an electrician, a warm and loving man who, he says, never used the word 鈥榣ove鈥�. Going out on a job with his father was a powerful bonding experience for all three sons in the family. 鈥楳ostly, for men, life is about doing,鈥� he says. Men externalise their experience of feelings through activity. But men do have their own, very creative forms of emotional expression. 鈥業n my world as a kid, and still as an adult, banter is a really major way for men to be intimate. It has a kind of avoidance of seriousness but also an extraordinary truth-telling, exposing, challenging quality to it. Women banter too, but on the whole I think it is a very male mode of relating. It is quite intimate and it allows them to use a bit of aggression. We like to compete, to knock each other about a little bit. It鈥檚 a mode of being that鈥檚 related to the lack of a more open, serious exchange of what is really going on for you and looking for support and a shared experience. But on its own, it doesn鈥檛 get you to where you need to be to process more difficult issues.

鈥楾hings go toxic when there is a lack of ability to reflect on and process the emotional world and the internal world breaks out and gets acted out rather than reflected on.鈥�

He co-founded a men鈥檚 group some five years ago, which he co-facilitates with another therapist. It is a closed group of some nine to 12 men, who meet regularly. 鈥楾here is a terrible defensiveness and stuckness in a lot of men, to the detriment of themselves, their relationships and society in general. It is still incredibly difficult for a lot of men to open up and be vulnerable to other men about who they are. It鈥檚 an insecure position, psychologically, being a man. Traditional modes of masculinity are to do with strength, competing successfully, being rather cut off emotionally. Maintaining that is hard work but also very important because it is about ego. But it keeps you unsafe. I think a lot of men really would get a lot out of a men鈥檚 group. They learn over time how to grow emotionally. My experience in every men鈥檚 group I鈥檝e been in is that, on the whole, if you put a group of men together in a room to talk about what really matters to us, then things really begin to move and change. There鈥檚 a frustration about not being able to talk about one鈥檚 inner world or relational world. For the group leader, the main thing is simply to offer some encouragement to go beneath the surface bit by bit, to open up to more vulnerable feelings, to what really matters in men鈥檚 lives, which men can be very good at covering up.鈥�

Michael Beattie sees it as his job as a counselling psychologist to help men 鈥榮often the delineations鈥� between male and female and, in the Jungian sense, integrate all the parts of themselves that they have locked away in different compartments. 鈥業 think some part of therapy for men is about making friends with all the different bits of their self. I use a lot of compassion-focused work with men because it鈥檚 a very effective way of working with shame, which is one of the key ways in which societies police men and women, boys and girls, into conforming to being appropriately male or female. Practising self-compassion can be very powerful for men. You can start off in a reasonably psychoeducational way so there is an engagement with the client, normalising different aspects of his experience by positioning it within gender socialisation as something that happens to all of us, and then you introduce the notion that he has a choice. That you don鈥檛 have to try harder to get better at things and get back to being a more effective competitor in the race; rather, you need to understand and have compassion for yourself in how you are experiencing that competition and recognise you share that with your tribe. Therapy is about softening some of the very critical aspects of the self that might be driven by shame and holding aspects of identity more lightly.鈥�

But, he says, the real work to be done is in primary schools, teaching young children that they don鈥檛 need to follow their allotted lanes in the motorway of life. 鈥楢 lot of these problems are social, and they are handed on. Regardless of what we may think of Prince Harry, what he said recently about how his father鈥檚 way of dealing with life were handed down from his father, and in turn handed on to him, and how he wanted to break that chain with his own son ring very true for many men, regardless of their status or class. As mental health professionals, maybe we need to do something about trying to break that chain.鈥�

Blasculinity

Beattie鈥檚 conceptualisation of the transgenerational pressures on men to conform to a masculine stereotype are echoed by Dwight Turner, counsellor and psychotherapist and a senior lecturer at Brighton University. Earlier this year, his blog on 鈥楲ove and the Black Man鈥�⁵, about how hard it is for black men to acknowledge love, given or received, struck a chord with many in the black community.

Children of first-generation migrants, of the Windrush generation, he argues, have been socialised by their own fathers into a semblance of unemotional, stoical endurance. Dwight recalls only once being told by his father that he loved him when, aged 14, he stood up in court as a witness in a trial after he and his friends were attacked by a white gang. His father wasn鈥檛 a bad man, Dwight says; he was simply enacting the role that he had himself inherited: 鈥楬e was a man raised within colonialism with a very Victorian idea of raising his kids. You can鈥檛 talk about black masculinity without talking about the injunctions placed upon black men within the colonial framework 鈥� that idea about children being seen and not heard and the father being the patriarch of the family. They still have an impact on young black kids seeking the love and caring attention of their fathers.鈥�

And for black boys in the UK, there is also the injunction 鈥榯o be an adult but not too much of a man鈥�. 鈥楰imberl茅 Crenshaw has written about this in relation to Black Lives Matter,鈥� Turner says. 鈥楾he George Floyd murder can be seen as white masculinity imposing its own domination over black masculinity and that鈥檚 nothing new for black men. And, when you are raised in a home with a father who has endured that, it compounds it - to be challenged within your own home is intolerable for a man who has already been defeated. The way one still has dominion in a white environment is by oppressing one鈥檚 own male kids. If you challenge the dominant male, you get thrown out. I鈥檝e seen that with black male kids who鈥檝e had to leave home at 16: 鈥淵ou鈥檙e a man now, get out.鈥� There鈥檚 no room for two men in the same house.鈥�

Changing cultural expectations

So how might a therapist work with this in the counselling room? 鈥楤y working to restore their sense of pride and identity,鈥� Turner says. 鈥榃ith my own clients, I will try to help them understand their internalised black father, how they have internalised those injunctions. Then, within our relationship, I hope they will internalise something from myself, discover what they can let go of within themselves, look to examples of strong black male people in their culture and the qualities they can identify with that they already have and that they can manifest with their own families and kids; how they want to be with their own kids and how they would have wanted to be with their own father.鈥�

Michael Beattie鈥檚 argument that therapists need to get into schools to challenge and change the way young children are guided into and rewarded for certain gender-role stereotypes is exemplified by counsellor Neema Fauvrelle. She works in a boys鈥� boarding school, where, by tradition, the English upper classes send their boy children to learn to be men. That such a school would employ a counsellor, other than to tick a box, opens a crack in the edifice; that she is brown, female and feminist widens that crack and, she hopes, means she is able to influence the school鈥檚 culture and values and bring about a revolution in its expectations, and those of their parents, on its pupils.

鈥業鈥檝e been working in that school for three years and I used to be sequestered away in an attic room; people barely liked to mention me out loud. And now I am reading The Huge Bag of Worries to Year One. I see these boys, aged 11-13, and every week I鈥檒l ask, 鈥淗ow are you doing?鈥�, and every week they鈥檒l say 鈥淚鈥檓 fine鈥�. They don鈥檛 feel there is a space where they are allowed not to be fine; they don鈥檛 know what that even means. Sometimes I am desperate for a kid to throw a chair around the room so I can say, 鈥淵ou are angry, let鈥檚 work with that鈥�. It can take weeks to establish that this is one such place.鈥�

These boys are presented with very binary models of masculinity and femininity, neither of which work for them. With her, she hopes they can discover there are alternatives. 鈥楾hey have a mum who embodies sadness and sensitivity, and a dad who embodies strength, achievement and courage, but if you are sensitive like mum, does that make you female? Is that OK? But do you want to be like dad, because that can be quite scary? And there鈥檚 money and power mixed in with that 鈥� being like dad gets you wealth and power but what does it take to get there? I am one person who can say, 鈥淥f course you are homesick, of course you are sad. It鈥檚 OK to feel like that.鈥� It is possible for them to escape from those expectations. We are breaking down that idea that you just have to get on with it. These boys have been able to cry and that is opening up this massive institution.鈥�

In Bristol, Martin Bisp runs Empire Fighting Chance, a charity that works with youngsters, from deprived homes and areas within the city, using the archetypal male sport of boxing to get them to engage with therapy. This isn鈥檛 primarily about boxing, he emphasises; hardly any of the young people who come to the gym go on to box as a sport. Rather, it鈥檚 about providing a venue that is acceptable to them, that doesn鈥檛 have the stigma of a health clinic or mental health environment, and something they can do (skipping, hitting bags) alongside their therapist (who is also a trained sports coach) while talking about their lives.

Moreover, boxing is, Bisp says, a sport whose stars are not afraid to admit to having emotions. He points to the current world heavyweight champion 鈥� arguably the toughest man on the planet 鈥� Tyson Fury, who has openly spoken about his own mental health issues, and to Frank Bruno. 鈥楩or the kids who come here, there鈥檚 an element of feeling you have to hide the fact that you are struggling, or maybe there鈥檚 nothing you feel you can do about it so it鈥檚 easier to try to ignore it, or you are from one of those social or cultural groups that see it as a weakness, so you try to pretend that everything is great. We found sport was a way of cutting through those barriers and start working with young people. But, as a group, boxers are quite open to talking about that kind of stuff. People assume boxers are these huge macho figures but actually people like Tyson Fury and Frank Bruno deserve massive credit for being open about their mental health and wellbeing. We leverage the machismo of the sport to say, if boxers can talk about this stuff, why shouldn鈥檛 you?

鈥榊oung people can discuss almost anything in the sessions and that starts to break down this ridiculous notion that men aren鈥檛 allowed to do anything except be tough. It challenges the stereotype of men as these one-dimensional beings when we all have different elements in our characters. The therapy model feels quite middle class and a lot of the people we see would find that highly intimidatory. When you are hitting a bag or skipping in a gym, alongside your therapist, those intimidatory barriers come down a bit. As a CEO of a large organisation told me, it鈥檚 the quality of the relationship that makes the single biggest difference.鈥�

What works for men

Australian psychologist Zac Seidler argues that the psychology and counselling professions need to change how they work with men, rather than expect men to change how they have been conditioned to be: 鈥楳en听do听want to seek help, and听will听engage in treatment, if they are given the right type of help,鈥� he has written. 鈥楾hese men may already have to overcome self-stigma, discomfort, and negative beliefs surrounding help seeking before initiating treatment鈥� Rather than focusing on听what听treatment is offered, attention should be directed to the听how听of treatment.鈥�⁶听

Seidler offers a set of principles for good practice when working with men - greater 鈥榞ender-competence鈥� in the counsellor; an initial emphasis on goals and tasks and active problem-solving, which fits men鈥檚 habitual ways of being in the world; a strengths-based framework that promotes autonomy over dependence; referencing 鈥榩ositive and pro-social masculine relationships鈥�, such as 鈥榤ates鈥�, and 鈥榝amily protector鈥�, and using ordinary language and purposeful self-disclosure to challenge the stigma and mythology around therapy.

John Barry has reviewed the research on the differences in the types of therapy men and women prefer. There are very few, but therapists should be aware of them, he says. 鈥楳en seem to like support groups more than women do, probably because they are more about sharing information rather than feelings. I鈥檇 argue that what is more important than the type of therapy is how male-friendly the therapist makes it.鈥� This means being knowledgeable about male-typical communication styles, like banter, and male-typical experiences, such as stress response to relationship breakdown. 鈥楢 theme that does emerge broadly from the research is that men respond well to a focus on the potential strengths of traditional masculinity, rather than its weaknesses. And good mental health isn鈥檛 just derived from therapy. Anything that gives life meaning is good for mental health,鈥� Barry says. 鈥業n my own research I鈥檝e found that, for men, important sources of mental health are job satisfaction and relationship stability. Playing sports or being a supporter can also be good for mental health. In many ways, I think the mental health professions are behind the times when it comes to men鈥檚 mental health, and many community organisations and charities are showing us the way forward.鈥�

He says that too often the ways men express their emotional or mental distress through behaviour are not acceptable in the counselling room and then become a matter for the criminal justice and forensic mental health systems. Instead of recognising the distress behind the behaviours, we judge and condemn the man: 鈥楳en tend to express their depression and trauma differently from women. It鈥檚 mirrored in how men approach therapy. They want a quick fix; they tend not to want to talk about their feelings as a way of dealing with their problems. Men also tend to stoicism and to self-medicate with alcohol and externalise their feelings in ways including aggression and violence. But we tend not to recognise these as symptoms of depression and trauma, other than in the context of PTSD in the post-conflict arena. Male depression is a more low-lying thing, and we tend to identify this as men behaving badly or aspects of toxic masculinity. And it鈥檚 a dead-end when no one recognises that their behaviour overlays their suffering. It鈥檚 a massive challenge for everybody when someone is violent; it is a massive challenge to help them. You just want them to be away from you, locked up. It鈥檚 a natural response but, as psychologists, if we want to do justice to our profession, we need to go beyond that. It鈥檚 important that we actually try to help them.鈥�

Sue Parker Hall, in contrast, works relationally with all her clients, men and women. 鈥業 might invite them to tell their stories about things that have happened in their life, and there is an invitation there to talk, but it鈥檚 not the story, it鈥檚 the relational environment that鈥檚 important. By the time they鈥檝e got to me, they鈥檝e tried every strategy 鈥� counting to 10, reframing, walking away. The truth is those strategies don鈥檛 work under stress 鈥� all our resources go out the window under stress. So therapy for me is more about giving them an experience of being regulated in the therapy room that I hope they will internalise; giving them an opportunity to tell their story in an environment that is respectful, caring, non-judgmental and receptive and takes them seriously. I do hand out a sheet of techniques but that鈥檚 not the focus of the work. It鈥檚 acknowledging that they鈥檝e had a hard time; they aren鈥檛 angry for no reason. It鈥檚 giving them a space to tell their story and connect with their goodness. Men do all the dirty dangerous jobs, and they get no thanks or acknowledgement for that and just thanking them for that is very therapeutic.

鈥業 also think there鈥檚 not been much modelling for their healthy aggression, as well as their gentler side. Healthy aggression is the life force with which we penetrate the world, that powers our mission in life. I think men鈥檚 aggression is misconstrued and managed too much 鈥� for example, with boys in school. They get blamed for being disruptive when it鈥檚 the system that is disrupting them by not allowing space for their healthy aggression and energy. We should be thinking about how we support men, not wanting them to change but changing society.鈥�

Interestingly, psychotherapist, Buddhist and author Manu Bazzano, who has written incisively and self-critically about the concept of masculinity, describes something similar when he talks about working with men and masculinity. For him, to be masculine is essentially and initially about being born with a male body with certain reproductive organs: 鈥楾hat is the first step, and the second is to feel comfortable with having that male body, and then use this as the start of an enquiry of what that could mean for the person. And that is difficult because there is a such a fixation at the moment with identity. But, as Michel Foucault would say, it鈥檚 not about identity, it鈥檚 about practices. It is about how you act, how you speak, not how you identify with one gender or sex or another. That is my dissatisfaction with men鈥檚 work today. The assumption is we know what it is to be a man and the position becomes defensive. For me the culprit is essentialism 鈥� people want everything to be fixed.

鈥楽o we start by helping a man be comfortable in their body, then say, let鈥檚 begin a journey and see what else is there, because the traditional masculine model doesn鈥檛 work 鈥� it brings pain to men and women. Perhaps,鈥� he wonders, 鈥榦ne route for therapists is to establish a role of helping practices of freedom and moving away from a fixation with identity.鈥�

Perhaps the solution to the 鈥榩roblem with men鈥� is for therapists to focus on providing spaces where men can free themselves from social and cultural expectations and risk trying out different ways of being in the world. 鈥楾here aren鈥檛 many places where we can think aloud without being judged. So maybe we therapists can dare to offer that space,鈥� Bazzano says.

Parker Hall says we need to make the therapy environment more accommodating for men so 鈥榯hey don鈥檛 get wounded or shamed or thought badly of. We ought to be changing as a profession and be way more respectful of men鈥檚 dealing with things in the way that they naturally deal with them. A therapeutic approach that over-focuses on the expression of feelings could be counterproductive with significant numbers of men.鈥�