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A Relational Perspective on The Psychological Treatment of Gay Men: Treating Symptoms or Treating People?

In Continuing on our health journey, our brother site, Inside First :Men’s Health Resource, we are aiming for better health, current and quality  information on issues of mental health, fitness and nutrition. We are expanding and strengthening our team everday. Below our teams newest contributor, Dr. Todd Troutman. “Dr. Troutman holds a Bachelor of Arts in Psychology, and a Masters and Doctorate in Clinical Psychology. He has delivered psychological services to children, adolescents, adults, couples, and families in multiple settings, including: the Marin City School District, Berkley Mental Health Community Clinic, Access Institute For Psychological Services, and Ann Martin Center. In 2009, Dr. Troutman was awarded the Mental Health Services Act (MHSA) stipend, which is a grant program that provides practitioners funding to deliver psychological services to underserved communities in California. His work through the MHSA program was focused on the assessment, diagnosis, and treatment planning of individuals struggling with complex cognitive, emotional, and behavioral challenges.

Dr. Troutman currently works delivering individual psychotherapy to adults and adolescents, and provides clinical consultation services in his private practice in San Francisco. When he is not working in his private practice, Dr. Troutman teaches several classes in the Community Mental Health program at the California Institute Of Integral Studies (CIIS) and the Masters in Counseling Psychology program at San Francisco State University.”  drtoddtroutman.com

Treating Symptoms or Treating People?
Why Some Therapies Succeed and Others Fail:

A Relational Perspective on The Psychological Treatment of Gay Men

 

Public health research conducted over the last decade indicates that gay men experience higher rates of depression, panic attacks, and psychological distress than their heterosexual counterparts (Cochran et al., 2003). For their distress, many gay men seek short-term psychological treatment that is primarily focused on reducing symptoms. However, despite the use of symptom-focused therapies such as cognitive-behavioral forms of treatment (CBT), a significant portion of gay men experience chronic or recurring bouts of depression and/or anxiety. While many factors contribute to the mental health of an individual (e.g., economic status, discrimination, trauma, etc.), one reason gay men experience chronic psychological distress may be the type of mental health treatment they are receiving.

 

Research indicates that when psychological treatment focuses on symptoms, without addressing the complexity of the individual who experiences the symptoms, and without attending to what happens in the therapeutic relationship, gains made in therapy are short lived, and relapse rates are high (Baumann et al., 2001; Hilsenroth, et al., 2003; Westen et al., 2004). Therefore, therapies that focus on only one phenomenon, such as the way an individual thinks, are in many instances likely to create only superficial change. Therapies that address problem-solving skills, relaxation training, and patterns of thinking in isolation from the complex emotional experiences that drive symptoms, are using a “top-down” approach (i.e., restructuring thinking) to treat mental distress.

 

However, there is ample evidence that suggests that the mind is mostly a “bottom-up” system, in which our complex and subtle emotional experience actually creates our thinking patterns, and not the other way around (Greenspan & Shaker, 2004). Emotional states that lead to mental distress take shape in the context of relationships (past and present), and are stored in the brain as emotional impressions of the self in relationship to others (BCPSG, 2007). Therefore, an affective therapy must engage individuals at the experiential level of these emotional impressions.

 

Looking at the phenomenon of depression, one would think from the current standard of care (e.g. short-term cognitive behavioral therapy and psychopharmacology), that all one has to do is alter the patient’s neurotransmitter levels, and change his thinking. However, the research indicates that treatments that focus solely on these limited areas are insufficient, and that interpersonal factors are central in the successful outcome of treatments for depression (Luyten, Blatt, Van Houdenhove, & Corveleyn, 2006). Individuals who suffer from depression have marked challenges with relationships—which act as both a catalyst for depression and a key element in maintaining depressive states. Subsequently, there is increasing agreement in the mental health field that therapists should be addressing the interpersonal dimensions of depression, as well as the cognitive and biological dimensions, when delivering psychological and psychiatric services (Hammen, 2005). For gay men, interpersonal issues that lead to depression can be quite complicated. Early in their development, gay men get many subtle emotional messages that impact their sense of self. Parents of gay sons are often not equipped to meet the unique emotional and relational needs of their children.

 

One typical parent-child interpersonal pattern that tends to be central in the emotional development of gay men who later suffer mental distress occurs in the context of the father-son relationship. Fathers of gay men are generally heterosexual, and therefore, are psychologically and emotionally wired through there own experiences to relate to a straight male child. Subsequently, a father of a homosexual son may withdraw from him because his son is not as “rough-and-tumble” as most boys, may not be as athletic or may have mannerisms and interests that are traditionally considered feminine (Isay, 1996). Generally, the less the boy conforms to traditional gender roles, the more likely the father will have difficulty relating to him, and unfortunately, will continue to withdraw from him because the interactions create too much anxiety. The developing child in this scenario may be left with the emotional impression that there is something inherently wrong with or unlovable about him. This pattern may become further played out and reinforced through peer relationship, social prejudice and discrimination, and in romantic relationships.

 

The continued attacks that many gay men experience to their self-esteem can predispose them to having challenges both in loving others and being loved (Isay, 2006), an interpersonal conflict that can result in the symptoms of depression. This is due to a fundamental emotional distortion of their self-worth in relationship to others, not in their thinking. Effective treatments for chronic or reoccurring depression in gay men must engage individuals at the level of self-esteem and fear of connection if they are going to have long-lasting benefits. Current research indicates that engaging individuals at the emotional and interpersonal level is the exact approach that is most effective for individuals who experience recurring or chronic symptoms (Leichsenring & Rabung, 2008).

 

A powerful way to accomplish the task of engaging depressed individuals at the emotional and interpersonal level is for the therapist to track and address emotional experiences as they as take shape in relationship to the therapist. This essentially means that the therapist and patient collaborate in understanding what transpires between the two of them consciously and unconsciously. Contemporary forms of psychoanalytic and psychodynamic therapy take this form. If gay men experience chronic or reoccurring mental distress, such as depression, they should consider starting therapy with a therapist who is well trained in attending to the emotional dimensions of mental life, and uses the therapeutic relationship to promote emotional growth.

 

 

 

 

Citations:

Cochran, Susan D., Sullivan, J. Greer;Mays, Vickie M. (2003). Prevalence of mental disorders, psychological distress,
and mental services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and
Clinical Psychology, Vol 71(1).

Baumann, B., Hilsenroth, M. J., Akerman, S. J., Baity, M. R., Smith, C. L., Smith, S. R., et al. (2001). The capacity
for dynamic process scale: An examination of reliability, validity, and relation to therapeutic alliance. Psychotherapy
Research, 11, 245-258.

BCPSG. (2007). The foundational level of psychodynamic meaning: Implicit process in relation to conflict, defense
and the dynamic unconscious. International Journal of Psychoanalysis; 88, 1-16

Greenspan , S. I., & Shanker, S. (2004). The first idea: How symbols, language, and intelligence evolve, from primates
to humans. Reading, MA: Perseus Books.

Hammen, C. (2005). Stress and depression. Annual Review of Clinical Psychology, 1(1),
293 – 319.

Hilsenroth, M. J., Ackerman, S. J., Blagys, M. D., Baity, M. R., & Mooney, M. A. (2003). Short-term psychodynamic
psychotherapy for depression: An examination of statistical, clinically significant, and technique-specific change. The
Journal of Nervous and Mental Disease, 191, 349-357.

Isay, R. A., (1996). Becoming Gay: The Journey to Self-Acceptance. Henry Holt and Company, NY

Isay, R. A., (2006). Commitment and Healing: Gay men and the need for romantic love. John Wiley & Sons Inc., NJ

Leichsenring, F. & Rabung, S. (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A meta-analysis.
The Journal of the American Medical Association, 300 (13), 1551-1565

Luyten, P., Blatt, S.J., Van Houdenhove, B., & Corveleyn, J. (2006). Depression research
and treatment: Are we skating to where the puck is going to be? Clinical Psychology
Review, 26(8), 985 – 999.

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported
psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-
663.

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