The effectiveness of gender role re-evaluation and non-gender-focused group psychotherapy in the treatment of recently separated men.
Psychotherapy (Health aspects)
Medical care (Utilization)
Medical care (Demographic aspects)
Lander, Nedra R.
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Summer, 2010 Source Volume: 9 Source Issue: 2|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Canada Geographic Code: 1CANA Canada|
This article explores the viability of Gender Role Re-Evaluation
(GRE) and Non Gender-Focused (NGF) group psychotherapy with recently
separated men. Sixty-one participants were randomly distributed into
three GRE or three NGF groups. Eleven psychometric measures were
administered at pre-pre-group, pre-group, post-group and six-week
follow-up. Results of a repeated-measures MANOVA revealed significant
changes in Emotional Expression, Self and Other Orientation, and
Psychological Well-Being, maintained at six-week follow-up. As the first
randomized empirical investigation of men's consciousness-raising
groups and gender role re-evaluation psychotherapy groups for men, these
results provide a more positive re-framing of men's accessible
potential for positive therapeutic change in groups, and a more hopeful
perspective of the therapeutic potential of group psychotherapy with men
undergoing a major psychosocial crisis.
Keywords: males, health care utilization, group psychotherapy, integrity, marital separation, values, gender role strain
The literature suggests that men present a unique therapeutic challenge due to their socialized gender roles. The present study is of both historical and current significance. At the time this data was collected, the emerging literature on men and counselling predicted that men were poor psychotherapy candidates in two important ways: (a) they were unlikely and/or unwilling to seek help and (b) if they did enter counselling, they would have significant difficulty in expressing their emotions, and in establishing a viable emotional connectedness with others. This continues to be a prevalent theme in the literature on psychotherapy with men. For example, Good and Brooks (2005) suggested that "men's help seeking is often tentative and complicated by conflicting motives, making it difficult for counselors to establish therapeutic alliances" (p. 8). Levant (1996) indicated that men do not readily use preventive and therapeutic help, due to difficulties in (a) admitting that there is a problem, (b) asking for help, (c) identifying and processing emotional states, and (d) dealing with intimacy. Richard (2000) suggested that because of the difficulty that traditional therapy comprises for men, it behooves therapists to find alternative forms of treatment that address men's needs.
The hypothesis of men's difficulties in help-seeking and emotional relatedness stems back to Jourard and Landsman's (1960) and Jourard's (1971) hypothesis of the non-self-disclosing male, Pleck's (1976) sex role strain hypothesis, and Garnets and Pleck's (1979) definition of sex role strain as linked to "discrepancies between an individual's perceptions of her or his personal characteristics and her or his standards for herself or himself deriving from sex role norms" (p. 275).
O'Neil (1982) proposed that men who experience gender role strain have adopted the values of"the masculine mystique" (p. 8), expressed through six patterns of gender role conflict and strain: (a) restrictive emotionality; (b) restrictive sexual and affectionate behaviour; (c) homophobia; (d) socialized control, power and competition issues; (e) obsession with achievement and success; and (f) health care problems. Nahon and Lander (1992) suggested that this model has become deeply ingrained in current conceptualizations of men and their potentials--or lack thereof--for emotional expression, help-seeking, and positive therapeutic change.
The question of whether men can viably engage in both individual and group psychotherapy and in support groups is of paramount clinical and theoretical importance. Men's consciousness-raising groups have been described as important therapeutic tools in helping men overcome their gender role strain (O'Neil, 1982; O'Neil & Egan, 1992; Stein, 1982). O'Neil and Egan proposed that by undergoing the cognitive process of examining their internal gender role belief systems through a gender role journey, men will be able to overcome their gender role strain. We will refer to the hypothesis that the process of gender role re-evaluation in a consciousness-raising group is a necessary precursor to overcoming the constraints of the male gender role as operationalized through the gender role strain model, as the gender role journey hypothesis. Following the predictions of the gender role strain model, many men would be unlikely to enter therapeutic or consciousness-raising groups because of the potential challenges toward help-seeking, emotional inexpressiveness and homophobia which men's groups may present.
The notion of men's difficulties around help-seeking and emotionality has remained a prevalent theme in the literature. Fischer and Good (1997) suggested that O'Neil's notion of restrictive emotionality "bears a striking resemblance to the descriptions of the clinical syndrome known as alexithymia" (p. 160). Levant (2001) indicated that "alexithymia also occurs in garden-variety or mild-to-moderate forms; these forms are very common and widespread among men. I have come to term this condition normative male alexithymia" (p. 424, original emphasis). Nahon and Lander (2008) provided clinical support for "an emerging, more positive view of men's potential for engaging in therapeutic services if these are offered with sensitivity to men's needs" (p. 232).
A number of clinical, qualitative, and anecdotal accounts (e.g., Andronico & Home, 2004; Brooks, 1998; Chauncey, 1994; Hetzel, Barton, & Davenport, 1994; Johnson & Hayes, 1997; Lander & Nahon, 2000b, 2008a; Nahon & Lander, 1992, 2008) suggested that psychotherapy groups can provide a viable psychotherapeutic approach in working with men. A parallel literature regarding the process men's group gatherings, men's peer-led/self-help, personal growth, educational, and support groups (e.g., Barton, 2003; Reddin & Sonn, 2003; Richard, 2000; Singleton, 2003; Vareldzis & Andronico, 2000) has emerged. In the only randomized empirical study of men's educational groups, Lepore, Helgeson, Eton, and Schulz (2003) found that compared to a control group, both group education (GE) and group education-plus-discussion (GED) interventions increased knowledge about prostate cancer in men treated for this condition. At one-year follow-up, men in the GED intervention were less bothered by sexual difficulties, and had a higher likelihood of keeping steady employment.
The literature (e.g., Baum, 2003; Caverhill, 1997) has begun to explore the hypothesis of a unique communication style in men. Robertson and Freeman (1995) suggested that men face a dilemma in dealing with strong emotions: they must avoid behaving in a "feminine" manner. Nahon and Lander (1992) stressed the need for therapists working with men to understand men's emotions in their own right; Heesacker and Pilchard (1992) and Lander and Nahon (2008a) have suggested that men's emotions have been misunderstood by virtue of being contrasted to women's emotions as the ultimate standard of comparison. Nahon and Lander (1998) have referred to the literature's negative portrayal of men's emotionality and help-seeking when needed as the myth of the "emotionally defective male" (p. 16). Nahon and Lander's (2008) review of the literature indicates that a number of empirical studies have pointed to the presence of a negative bias in the attitudes of therapists with respect to male clients.
This article aims to address these questions through an empirical investigation of the outcome of two approaches--the Gender Role Re-Evaluation and the Non Gender-Focused group psychotherapies--in the treatment of recently separated men. The overall hypothesis for this study was that, for men who are experiencing both psychological conflicts and gender role strain related to their changing social roles as men, a treatment approach integrating a non gender-focused psychotherapeutic approach with a gender role re-evaluation component--the Gender Role Re-Evaluation group--would allow for the following positive therapeutic changes to occur: (a) a decrease in psychological distress; (b) a resolution of individual and interpersonal conflicts; and (c) an increase in emotional expressiveness and the ability to viably relate to others. These changes would (a) occur in the pre-test post-test phase, (b) be maintained over a six-week delayed pre-test phase, and (c) not occur during the natural waiting time prior to the start of the group.
The second hypothesis was an exploratory one, based on the gender role journey hypothesis. We predicted that a Gender Role Re-Evaluation group would result in pretest/post-test changes in gender role strain. In contrast, these changes would not be found for the Non Gender-Focused group.
We selected men who had been separated from a marital or common-law relationship for a period of less than two years as the focus of our investigation of the viability of gender role re-evaluation psychotherapy. Recently separated men constitute a group of individuals who characteristically experience a high level of distress (Nahon & Lander, 2008), linked to multiple losses, including a loss in their previous socially sanctioned role, which may in turn precipitate the need to re-evaluate one's identity as a man in contemporary society. O'Neil and Egan (1992) suggested that divorce comprises a gender role transition in a man's life that may necessitate a re-evaluation or reintegration of one's gender role values and definitions. Zimpfer's (1990) review of the literature on group interventions for separated/divorced individuals prior to 1990 noted that only one unpublished study was specifically aimed at men. He stressed the need for further research, incorporating a follow-up group approach. None of the studies on groups for separated individuals published since 1990 have examined group interventions with all-male groups. An intervention program aimed at helping recently-separated men reach a healthier adjustment to this major life transition in the climate of a supportive group environment would not only fulfil a vital clinical need but also provide a viable theoretical vehicle for the exploration of Gender Role Re-Evaluation psychotherapy and the gender role journey hypothesis.
This study was carried out at the Ottawa Civic Hospital (now The Ottawa Hospital) Men's Clinic. The Men's Clinic (1984-1994) was the first documented mental health program for men in a tertiary care setting in North America (if not the world) (Nahon & Lander, 1992, 1998, 2008).
The study was approved by the Research Ethics Committee of the Ottawa Civic Hospital. Each individual completed an informed consent form agreeing to take part in this study; individuals were informed that lack of completion of the research protocol would in no way compromise their treatment in the Men's Clinic at the hospital.
Two pilot phases were conducted with a total of 36 participants. The first pilot study explored the outcome of a Gender Role Re-Evaluation group in a psychiatric outpatient clinic. Results of this study provided a beginning empirical confirmation for the therapeutic potential of the Gender Role Re-Evaluation group therapeutic approach with an adult male population in an outpatient tertiary care setting. A second pilot was conducted in order to ensure the integrity of treatment by fine-tuning the therapeutic approaches for both the Gender Role Re-Evaluation and the Non Gender-Focused groups. The treatment protocol was refined in order to address the clinical needs of group participants (Nahon & Lander, 2008). This played an important role in ensuring the participants' successful adherence to the study's research protocol and their engagement in the group process. It allowed for the research protocol to become well established and replicable by different therapists in the experimental phase of the study.
Participants were over 17 years of age, with at least Grade 10 education, and recently separated from a marital or common-law relationship. They were not involved in any concurrent psychotherapy, were at least three months abstinent from any substance abuse, were stabilized on psychotropic medication, if necessary, and were not found to suffer from any psychotic disorders.
Sixty-one men were randomly distributed into one of six groups-three Gender Role Re-Evaluation groups and three Non Gender-Focused groups. One individual completed the Non Gender-Focused group, but did not fill out any of the questionnaires during the experimental phase of the group, and was not included in the data pool. Fifty-four individuals (89%) finished the group, and 6 (10%) dropped out of the group.
The mean age of the participants was 41.3 years, with a standard deviation of 8.8 years. Mean annual income fell between $41,634.84 and $69,391.41 (current equivalent, Canadian dollars) per year. Mean total years of education was 15.96 years, with a standard deviation of 3.41 years.
Seventy-six point seven percent of the participants were self-referred to Beyond Separation, a group psychotherapy program for separated men. Twenty-three point three percent of the participants were referred by a health professional. Sixteen point seven percent of individuals initiated the marital separation; in 65% of the participants, the separation was initiated by their spouse; and in 18.3% of the participants, it was initiated through mutual consent. Seventy-three point three percent of the participants had been separated for a period of up to and including one year; 20% of the participants had been separated from 13 months to two years inclusive; 5% of the participants had been separated from 25 months to three years inclusive; and one participant had been separated for 7 1/2 years.
Six psychometric instruments were administered at each of the four testing phases: (a) "intake," at the end of the intake meeting; (b) "pre-test," immediately prior to the start of the group; (c) "post-test," immediately at the end of the group on the tenth week; and (d) "delayed post-test," six weeks after the end of the group.
The Personal Orientation Inventory
The Personal Orientation Inventory (POI; Shostrom, 1974) provides a measure of an individual's level of positive mental health and psychological growth. This test provides a number of measures of self-actualization: each of ten clinical subscales is intended to reflect a facet of development of the self-actualizing individual. Three sub-scales are of particular relevance to the hypotheses of this study: Self Acceptance, Self-Actualizing Value, and Capacity for Intimate Contact. Test-retest reliability for a sample of 48 college students over a one-week period was .69 for Self Actualizing Value, .77 for Self Acceptance, and .67 for Capacity for Intimate Contact (Shostrom).
Numerous studies have indicated that the POI is quite resilient to deliberate faking, either within or outside of a counselling context (Shostrom, 1974). The POI was able to differentiate between a group of actualizing and non-actualizing individuals (n = 29 and n = 34, respectively) beyond the .01 level of significance for the ten clinical sub-scales. Validity studies have indicated that the POI scales reflect meaningful components of mental health (Shostrom). Lalande's (1981) review concluded that the POI is a useful instrument for use in both clinical research and practice.
The Rosenberg Self-Esteem Scale
The Rosenberg Self-Esteem Scale (Rosenberg, 1979) is a 10-item Guttman scale aiming to distinguish individuals with high self-esteem from those with low self-esteem along a uni-dimensional continuum. Based on a sample of 5,024 high school students, the reported reproducibility of the scale is .92, with a scalability score of 72, and an alpha reliability coefficient of .75 (Rosenberg). A two-week, test-retest reliability of .85 for a sample of 44 college students was reported in an earlier study (Silbert & Tippet, 1965). This scale was shown to be sensitive to change in a psychotherapeutic context with an adult population, and to reflect significant therapeutic improvement in groups with recently separated individuals (Farenhorst, 1982; Gaff, Whitehead, & LeCompte, 1986).
The Expression of Emotion Scale
The Expression of Emotion Scale (Balswick, 1979) consists of a 16-item scale, with four items corresponding to four feelings: love, hate, happiness and sadness in three target situations: when alone with a person, in a small, and in a large group. This scale has proven useful in studying sex differences in expression of emotions (Balswick & Avertt, 1977). Results of a factor analysis procedure revealed a strong theoretical soundness for its four dimensions with the loadings for each factor ranging from .58 to .82. The test-retest reliability for the Expression of Emotion Scale was .83 at one week for adults (n = 34) and .72 at six weeks for college students (n = 33) (Balswick, 1988).
The Jourard Self-Disclosure Questionnaire (JSDQ)
The JSDQ (Jourard & Lasakow, 1958) is the earliest and most frequently used self-report measure of individual self-disclosure (Dosser, 1982). Its general psychometric quality is considered quite good (Chelune, 1978) with an overall split-half reliability coefficient of .94 in a sample of 70 unmarried college students (Jourard & Lasakow). Although Cozby's (1973) review concluded that a significant correlation between the JSDQ and actual disclosure in a given situation had not been demonstrated, subsequent studies found the JSDQ to be significantly correlated with self-concept (Shapiro & Swensen, 1977), capacity for intimacy and behavioural self-disclosure (Prager, 1986), competitiveness and perceived closeness of friendship (Busse & Birk, 1993). Given the mixed reviews of the scale's predictive validity, it may be more prudent to conclude that the greater value of the JSDQ lies in its format and method of evaluation, which has served as a model for most other self-report measures of self-disclosure (Dosser). The JSDQ was selected in this study as one of the "better" available and frequently-used measures of self-disclosure, intended as a complement to the Expression of Emotion scale. In view of the potential limitations to the predictive validity of the JSDQ, the results obtained on this scale must be subject to a limitation in interpretation. This proviso may be somewhat tempered by the strict use of the JSDQ as a pre-group/post-group comparison measure, rather than as an absolute index of general self-disclosing behaviour.
The Gender Role Conflict Scale (GRCS)
The GRCS (O'Neil, Helms, Gable, David, & Wrightsman, 1986) is an assessment of the respondent's self-rating on an attitude or behaviour which was previously categorized as a gender role conflict on four factors: (a) success, power and competition; (b) restrictive emotionality; (c) restrictive affectionate behaviour between men; and (d) conflicts between work and family relations. This scale was standardized on 527 undergraduate men with a mean age of 19.8 years. A four week test-retest reliability ranging from .72 to .86 for each factor was reported (O'Neil et al.). Moradi, Tokar, Schaub, Jome, and Serna (2000) have provided empirical support for the structural validity of the GRCS. Good et al. (1995) found that the GRCS had good internal consistency in a sample of undergraduate men from three college settings; Good & Mintz (1990) reported internal consistency scores ranging from .78 to .89 for the subscales in a sample of 401 undergraduate male students.
In the current study, the GRCS was administered in order to measure the four factors of gender role conflict. This is only the second study after Mankowski, Maton, Burke, Hoover, and Anderson (2000) that utilizes the GRCS as an outcome study of men's groups, and the first that utilizes the GRCS as an outcome measure for men's psychotherapy groups, the results obtained on this scale must be viewed as exploratory in nature.
The Revised Symptomatic Checklist (SCL-90-R)
The Revised Symptomatic Checklist (Derogatis, 1984) was designed to assess the symptomatic behaviour of psychiatric outpatients. Nine primary symptom dimensions and several global indices of distress are provided. Cronbach's alpha for the nine clinical scales ranged from .77 to .90. Test-retest reliability for 94 psychiatric outpatients over a one week period ranged from .78 to .90 (Derogatis).
The SCL-90-R has proven to be very sensitive to change in a broad variety of clinical and medical contexts, is a widely used measure in clinical assessment and psychopharmacological research, is considered a favourable psychotherapy outcome measure and is recommended as a group psychotherapy outcome measure by the American Group Psychotherapy Association (Coche, 1983).
Each individual referred to the Men's Clinic (Nahon & Lander, 2008) was invited to attend a multi-disciplinary intake interview integrating bio-psychosocial and valuebased perspectives. Each individual found to meet all the inclusion criteria was invited to join the Beyond Separation group. The purpose of the group was explained as an opportunity for separated men to work through issues stemming from their separation, as well to give and receive support from peers who had undergone similar experiences. All individuals who agreed to join the group were entered into the participant pool and randomly distributed into either a Non Gender-Focused or a Gender Role Re-Evaluation psychotherapy group. Each group was made up of eight or nine members. Each group session was two hours in duration, once a week for a period of 10 weeks.
The participants identified their treatment goals as resolving the feelings of sadness and grief surrounding their separation, speaking with other men who had undergone similar experiences, and breaking out of their sense of isolation.
Each group was facilitated by a male-female co-therapy team. The senior leaders were qualified mental health professionals with a minimum of three years of experience in leading psychotherapy groups. The junior leaders were graduate students in a counselling discipline (including psychology, educational psychology and pastoral care) or residents in psychiatry, all enrolled at the time in an internship or practicum program in the Men's Clinic.
The leaders were aware of neither the specific hypotheses of the study nor the particular outcome measures. Their task with the Men's Clinic was to offer the highest standards of clinical care while adhering to the therapeutic protocol.
Control and Treatment Groups
The intake-pretest comparison, a measure of the natural waiting time prior to the beginning of the group, was utilized in order to investigate the impact of maturational effects alone on the dependent variables. The mean waiting time was 7.3 weeks between intake and first group session.
The Non Gender-Focused Group
This approach comprised an integration of time-limited crisis-oriented group psychotherapy with the unique treatment needs of recently separated men. The theoretical perspective underlying the therapeutic interventions was the Integrity model (Lander & Nahon, 1992, 1995, 2000a, 2005, 2008a, 2008b; Mowrer, 1964), a value-based approach that has been found clinically helpful in working with this population (Lander & Nahon, 2000b; Nahon & Lander, 1992, 2008) and with men dealing with occupational stress (Lander & Nahon, 2008a). Leaders refrained from overtly initiating discussion regarding the masculine gender role throughout the duration of the group. If these issues were to arise in the course of the discussion, the leaders were asked not to interfere with their exploration by the group, but to refrain from intervening in the discussion.
The Gender Role Re-Evaluation Psychotherapy Group
This approach aimed to integrate the therapeutic orientation underlying the Non Gender-Focused approach with a gender role re-evaluation or consciousness-raising component. The first part of each session comprises a brainstorming process, in which leaders presented a given theme from a brainstorming questionnaire. In the second half of each session, members were encouraged to engage in an unstructured exploration of issues of concern. The group proceeded in a fashion identical to the Non Gender-Focused Group, with the exception that here the leaders were free, wherever appropriate, to either initiate and/or interpret material relating to an exploration of the masculine gender role. At the end of each session, the leaders handed out a set of questions stemming from a consciousness-raising manual questionnaire to be completed on the group members' own time before the start of the next group. These exercises comprised a slightly modified version of Sargent's (1977) gender role manual, adapted for use with a population of recently separated men.
The design comprised two independent and 11 dependent variables. The independent variables were time and treatment respectively. Time had four levels: intake, pretest, post-test, and delayed post-test. Treatment had two levels: the Non Gender-Focused group and the Gender Role Re-Evaluation psychotherapy group. The 11 dependent variables were: the Global Severity Index of the SCL-90-R; the Self Acceptance, Self-Actualization and Capacity for Intimate Contact scales of the POI; the Self-Esteem score of the Rosenberg Self-Esteem Scale; the Emotional Expression score of the Expression of Emotion Scale; the Total Self-Disclosure score of the JSDQ; and the four gender role conflict factors of the GRCS.
Hypotheses regarding differences in group means were examined through a Doubly Multivariate Repeated-Measures MANOVA (O'Brien & Kaiser, 1985; Tabachnick & Fidell, 1989).
Reduction of the Dependent Variables
Results of a Pearson product-moment correlation matrix for the 11 dependent variables measured at the pre-group phase (n = 58) indicated that although some of the correlations among the dependent variables were statistically significant, the largest amount of shared variance between any two given variables was no greater than 36%. It thus appeared more viable to reduce the total number of variables by distributing the 11 dependent variables into subclusters, derived on theoretical grounds, which could be examined through separate repeated-measures MANOVAs. The subclusters were as follows:
Cluster 1: Emotional expression. The aim of this cluster was to measure the extent to which the individuals engaged in disclosure to others of their feelings, emotions, and the significant events in their lives. The theoretical relevance of this cluster was to target key behaviours identified in the Restrictive Emotionality factor of O'Neil's (1982) model of male gender role strain. Two measures were included in this cluster: the Emotional Expression score of the Expression of Emotion Scale; and the Total Self-Disclosure score of the JSDQ.
Cluster 2: Self and other orientation. This cluster comprised three measures: the Self Acceptance, Self-Actualization Value, and Capacity for Intimate Contact scales of the POI. The aim of this cluster was to provide an empirical measure for the gender role strain hypothesis regarding the negative impact of male gender role strain on psychological functioning as a "conflict between the real self and the ideal self concept ... [resulting in] the restriction of the person's ability to actualize their human potential" (O'Neil, 1982, p. 10, original emphasis). In an attempt to investigate this hypothesized impact of male gender role strain, this cluster was intended to measure those attitudes which are linked to an actualization of one's values with reference to one's relationship with self (corresponding to Self-Actualization Value and Self Acceptance) and to relationship with others (corresponding to the Capacity for Intimate Contact).
Cluster 3: Gender role strain. The aim of this cluster was to offer a direct measure of male gender role strain as operationally defined in the GRCS. It comprised four measures, corresponding to the four gender role conflict factors of the GRCS: (a) success, power and competition; (b) restrictive emotionality; (c) restrictive affectionate behaviour between men; and (d) conflicts between work and family relations.
Cluster 4: Psychological well-being. The aim of this cluster was to offer an overall measure of the individual's psychological well-being and positive self-esteem. This cluster was intended to measure the possible impact of gender role strain on psychological well-being, as hypothesized in O'Neil's (1982) model, providing a more general outcome measure for crisis-oriented short-term psychotherapy. This cluster comprised two measures: The Global Severity Index of the SCL-90-R and the Self-Esteem score of the Rosenberg Self-Esteem Scale.
Formulated with reference to the dependent variable clusters, the hypotheses were:
H1: Men in the Gender Role Re-Evaluation psychotherapy group will obtain a significant difference in the predicted direction in the pre-group/post-group comparison on the following clusters:
H1.1: An increase in emotional expression, as measured by Cluster 1. Furthermore, subsequent univariate analyses of variance will reveal a significant increase in self-disclosing behaviour, as measured by the Jourard Self-Disclosure Questionnaire (JSDQ), and in emotional reactivity and emotional expressiveness, as measured by the Expression of Emotion Scale.
H1.2: An increase in self and other orientation, as measured by Cluster 2. Furthermore, subsequent univariate analyses of variance will reveal a significant increase in Self-Actualization, Self Acceptance and Capacity for Intimate Contact, as measured by the POI.
H1.3: A decrease in gender role strain, as measured by Cluster 3. Furthermore, subsequent univariate analyses of variance will reveal a significant decrease in each of the four gender role conflict scales as measured by the four scales of the GRSC.
H1.4: An increase in psychological well-being, as measured by Cluster 4. Furthermore, subsequent univariate analyses of variance will reveal a significant increase in self-esteem as measured by the Rosenberg Self-Esteem Scale and a significant lowering in psychological distress as measured by the SCL-90-R.
H2: There will be no significant difference on mean scores obtained for each of the four dependent variable clusters in the pre-pre-group/pre-group comparison, in other words during the waiting time between intake to the clinic and the start of the group.
H3: There will be no significant difference on mean scores obtained for each of four dependent variable clusters in the post-group/follow-up comparison.
H4: There will be no significant difference between the Gender Role Re-Evaluation psychotherapy group and the Non Gender-Focused psychotherapy group in the pregroup/post-group comparison on Cluster 1-Emotional Expression; Cluster 2-Self and Other Orientation; and Cluster 4-Psychological Well-Being.
H5: Men in the Gender Role Re-Evaluation psychotherapy group will show significantly greater change than men in the Non Gender-Focused psychotherapy group on gender role strain, as measured by Cluster 3, in the pre-group/post-group comparison. Results of subsequent univariate analyses of variances will reveal significant differences on each of the four factors of the GRCS.
Pre-Group Symptomatic Profile
In order to obtain a psychological profile of the participants at the pre-group phase (N = 58), the SCL-90-R profiles of participants across treatment groups were compared to the SCL-90-R norms for psychiatric outpatient males and for non-patient males. This comparison indicated that overall, the pre-group participants comprised a group of individuals who experienced moderate-to-significant symptoms of psychological distress, including the presence of feelings of depression, interpersonal alienation, difficulties with concentration and a sense of decreased ego-mastery. This is consistent with a profile of individuals, currently seeking psychological help, who faced a psychological crisis in response to a recent and profound psychosocial loss.
The dependent variables were examined through SPSS-PC programs for accuracy of data entry, missing values, and adherence to the assumptions of univariate and repeated-measures MANOVAs. Missing values, found in approximately. 1% of the data, were replaced by respective group means (Tabachnick & Fidell, 1989).
Comparison of Scores Obtained by Men in the Non Gender-Focused Group and the Gender Role Re-Evaluation Group at the Pre-Group and Post-Group Phases
Cluster 1: Emotional Expression. A significant difference was found for Cluster 1 on the main effect of treatment, F(2,44) = 4.75, p < .014. Results of corresponding univariate repeated-measures analyses of variance indicated that the significant difference fell primarily on the Jourard Self-Disclosure variable, F(1,45) = 8.29, p < .006, significant at the .01 Bonferroni-corrected level. A significant difference was found for the main effect of time, F(2,44) = 5.69, p < .006. Results of corresponding univariate repeated-measures analyses of variance indicated that the significant difference fell primarily on the Jourard Self-Disclosure variable, F(1,45) = 8.79, p < .005, significant at the .01 Bonferroni-corrected level. Univariate repeated-measures analyses of variance did not yield significant results for the Expression of Emotion score, F(1,45) = 2.22, p < .143. The treatment-time interaction effect for Cluster 1 was not significant, F(2A4) = 1.84, p < .171.
Cluster 2: Self and Other Orientation. An overall significant difference was found for the main effect of time on this cluster, F(3,43) = 3.08, p < .037. Results of corresponding repeated-measures univariate analyses of variance revealed significant differences on the Capacity for Intimate Contact variable, F(1,45) = 7.33, p < .010, significant at the .05 Bonferroni-corrected level. Univariate repeated-measures analyses of variance did not yield significant results for the Self-Actualizing Value score, F(1,45) = 2.51, p <. 120, nor for the Self Acceptance score, F(1,45) = 1.54, p < .221. No significant differences were noted on this dependent variable cluster on the main effect of treatment, F(3,43) = 1.91, p <. 141, nor for the treatment-time interaction effect, F(3,43) = [.06, p < .375.
Cluster 3: Gender Role Strain. No significant differences were found at the .05 level of significance on this cluster for the main effect of treatment (F(4,42) = .43, p < .785), time (F(4,42) = .73, p < .576), nor time-treatment interaction (F(4,42) = 1.32, p < .277).
Cluster 4: Psychological Well-Being. An overall significant difference was found on this cluster for the main effect of time (F(2,44) = 10.11, p < .001). Results of subsequent univariate repeated-measures analyses of variance indicated the presence of a significant difference with respect to both variables: On the Rosenberg Self-Esteem score, (F(1,45) = 5.67, p < .022, significant at the .05 Bonferroni-corrected level) and on the SCL-90-R Global Severity Index score (F(1,45) = 19.48, p < .001, significant at the .001 Bonferroni corrected level). Lower scores-indicating an increased level of self-esteem and a lowering in psychological distress-were found at the post-group phase for both group treatment approaches. There was no significant treatment-time interaction effect on this cluster.
Comparison of Scores Obtained by Men in the Non Gender-Focused Group and the Gender Role Re-Evaluation Group at the Pre-Pre- and Pre-Group Phases
Cluster 1: Emotional Expression. No significant differences were found at the .05 level of significance for this cluster for the main effect of treatment, F(2,20) = 1.29, p < .298, time (F (2,20) = 2.44, p < .113) nor treatment-time interaction (F(2,20) = 2.13, p < .145).
Cluster 2: Self and Other Orientation. No significant differences were found at the .05 level of significance for this cluster for treatment, F(3,19) = .39, p < .756, time, F(3,19) = .11, p < .950, nor treatment-time interaction, F(3,19) = 1.84, p < .175.
Cluster 3: Gender Role Strain. No significant differences were found at the .05 level of significance for this cluster for treatment, F(4,18) = 1.15, p < .367, time, F(4,18) = .68, p < .615, nor treatment-time interaction, F(4,18) = 1.44, p < .367.
Cluster 4: Psychological Well-Being. No significant differences were found at the .05 level of significance for this cluster for the treatment, F(2,20) = .15, p < .857, time, F(2,20) = .76, p < .479, nor treatment-time interaction, F(2,20) = .64, p < .537.
Comparison of Scores Obtained by Men in the Non Gender-Focused Group and the Gender Role Re-Evaluation Group at the Post-Group and Follow-Up Phases
Cluster 1: Emotional Expression. No significant differences were found at the .05 level of significance for this cluster for treatment, F(2,40) = 2.80, p < .073, time, F(2,40) = .38, p < .69, nor for treatment-time interaction, F(2,40) = .38, p < .69.
Cluster 2: Self and Other Orientation. No significant differences were found at the .05 level of significance for this cluster for treatment, F(3,39) = .60, p < .617, time, F(3,39) = 2.68, p < .060, nor treatment-time interaction, F(3,39) = 1.55, p < .215.
Cluster 3: Gender Role Strain. No significant differences were found at the .05 level of significance for this cluster for treatment, F(4,38) = .81, p < .526, time, F(4,38) = .87, p < .493, nor treatment-time interaction, F(4,38) = .04, p < .996.
Cluster 4: Psychological Well-Being. No significant differences were found at the .05 level of significance for this cluster for the treatment, F(2,40) = .40, p < .673, time, F(2,40) = 1.56, p < .223, nor treatment-time interaction, F(2,40) = .05, p < .95.
Hypotheses Regarding Cluster 1-Emotional Expression
The overall hypothesis with respect to the Emotional Expression Cluster received statistical support at the .01 level of significance. Results of subsequent univariate analyses of variance indicated that the majority of the variance noted for this cluster was accounted for by the JSDQ score.
The positive results with respect to the JSDQ may be interpreted as follows: These changes may be a function of being in a therapeutic group with others undergoing a similar situation, with the opportunity to engage in self-disclosure through the process of exploring and resolving one's presenting crisis. It is worthy of note that (a) increased self-disclosure occurred spontaneously and without coaching, and (b) members of both the Gender Role Re-Evaluation and the Non Gender-Focused groups underwent significant changes in self-disclosure. This raises interesting hypotheses regarding (a) the accessibility of the ability to self-disclose as part of men's behavioural repertoire, and (b) the possibility that an actual cognitive exploration of the acceptability of emotional expression in the context of a men's group is not a precursor for men to undergo a positive increase in self-disclosure, challenging the tenets of the gender role journey hypothesis.
The potential impact of the pre-group preparation process in validating participants' emotional voice (Nahon & Lander, 2008) points to an additional variable which may impact on both the Gender Role Re-Evaluation and the Non Gender-Focused groups. The intake process may have helped participants to reclaim their eloquent emotional voice (Lander & Nahon, 2008a), providing a precursor to the process of entering the group.
The hypothesis of significant pre-test post-test differences on the Expression of Emotion score was not borne out. The difference in results obtained for the JSDQ versus emotional expression may be accounted for as follows: First, as Balswick (1988) attested to, more research must be done in order to increase this instrument's predictive validity. Second, whereas the Expression of Emotion Scale investigates the individuals' level of emotional expression by inquiring how often an emotion is expressed by itself, the JSDQ inquires about the frequency with which the individual has disclosed an emotion within a given context. In other words, what is disclosed in the JSDQ is not only a feeling, but also the circumstances or determinants which surround it. Group participants may have been more comfortable expressing their emotions within a situational context, for example, as in communicating, "I feel really 'down in the dumps' when my children leave after my weekend with me," versus "I felt sad on the weekend." Such a communication style might integrate expressive and instrumental modes (Olson, 1978; Parsons & Bales, 1955); this would correspond with what O'Neil (1982) described as a more fully integrated level of communication between individuals.
Men's communication style in therapeutic groups can be investigated in future outcome studies using behavioural observations or qualitative approaches in addition to self-report measures of self-disclosure.
Hypotheses Regarding Cluster 2-Self and Other Orientation
The overall hypothesis with respect to this cluster received statistical support at the .05 level of significance. Results of subsequent univariate analyses indicated that the majority of the variance noted for this cluster was accounted for by the Capacity for Intimate Contact. This score reflects the ability to develop meaningful intimate relationships with others, unencumbered by social expectations and obligations.
These results may be interpreted as follows: Secondary to the recent loss of what may have comprised the major affective bond in their lives, recently separated men may be particularly receptive to a closer and perhaps more emotionally intimate relationship with others. Alternately, the increase in the Capacity for Intimate Contact may simply be a function of being in a group of men offered the opportunity, often for the first time in their lives, to get to know and talk with a group of other men about a significant emotional crisis. This opportunity for personal sharing and self-disclosure (reflected in Cluster 1), may open a door into a deeper level of relatedness, resulting in a deeper level of emotional intimacy with others-the psychological variable measured by Capacity for Intimate Contact variable.
These results are of clinical value in pointing to a significant association between both the Gender Role Re-Evaluation and the Non Gender-Focused group treatment approaches and a process of personal growth. The target population for this group treatment approach was a group of individuals whose presenting concerns included the loss of a primary relationship in their lives, along with feelings of loneliness and the loss of a social support system. For these men, the increase in the capacity for intimate contact may have a positive impact in terms of (a) the likelihood of seeking emotional support around their separation-a factor which the literature associates with the mitigation of severe stress secondary to marital breakdown, and (b) the likelihood of establishing more satisfying and intimate interpersonal relationships. These would be of long-term therapeutic significance, in the likelihood of maintaining a long-term support network, thus maintaining the preventative mental health value of the group, and in potentially increasing the quality of future interpersonal relationships. These hypotheses could be evaluated through longitudinal research with men in psychotherapy groups examining quality of life and interpersonal relationships.
The lack of significant results with respect to the Self-Actualizing Value and Self Acceptance variables may be interpreted as follows: The increase in the capacity for intimate relationships with others may comprise a necessary precursor for achieving a higher level of awareness and actualization of one's value system, ultimately resulting in increased self-acceptance. This may be of particular relevance to recently separated men. Secondary to the loss of one's primary affective partner, there may be a strong want or receptivity to grow in one's capacity for intimate contact as a precursor to further psychological change. There may be an initial receptivity to this type of personal growth in view of the relative lack of opportunity, as men in current Western society, to relate to other men in a meaningful and intimate manner.
These hypotheses could be tested in future studies with various populations, such as bereaved fathers, unemployed men, or men who have recently begun a committed long-term relationship.
Hypotheses Regarding Cluster 3--Gender Role Strain
The results with respect to Cluster 3 failed to provide statistical support for the gender role journey hypothesis that the Gender Role Re-Evaluation group program would result in a decrease in gender role strain for the participants in this study. This could be explained as follows: First, the GRCS has never been previously used as a psychotherapy outcome measure, and thus its psychometric properties in this context have not been tested. Second, a phenomenon such as an individual's gender role definition may be deeply engrained, necessitating a longer period of time, either in or subsequent to the group, to change. This would add a nuance to the gender role journey hypothesis. O'Neil and Good (1989) have suggested that gender role conflict operates along four overlapping dimensions: (a) cognitive; (b) affective; (c) behavioural; and (d) unconscious. Our finding that individuals engaged in non-gender-stereotyped behaviours, such as increased self-disclosure, before consciously having altered their gender role definitions would suggest that the gender role re-evaluation process in a Gender Role Re-Evaluation group may occur first at the behavioural, unconscious and affective levels, prior to being manifested on a more conscious, cognitive level.
The altering of gender role attitudes was not amongst the identified treatment goals of the participants in this study, a population of individuals in crisis. This provides a point of contrast with the Mankowski et al. (2000) study of the outcome of New Warrior Training Adventure Mythopoetic men's weekend workshops, where positive changes in gender role strain were reported. Based on the Mythopoetic nature of the program and the reference in its name to a training adventure, it may reasonable to expect that a participant goal may have included engagement in self-exploration and/or exploration of the male gender role. These were not as likely to be identified goals for the participants in our study, individuals experiencing a high level of psychological distress and seeking assistance in dealing with this.
Of interest, our data concur with Rochlen and Hill's (2005) findings that-despite having anticipated that men with higher gender role conflict would not value dream work as much as those with lower gender role conflict-men's response to dream work (session outcome) was not related to gender role conflict, leading the authors to conclude that men who volunteered for a dream session were able to benefit, regardless of level of gender role conflict.
Hypotheses Regarding Cluster 4-Psychological Well-Being
The overall hypothesis with respect to Cluster 4 was substantiated at the .001 level of significance. Results of subsequent univariate analyses of variance indicated that the variance noted for this cluster was accounted for by both the Rosenberg Self-Esteem score and the SCL-90-R score, pointing to a significant increase in self-esteem and lowering in psychological distress. These results may be interpreted as follows: An improvement in psychological well-being as a result of a short-term group intervention has been documented in the literature on short-term crisis groups, as well as in the emerging literature on groups for divorced individuals. This type of improvement is generally understood to result from both the emotional support and the psychotherapeutic components inherent in the group. This study adds further corroborating data regarding the viability of therapeutic groups for separated/divorced individuals, with an increased internal validity through the inclusion of a relatively large sample size, and a statistical control for the effects of time alone on psychological well-being.
The noted improvement in overall psychological well-being and the concomitant decrease in psychological distress documents the effectiveness of both the Gender Role Re-Evaluation and the Non Gender-Focused groups as viable treatment interventions for a crisis population of men for whom the resolution of feelings of distress was a primary treatment goal. The clinically meaningful enhancement in psychological well-being addresses a phenomenon that O'Neil (1982) characterized as one of the most deleterious impacts of gender role strain.
Hypotheses Regarding the Maintenance of Changes into the Follow-up Phase
The hypothesis that no significant differences would be found on mean scores obtained for each of four dependent variable clusters during the follow-up phase was substantiated at the .05 level of significance. These results indicate that the significant pre-group/post-group improvement on self-disclosure, capacity for intimate contact, self-esteem and psychological well-being were maintained during the no-treatment, follow-up six-week period subsequent to the end of the group. This provides (a) additional confirmation for the therapeutic viability of both the Gender Role Re-Evaluation and the Non Gender-Focused Group approaches with recently separated men, (b) further validation for the viability of group interventions with separated/divorced individuals through the inclusion of a follow-up evaluative component, and (c) providing further evidence for the health promotion aspects of the Beyond Separation program (Nahon & Lander, 2008).
Hypotheses Pertaining to a Comparison Between the Gender Role Re-Evaluation and Non Gender-Focused Groups
As predicted, there appears to be no difference, from a statistical perspective, between the Gender Role Re-Evaluation and the Non Gender-Focused groups in terms of overall therapeutic effectiveness on Clusters 1,2 and 4, and thus, the Gender Role Re-Evaluation group offers a viable alternative to the Non Gender-Focused psychotherapy group approach in the treatment of recently separated men. Both the Gender Role Re-Evaluation and the Non Gender-Focused groups are novel approaches in group psychotherapeutic work with men, based on an Integrity model, value-based perspective of both the pre-group preparation program (Nahon & Lander, 2008) and the group treatment approach.
A further variable which must be considered is that in inviting a group of men undergoing a similar crisis to come together in a therapeutic group context in order to receive support and assistance in dealing with their difficult life transition, the Non Gender-Focused group may have offered a gender role re-evaluation component, in validating covertly and overtly that it is both acceptable and viable for men to get together and share or discuss their common difficult or crisis situations with one another. This potential influence of the manner in which a program is presented on the ensuing results in terms of male expressiveness suggests that an additional nuance may be needed in the understanding of male self-disclosure. Balswick (1988) had put forward the view that the lack of expressiveness in men stems from the variables of self-concept, perception of the role of the other, and of the others' expectations. We propose that an additional variable in this model may be what we have previously characterized as the actual expectations of the other regarding the subject's capacity to become self-expressive. By the very act of inviting men to come together in a counseling group with the implicit assumption that it is within their accessible behavioural repertoire to be real, one may be giving men permission to relate in an emotionally open and sharing fashion. It may be neither that men do not self-disclose nor that men to not seek help but, rather, that the social structures that men are generally in do not sanction men's expression of their emotionally vulnerable sides. (Nahon & Lander, 1992, p. 413, original emphasis)
This in turn suggests the possibility of a self-fulfilling prophecy in that "this kind of empirical research leads to further theory-building, resulting in turn in a reinforced view among psychotherapists that men are unlikely, unwilling or unable to seek help" (Nahon & Lander, 1992, p. 413), inviting researchers to consider what the picture would "look like if we were to ask not what men cannot do, but rather what men can do in the arenas of help-seeking and utilization of group therapeutic services" (Nahon & Lander, 2008, p. 232, original emphasis).
The current study adds to the understanding of group psychotherapy with men in several ways. First, it provides empirical validation for the hypothesis that the Gender Role Re-Evaluation and the Non Gender-Focused groups are viable treatment approaches in group psychotherapy with recently separated men. The noted therapeutic gains in the areas of psychological well-being, self-disclosure and the capacity for emotional contact signify not only a lessening in the sense of crisis and distress in group members, but also an enhancement in the capacity for emotional relatedness to others. This would thus enhance the members' interpersonal and social adjustment beyond the group treatment-especially in view of the fact that these changes were maintained into the delayed post-test period. Furthermore, these therapeutic gains have a high degree of overlap with the members' pre-group therapeutic goals of (a) resolving their felt sense of crisis, (b) relating to others experiencing similar difficulties, and (c) breaking out of their sense of isolation. The therapeutic viability of this intervention program is also validated through the lack of significant changes in the pre-group phase, the low group drop-out rate of 10%, and the fact that this population of men whom the literature predicted would not come for help, were mostly self-referred with a four-month waiting list (Nahon & Lander, 2008).
Second, this study contributes to the knowledge base with respect to therapeutic interventions with separated/divorced individuals: It provides further evidence with respect to the therapeutic viability of a group intervention in improving overall psychological well-being with this population. It presents a methodological improvement over previous studies through the inclusion of a relatively large sample size, heeding Zimpfer's (1990) recommendations for a follow-up evaluation and fine-tuning of the treatment approach prior to the experimental phase program, overcoming what Zimpfer referred to as the "frontier character" (p. 50) of much of past research on groups for separated/divorced individuals. As the second study aimed specifically at men, it adds to the findings of Swann (1980) in its inclusion of a comparison treatment group, and its significant results for positive therapeutic changes. Through its focus on self-disclosure as a therapeutic group outcome measure, it adds to the findings of Avery and Thiessen's (1982) study of mixed-gender groups by pointing to a positive pre-group/post-group change in self-disclosure in an all-male group, without the inclusion of a relationship-skills training approach.
Third, this study adds to the knowledge base in the arena of men's groups, and more specifically, group interventions that address the masculine role as a component of the group, or in other words, gender role re-evaluation groups, as follows: It comprises the first empirically controlled investigation of the effectiveness of both (a) men's consciousness-raising groups and (b) gender role re-evaluation psychotherapy groups (outside of the area of communication skills training groups) for men, and the first empirical outcome study of both men's consciousness-raising groups and gender role reevaluation psychotherapy groups which is conducted in a clinical setting and aimed at individuals dealing with psychosocial losses or developmental crises, and more specifically, with marital separation. It presents a methodological improvement over previous group outcome studies utilizing an empirical evaluative format in its inclusion of (a) a much larger sample size, (b) a comparison of scores over the natural waiting period between intake and the start of the group, and (c) a follow-up evaluation phase. It is the first group empirical study providing empirical evidence for changes in both emotional expression and the capacity for emotional contact in men without the inclusion of a communication skills training approach.
Fourth, this study adds to the understanding of the gender role journey. It offers empirical support for Mankowski et al.'s (2000) findings of significant changes in depression and self-esteem in an evaluation of a men's initiatory New Warrior Training Adventure series of weekend workshops, while providing a number of methodological improvements through the inclusion of: (a) a larger sample size of completed evaluations reflecting a higher response rate; (b) the inclusion of a comparison group; (c) the reporting of empirical including statistical data; and (d) the comparison of scores over the natural waiting period prior to the start of the group and at a follow-up evaluation phase.
Fifth, this is the first empirical study of an Integrity-based group psychotherapeutic intervention with men. The Integrity model provided the theoretical foundation for both the therapeutic program, and the pre-group preparation phase. The high participant self-referral to the program and the low group drop-out rate (Nahon & Lander, 2008), as well as the pre-group/post-group improvements in psychological functioning reported in this study provide support for the viability of both the Gender Role Re-Evaluation and the Non Gender-Focused groups in engaging and working with men in groups.
These results provide further support for Lander and Nahon's (2000b, 2008a) and Nahon and Lander's (2008) clinical findings that an Integrity model, value-based existential approach offers a useful vehicle in engaging and working with men in therapy. The common elements between the Gender Role Re-Evaluation and the Non Gender-Focused groups were: (a) the use of a value-based, Integrity model crisis-oriented group intervention approach; and (b) the opportunity for a group of men sharing a similar psychosocial crisis to come together in a group therapeutic context, providing social support and helping one another resolve their difficulties. In tandem with the pre-group preparation process (Nahon & Lander, 2008), these elements would seem to have comprised a necessary and sufficient therapeutic environment for the positive changes in the areas of psychological well-being, self-esteem, capacity for intimate contact and self-disclosure to take place. The fact that these facets of psychological functioning were able to undergo significant changes without either the need for a communication skills training program, or the necessary inclusion of an overt consciousness-raising component would suggest that these skills may be more accessible in men's behavioural repertoire than the bulk of the literature had previously considered. This may invite researchers and clinicians to revisit underlying assumptions regarding men's potentialor lack thereof-for emotional expression in the therapeutic context. Our results offer empirical support for Andronico and Home's (2004) hypothesis that men's groups offer a viable treatment alternative for men, avoiding the blocks to therapy that many studies have identified.
The only published empirical randomized study of men's groups (Lepore et al., 2003) provided beginning empirical evidence that an educational group approach can be beneficial in post-treatment adjustment in men treated for prostate cancer. The current study, with a differing clinical population and therapeutic focus, adds to Lepore et al.'s work by providing further empirical support for the hypothesis that groups offer a viable treatment approach for men. It adds support to the qualitative as well as clinical studies that are beginning to explore the helpful aspects of men's therapy groups, and provides support for Nahon and Lander's (1992) original positive model of men's capacity for viably utilizing group therapeutic services.
After over three decades of a literature that has characterized psychotherapy with many men as a difficult endeavour, these results provide a more hopeful perspective regarding (a) men's accessible potential for positive therapeutic change in group psychotherapy and (b) the therapeutic potential of group psychotherapy in the treatment of men undergoing a major psychosocial crisis.
The authors would like to thank the men they have worked with over the decades for both proving and affirming their faith in their ease of accessibility to their emotional voices. As always, they want to thank Stephen West for his impeccable editorial skills and Emil Lander for his generous gift of time.
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Danielle Nahon (a) and Nedra R. Lander (a)
(a) University of Ottawa.
Correspondence concerning this article should be sent to Dr. Danielle Nahon, 250B Greenbank Road, Ottawa, Ontario, Canada K2H 8X4.
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