Why men won't go to therapy
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A reader asked me to write about why men won’t go to therapy.
So my first question is: How big is the gender-therapy gap? I’ve read women are more likely to see a therapist than men. But is this true? And if so, by how much?
Here are a few facts.
On the left is the percentage of U.S. women who received mental health treatment or counseling in the past year from 2002 to 2021 and on the right is the percentage of men.
In 2021, there were 55% more women than men in therapy. That’s a pretty big gap.
Why might this be? One explanation is that women have more or more severe mental health issues than men on average. If women broke their arms more often, you’d expect them to see bone doctors more often too.
Whether men or women need therapy more desperately on average is a complicated question.
Doctors diagnose women with depression and anxiety disorders at about twice the rate of men. However, that may not mean women are actually twice as likely to suffer from them. Women see their doctors more often than men and are more likely to seek help specifically for depression and anxiety than men, giving us more opportunities to get a diagnosis.
Then there’s the fact that doctors are far more likely to incorrectly diagnose women’s chronic physical ailments as depression. (For evidence for this claim and why it happens check out How Medical Misogyny Replaced Hysteria With Depression.)
Apart from mood and anxiety disorders, psychotic disorders are another common category of mental health conditions. Recent studies show no gender difference in likelihood of developing schizophrenia. However, most studies show men are more prone to it, tend to show symptoms earlier in life, and their illness tends to be more severe.
Eating disorders are also far more common in women than men.
What else might someone go to therapy for? Doctors are twice as likely to diagnose men with alcohol use disorder than women. Men make up 80% of adults in drug treatment.
Men are also three times more likely than women to commit suicide and more than twice as likely to drink themselves to death or fatally overdose on drugs. Loneliness may be the single biggest predictive factor in who will commit suicide, and men are lonelier than women on average.
Are women happier than men overall? The research is mixed. Most studies show they are. However, “If you look at unhappiness metrics—sadness, anxiety, depression, loneliness—women are less happy than men,” Alex Bryson, a professor of quantitative social science at University College London, told QZ.
Even if women are more likely to be depressed and anxious, we paradoxically seem to be having a better time mentally overall. And we’re definitely less likely to kill ourselves or drink or drug ourselves to death. Which says to me that the “women need it more” hypothesis doesn’t fully explain the 55% gender gap in seeking out therapy.
Plus, at least one study found “men’s masculinity ideals are a significant barrier to their psychological help-seeking.”
For more evidence that even when they need it equally, men are still less likely to go to therapy, consider that 72–89% of women who killed themselves had talked with a mental health professional at some point versus 41–58% of men.
One factor that probably plays a role is the way we think of therapy. It has a reputation for being helpful for psychological problems that are low-level and ongoing. Things like anxiety, depression, OCD, eating disorders, ongoing self-harm, etc.
By contrast, men tend to have conditions that are more acute and where the symptoms have firmer boundaries, such as schizophrenia and substance use disorder. These disorders are more likely to lead to hospitalization and/or inpatient treatment versus therapy.
But I think many, if not most, men (and women) with substance use disorders are self-medicating the same anxiety and depression.
I think gender norms are the main reason men are underrepresented in therapy. I reviewed The Hazards of Being Male, which was written by a therapist who focused on men. I think everything he wrote about masculinity in the 1970’s is equally true today, but worse in terms of the disparity between masculine gender norms and economic and social realities. In short, as Richard Reeves described in Of Boys and Men (reviews part one and part two) the world has changed much faster than masculine gender norms.
Part of the reason masculinity is so static is that society punishes men far more for performing femininity than women for performing masculinity. Because in a misogynistic society, femininity is bad, right?
So women, far more than men, have the freedom to act like men. In doing this, we’ve created a new set of roles and expectations for ourselves that fit much better within macroeconomic realities. This, by and large, hasn’t happened for men.
Women and men punish men severely for doing everything associated with going to and getting value out of therapy. This includes, but is not limited to:
Asking for help
Admitting weakness of any kind
Showing any emotions other than anger and happiness
Talking about their emotions
Being vulnerable
We’ve coded independence, stoicism, self-reliance, emotional detachment, etc. as masculine and interdependence, vulnerability, emotionality, etc. as feminine. And we punish men for acting like women. So it’s no surprise whatsoever that men would eschew therapy.
“These men had been conditioned to be the strong ones, the ones that other people lean on,” this NYT article explains. “So the idea of seeking help, especially for their minds, was a foreign and off-putting concept.”
So how do we get men into therapy? I liked some of the recommendations in the NYT article. Reframe therapy as working out to make your brain stronger as opposed to going to the doctor because you’re sick (something else men do less than women even when equally sick).
Ultimately, the solution, as always, is to abolish gender. We really don’t need to give vulnerability a gender. My genitals do not determine my ability to ask for help or talk about my feelings.
But in the meantime, maybe it can help to try to make therapy seem like less of a lady thing. Because it seems clear to me that everyone can benefit from it. I certainly have.
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I don’t have time for a long comment, but I think there are four interlocking problems.
First, going to therapy (for men), as you said, carries a stigma.
Second, because most therapists are women, they don’t have any instinctive understanding of men and have real problems offering legitimate help. I knew a man who went to marriage counselling and left convinced the counsellor was completely on his wife’s side.
Third, men won’t often go to see a therapist unless the need is urgent and they’re honest enough to admit to themselves it IS urgent. But this forces them to vent their feelings – which can be utterly terrifying to witness – or confess to violent urges that the therapist has a legal duty to report, which can result in serious consequences.
Fourth, the therapists are rarely able to offer practical help. I knew a young man who was surly because no girl wanted to date him (and who can blame them, because he was surly?) I also knew a man who was trapped in long-term unemployment hell and would probably have done much better if he’d had a job, but how could the therapist just give him a job?
Providing practical programs to actually help, that show results, would be much more productive in the long run.
Chris
My problem with therapists, which is also something I noticed with lawyers who are dealing with something out of their depth, are paid to do it, and have no idea how to even begin to handle a case they're unprepared to do, is the focus on something that entirely misses the point. That is the best scenario. The worst scenario is essentially being kidnapped by my therapist at school and placed in an asylum for no discernible reason except I grieved... because I watched helplessly as my close friend burned to death and I had to knock on door after door in rural Vermont looking for a phone to call 911 since my school had no cell reception the entire time I was there (2005-2009) and the school, as it was 6 hours after finals ended, offered no help, not even an email, and barely acknowledged the event. And like others in my cohort, we used drugs and alcohol, perhaps to excess to the outsider but nobody died on my watch on campus via anything I introduced onto campus. But nevertheless because I didn't just lie, I lost my liberty - and the ability to finish my homework, no less - over bullshit reasons. In the end only 3 out of 12 students in the dorm graduated. But after this I learned to tell the therapist what they want to hear, but not the truth, unless I had to.
Psychiatrists have continually under-prescribed me medication (thank you DEA, at least I got it on the record in the Federal Register an official policy of 'prohibition first, patient access never) and self-medication carries risks, one of which turned out to be a therapist using the immigration apparatus, which as an attorney I actively fought against every day, to attempt to essentially put me into indefinite detention. ICE of course isn't police but the administrative nature of their actions make them immune to responsibility and I had actually dealt with clients who are Americans who got deported and had to make their way back "illicitly". Whether knowingly or not, this is one hell of a threat with clear racial undertones. After getting kidnapped and having spent 2 years fighting an uphill battle every day and barely make rent I was burned out, only to be threatened in a fundamental way - ICE also doesn't require a judicial warrant to hold anyone, and indeed they can't serve judicial warrants, but that also meant that they answer to nobody but the president and the AG via the DHS. I had a pretty unambiguous case of ADHD that Adderall was no longer really helpful at the 90mg IR level and at the same time, I had paradoxical effects to benzodiazepines so that Klonopin did nothing at all while Alprazolam past the 4mg range made me appear hypomanic. I eventually worked out a combo that made me productive and more or less stable, but with absolutely 0 help from psychiatrists and therapists kept asking me to stop doing illegal drugs and I kept saying if you insist on ignoring the fact that for a year I handled nothing but drug felonies as a public defender and know that it's not the drugs but enforcement that causes issues then I'm going to ignore the fact that you pretend to have listened to me at all. I had a doctor drop me from my Xanax script giving me a week to withdraw (obviously, I ended up having a seizure). Then, my friends started dying from what was clear to me - because everyone said it as such and I was part of that - switching from the soon-to-be-reformulated OC80s to Heroin. One can argue whether one NEEDS heroin, but this was the middle of the recession and I had been asked to leave a Cutco presentation. I quit after an overdose that I survived. Many of my friends didn't, and even more died when the DEA, as reported by their own IG, operated without congressional authorization and was actively laundering cartel money to set up some sort of sting that never happened, but did make a few million dollars in income, which of course implied accomplice liability, under their own theory of law. I almost punched out my laptop when I saw a clip of the Oklahoma state AG gloating about the extortion they committed against Purdue Pharma knowing full well that Purdue doesn't do shit without the DEA and FDA in charge. This is also never picked up or understood by the few therapists I've seen after that. I haven't been back to see anyone since 2018 and I can't imagine things have gotten better.
The therapists, psychologists, and psychiatrists are, in many ways, like the IP lawyers who send out gibberish DMCA notices. I have diligently counter-noticed all of the ones that I wanted restored (since restoring the content is the only direct remedy, I don't respond to those that fail to see that my work, which is never infringing since I keep track of the law closely and my mentor was an IP firm's partner who tried vigorously to recruit me after acing every class he taught). The fact is, defense attorneys do not "pound the table" when the law and facts aren't on their side. They try to manage the client's expectations to ameliorate harm. That was what I was taught and that was what I did in practice. The therapists, upon meeting a situation they are unprepared for, have never attempted to ameliorate the actual injury and instead, fell back on a mixture of victim blaming, generic missives that implied the legitimacy of the law - forgetting the audience, I guess - or well, threaten my actual liberty. It can't be a coincidence since this occurred in 4 states over 12 years. I don't believe in state charity so I paid for the sessions myself and I always felt ripped off. Unlike Blanche duBois, I have never relied on the kindness of strangers (if that stranger is a therapist), but so many of my friends have died from the supply-side introduction of fentanyl into ECP - fentanyl which I had been able to acquire in Actiq pop format in 2006 and had no euphoric effects but was obviously delivered safely - and the complete unwillingness by any with authority to even acknowledge that prohibitionism is the problem and I've lost more friends than my uncle who literally fought in combat in 1979 in Vietnam as an PLA officer. My only conclusion is that they don't understand where I'm coming from, there's no frame of reference for them, and it's a systemic problem since I don't have the sort of luck to hit up that many bad therapists and no good ones.
Note: I'm not entire honest with my therapists in the background and degree to which I have attempted to fix my own problems, but that's more of a 'don't answer a question that wasn't asked' situation. If they inquired in good faith, I'd be happy to explain how I manage. But I'm not holding my breath. I know I'm an edge case, but to me, that is the entirety of my only case.