Treating the Whole Man

The purpose of this article is to begin a more deliberate dialogue about men's issues in addiction treatment and recovery. Current models fail to address the relational needs of men; fall short of adequately addressing the impact of abuse and trauma that is so strongly linked with addiction and the life of the male addict; ignore any social context and/or the consequences of political, social, and economic power; and provide little direction in helping men to establish a healthy sense of self outside of normative masculine scripts. We suggest that a theory-based relational model could offer a road map in assisting recovering men to discover a fuller experience of themselves and to transform their experience of recovery.

Why question if men's issues are being adequately addressed in alcohol and other drug (AOD) treatment? Haven't men been the beneficiaries of treatment all of these years? The answer, quite simply, is yes and no. While countless men have successfully walked the path of recovery and have gone on to enjoy rich and full lives, too many stumble and become lost.

Until recently, professionals seldom have seemed to question the traditional approach toward treatment. Yet in the past several decades as women and other cultural and racial groups have entered the Western discourse of human experience, they have begun to question long-held views and assumptions. This has resulted in transformational models responsive to a broader range of human psychological development, and this in turn has led some to ask if the same theories, assumptions, and explanations are in fact truly representative of the male experience as well.

We acknowledge that we are not alone in being concerned with or writing about this issue.1,2 However, a simple literature search (both academic and clinical) will demonstrate the incredible dearth of information and inquiry that has been carried out thus far on this topic. This article does not pretend to offer all the answers, and its primary aim is not to question or minimize current treatment efforts. Rather, we wish to begin a more deliberate dialogue about men's issues in treatment and the recovery process.

Also, the focus of this work is primarily on the experiences of white male heterosexuals in treatment; however, it is our intention that this discussion ultimately be expanded to men of color and other socioeconomic realities and sexual orientations.

Using a relational approach

Our premise is that the relational cultural model espoused by such writers as Miller, Jordan, Kaplan, Striver, Surrey, and Covington3,45, with some adjustments, is a fitting theoretical model for men. Relational cultural theory, developed at the Stone Center at Wellesley College, originated as a response to understanding and conceptualizing women's psychological development.

The resulting theory places emphasis on connection with others or “self in relation,” stating that psychological growth is the interplay of connection and disconnection. It places emphasis on the importance of mutual, growth-fostering relationships as the source of health and happiness—and disconnection as the source of psychological problems. The theory recognizes that dominant culture through power, socialization, norms, and values plays a pivotal role in our ability to connect and stay in connection with one another.

We suggest that a theory-based relational model could offer a road map in assisting recovering men to discover a fuller experience of themselves. In the book Helping Women Recover, author Stephanie Covington, PhD, has created a relational-based curriculum designed for women entering treatment that is used by chemical dependency treatment and correctional facilities worldwide. 6 Covington's work focuses on four areas essential to recovery: self, relationships, sexuality, and spirituality. It should be noted that Covington has created a separate curriculum to address the significance of and work necessary to address the impact of trauma. 7 With Covington's permission, we offer a similar template incorporating the developmental differences inherent in men's psychological growth.

In a seminal essay, Stephen Bergman has addressed how the relational model applies to men.8 He states that traditional male psychological models fail to capture the whole of men's experience, neglecting to recognize fully the importance of mutual relationships and relational connection. Traditional theories support psychological growth as development of “self” dependent on separation and individualization—self in comparison, competition, and power over others. Drawing on relational cultural theory, Bergman suggests that men, like women, experience a primary desire for connection with others, further adding that “the seeds of misery in men's lives are planted in disconnection from others.”

The significance of this concept is particularly evident when working with men with AOD addiction. As spelled out in the text of the Twelve Steps and Twelve Traditions, one of the primary texts for Alcoholics Anonymous, “But it is from our twisted relationships with family, friends, and society at large that many of us have suffered the most.”9 After a person with AOD problems has achieved sobriety, much of his recovery is contingent upon his ability to build relationships with self, others, and, in 12-Step parlance, a higher power. (We recognize, of course, that there are many ways for an individual to recover from substance dependence, but much of our focus here is on the Minnesota Model and its similarities to and differences from the relational cultural model.)

Self

The “self” viewed from a relational perspective must be placed in a psychological, social, political, and cultural context, as these are the principal forces shaping the self's development. As previously noted, male psychological development is deeply rooted in numerous myths and expectations. The vast majority of these are social constructions grounded in normative concepts of masculinity that may have served human beings at one time—but it seems erroneous to conclude that they continue to do so. Much has changed in our society in the past 50 years. “Father Knows Best” is a distant memory and no longer represents the current reality of our world; it is even questionable whether such a depiction was ever representative.

When men come into treatment, they have a sense of who they are supposed to be as men. They have a good idea about how they should be acting as men—or at least how they think they should be acting. Men are trained through socialization at a very early age in how to be men10—just as women are trained in how to be women. That training follows some specific scripts that are well-known. Nakken identified them as the “10 myths of manhood.”11 Some of these include that men need to be tough. Men are in control. Men can never be emotionally vulnerable. Men are disposable because of the limited role they play in the lives of their families. Men are competitive. Men do not share their inner lives with others. Men are loners—John Wayne syndrome, rugged individualism.

Perhaps most significant is the great lie that keeps men isolated from other men, women, and themselves. This is the idea that men do not know how to have relationships. It is this idea that says relationships are not really important to men—they are the domain of women. This idea has permeated not only the lives of men but also the thinking of men, the structures of Western society, and the tenets of Western psychological theory. As a result, relationships and relational concepts are disparaged as insignificant and secondary in most psychological and sociological theory when it comes to men's needs.

The cornerstone male identity lies with the role that power and privilege play in enforcing these myths. Understanding the dynamics of power, how it leads to “power over others” and potential disconnection from others is paramount for men who, for the most part, find themselves “disempowered” through their addiction to alcohol and other drugs. 2 This can be a troubling paradox leading to confusion and anger. Seeing themselves differently in relationship to power and how they have used or misused their power can be challenging for men at best. Nelson says, “When we men orient ourselves to the world hierarchically … we become chronically insecure and emotionally isolated.” 2

For most men, the power they have and the privilege it bestows on them is often invisible. 12 Along with power is the concern of male violence, which is seldom addressed in AOD treatment or is often masked as “anger management.” There is a cost to having power, which by its very nature leads to painful disconnection and therefore isolation. Helping men to begin the process of experientially developing a truer sense of self can mean placing them in a broader social context of relationship, and this results in the experience of “power-with—a more feminine expression of power, exemplified in the community-based non-hierarchical setting of 12-Step meetings. Seeing oneself through the lens of others and listening to the stories of others as they discover who they are can provide a powerful awakening to self.

Others

Perhaps the crux of this article lies within the concept of the “other.” In a relational model our lives as human beings, as social beings, are defined in relation to others. This is counter to traditional Western psychological theory, which places emphasis on the individuation of the self and the necessary moving away from others into increased self-reliance.

From a very early age, men are socialized to separate from their caregivers and become independent from others. Dependency is seen as a character flaw, while women are encouraged to seek relationships to “hold together the relational and emotional demands of the family.” Boys turn to their father or male role model for guidance in their development. Unfortunately, often the adult male is the product of the same developmental path and is unequipped to facilitate much relational support or, for that matter, connection with the young male. So the opportunities to garner relational skills are most often lost.

We then find the young man as he grows, attempting to establish meaningful and intimate relationships devoid of the skills necessary to achieve such intimacy and, in all likelihood, feeling inadequate to the task. The outcome is what Bergman terms “male relational dread.”8

In their extensive work with men and women, Bergman and Surrey (Bergman published under pen name S. Shem)13 have used relational and gender dialogues to help couples move to deep and meaningful connection. They have unmasked how men experience and are often overwhelmed by a sense of dread when it comes to relationships. They describe this phenomenon as invisible to both the woman and the man. It begins with the woman wanting to move toward a deeper connection, seeking to understand more about the man and his feelings. The man, limited in relational expression, feels threatened, inadequate, and criticized, so he withdraws. This creates a relational impasse and disconnections, and provides justification for, in the context of this article, increased AOD use.

Bergman, commenting in a personal communication on “men who make it in AA (the authors would add 12-Step recovery in general) and the men who don't”, says that “when a man wants to use, and everything in his body and conditioning (psychological, including dread) tells him to withdraw and try to handle it himself, the ones who make it go against all of these powerful forces and move in the exact opposite direction.” Bergman and Surrey suggest that shedding light on this gender difference is the first step as it opens the door for continued dialogue and further opportunity for connection.

Sexuality

Men, like women, are sexual beings. This is a given. Nelson states that recovery for men is rooted in the body—returning to and honoring our bodies is “an important mark of recovery.”2 However, for the most part men's sexual issues are not considered in men's treatment.

The work of Covington and others has said that women are sexual beings, and that recognition of this fact is imperative to the recovery of women with alcohol and other drug problems. Many men define themselves by their sense of their sexual self. That sexual self is often limited to conquest, performance, and bravado. However, that is the surface of the story. Look underneath and one will inevitably see the myriad issues that women also confront as sexual beings: insecurity, sexual trauma, body image issues, confusion about sexuality, and many others. However, very often there is a conspiracy of silence that keeps men from acknowledging these issues in their lives, particularly because they are traditionally relegated to the female experience.

In addition, there are also those issues that are specific to men regarding sexuality. There is the common experience that persons early in recovery have with relationships, primarily addictive relationships, which replace the use of drugs and recreate the chaos of addiction. For many men this type of relationship is fueled by an unrestrained and misunderstood sexuality. Therefore, to not have awareness of sexuality as a core part of a man's treatment and recovery program is simply to ignore an integral part of human experience.

Spirituality

Spirituality is defined in many ways. For purposes of this article, spirituality is the recognition of a power greater than oneself and the ability to build a relationship with the world outside of oneself. This does not mean “God” per se, but rather the realization that one is one being amongst many living in a sea of competing needs and desires, and the all powerful “I” is not the most important interest needing to be served.

For many men, surrendering to their spiritual selves means admitting weakness or “powerlessness.” Quite simply, this can be defined as recognizing the need for help and seeking that help or support. The fear of admitting powerlessness is a practice that many men have inculcated into them at very early ages and through their entire lives. As men grow in recovery they find that personal growth and connection with others are inextricably linked; the degree to which men can build a relationship with others and a “power greater than themselves” (merely the recognition that they do not have to live life alone) is the degree to which they experience the fullness of recovery.

Trauma

The relationship of trauma and AOD use is well-supported.14,15 The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 75% of women and men in AOD treatment reported abuse and trauma histories. Up to one in six men report having had unwanted direct sexual contact with an older person by the age of 16. These statistics are highly relevant when one considers that in many cases AOD use can be an individual's primary method of coping with untreated trauma.

Sadly, for many of these individuals entering AOD treatment the trauma is seldom assessed and is less likely to be treated. Because alcohol and other drugs can be the main coping strategy for this person, AOD treatment that does not look at the potential impact of trauma on the individual man is insufficient and compromises his chance of achieving long-term recovery. Many times the person suffering from undiagnosed (or unrecognized) trauma is often labeled resistant, chronic, or not amenable to treatment.

It is only in recent years that trauma is being addressed as part of AOD treatment protocols. Once again it is the field of women's recovery that is breaking new ground.7,16 Several models designed to meet the needs of women in treatment are being successfully utilized.17 There is, however, little research or movement in addressing and/or treating men with AOD addictions and trauma histories.18

Conclusion

Each person who comes into AOD treatment enters from a certain psychosocial perspective. That is, each person has his own sense of self and who he is when he begins on his road to recovery. However, few men have a sense of who they really are when they come into treatment. Covered by years of alcohol and other drug use, their true selves lie dormant waiting to be discovered or recovered.

That process of recovery is one that looks different for each man. However, what clinicians must not do is limit what a man can discover in this process. So long as clinicians create a safe place for men, they will find that what men carry with them, are able to talk about, and are able to learn is so much greater than what our society's myopic understanding of men would indicate.

Obviously there is more research and study needed in the area of men's treatment for AOD addiction. That should not prevent treatment professionals and others interested in this area from questioning how that service is being delivered. Are we meeting all the needs of men in treatment? Can we do better? The answer, unequivocally, is yes.

It is time. It is time to end the myth that the traditional “male” model is adequate for addressing the multifarious issues men carry with them as they enter treatment. It is time for men to be given permission to be as fully human as they have been created to be and to offer them the opportunity to free themselves, once and for all, from the restrictive armor of masculinity from which they are dying to be freed.

Larry Anderson, PsyD, is a licensed psychologist in private practice specializing in trauma and addiction, and consults with a number of chemical dependency programs. His e-mail address is larryanderson123@yahoo.com. Dan Griffin, MA, has worked in the chemical dependency and mental health fields for 12 years, and is the author of the forthcoming book Recovering Masculinity. His e-mail address is dan@dangriffin.com.

References

1. Cunningham W The myths of manhood: addressing men's addiction and recovery through relational therapy. Addiction Professional 2004 2 26–31
2. Nelson J Thirst: God and the Alcoholic Experience Louisville, Ky Westminster John Knox Press 2004
3. Miller J Toward a New Psychology of Women Boston Beacon Press 1976
4. Jordan J Kaplan A Miller J et al Women's Growth in Connection: Writings from the Stone Center New York City The Guilford Press 1991
5. Covington S Surrey J The Relational Model of Women's Psychological Development: Implications for Substance Abuse Wellesley, Mass. Stone Center Working Paper Series 2000
6. Covington S Helping Women Recover: A Program for Treating Addiction San Francisco Jossey-Bass 1999
7. Covington S Beyond Trauma: A Healing Journey for Women Center City, Minn. Hazelden Publishing 2003
8. Bergman S Men's Psychological Development: A Relational Perspective Wellesley, Mass. Stone Center Working Paper Series 1991
9. Alcoholics Anonymous. Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services; 1952
10. Pollack W Real Boys: Rescuing Our Sons From the Myths of Boyhood New York City Random House 1998
11. Nakken C Men's Issues in Recovery: The Ten Myths of Manhood Center City, Minn. Hazelden Publishing 1991
12. McIntosh P White Privilege and Male Privilege: A Personal Account of Coming to See Correspondences Through Work in Women's Studies Wellesley, Mass. Stone Center Working Paper Series 1988
13. Shem S Surrey J We Have to Talk: Healing Dialogues Between Women and Men New York City Basic Books 1999
14. Herman J Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror New York City Basic Books 1997
15. Harris M Fallot R Envisioning a trauma–informed service system: a vital paradigm shift In Harris M and Fallot R Using Trauma Theory to Design Service Systems San Francisco Jossey Bass 2001
16. Najavitis L Seeking Safety: A Treatment Manual for PTSD and Substance Abuse New York City The Guilford Press 2001
17. Finkelstein N Vande Mark N Fallot R et al. Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment Washington, D.C. National Trauma Consortium for Center for Substance Abuse Treatment 2004
18. Fallot R Men's Trauma Recovery and Empowerment Model (M-TREM): A Clinician's Guide for Working With Male Survivors in Groups Washington, D.C. Community Connections, Inc. 2001