transforming psychotherapy in order to succeed with adolescent boys: male-friendly practices

Transforming Psychotherapy in Order to Succeed WithAdolescent Boys: Male-Friendly Practices

�

Mark S. Kiselica

The College of New Jersey

The purpose of this article is to describe a “male-friendly” therapeuticprocess with troubled adolescent boys. A male-friendly process is one inwhich the therapist employs a wide variety of strategies and activities thatare likely to appeal to male youth and that facilitate the establishment andmaintenance of rapport. The nuances of practicing a male-friendly approachare highlighted and then applied in a case study of psychotherapy with adepressed adolescent boy. The implications of this approach for redefiningprofessional conceptions about boundaries in the client–therapist relation-ship and reexamining inaccurate stereotypes about the emotional livesof boys are discussed. © 2003 Wiley Periodicals, Inc. J Clin Psychol/InSession 59: 1225–1236, 2003.

Keywords: adolescent psychotherapy; adolescent boys; psychotherapy; men

All too often, mental health professionals attempt to help troubled adolescent boys byusing a clinical approach that is incompatible with the relational styles of boys and theirviews about the helping process. Applying concepts from traditional models of psycho-therapy, practitioners typically attempt to counsel boys during formal sessions conductedin their offices during which young men are expected to verbalize intimate thoughts andfeelings about the difficulties in their lives. While some boys respond well to this approach,other boys are ill at ease with these conventional practices because their natural way ofrelating to others is through active, instrumental, and group activities (Kiselica, 2001,2002). Although a substantial body of research indicates that this latter population ofboys do indeed want assistance with their concerns (e.g., Achatz & MacAllum, 1994;Hendricks, 1988; Kiselica, 1988), mental health practitioners tend to misinterpret theboys’ discomfort as a sign of resistance or as an indication of flawed masculine

Correspondence concerning this article should be addressed to: Mark S. Kiselica, PhD, Department of Coun-selor Education, 332 Forcina Hall, The College of New Jersey, P.O. Box 7718, Ewing, NJ 08628–0718; e-mail:[email protected].

JCLP/In Session, Vol. 59(11), 1225–1236 (2003) © 2003 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10213

development, rather than considering that there might be a mismatch between their clin-ical approach and the boys’ relational style.

In order to correct this mismatch, practitioners can make adjustments in psychother-apy with young men. These adjustments adhere to a “male-friendly” therapeutic processthat taps into the natural ways boys relate to the world. A male friendly process is one inwhich the therapist employs a wide variety of strategies and activities that are likely toappeal to male youth and that facilitate the establishment and maintenance of rapport.These strategies include using flexible time limits for sessions and informal settings,expressing humor and self-disclosure, employing a variety of rapport-building and facil-itative tactics, working with boys in groups, and reexamining professional constraintsand inaccurate stereotypes about the emotional lives of boys. In this article, each of thesetopics is addressed, followed by a case illustration of a male-friendly approach with adepressed teenage boy.

The recommendations suggested in this article are based on extensive empiricalresearch on helping teenage fathers, a population of boys that has been neglected, misunder-stood, and disparaged by the helping professions (see Kiselica, 1995; Kiselica & Sturmer,1993). In response to the low utilization of teen parenting programs by adolescent fathers,numerous demonstration projects have identified barriers inhibiting young fathers fromprogram participation and have developed programmatic changes that would increaseservice utilization. Collectively, the findings from these studies revealed that adolescentfathers avoided using teen parenting services because they tended to be geared toward theneeds and relational styles of teen mothers and often were delivered by practitioners whoharbored rigid, judgmental attitudes about young men involved in adolescent pregnancies(e.g., Achatz & MacAllum, 1994; Brown, 1990). These investigations also found that theutilization of services by teen fathers increased substantially when therapists tailored teenparenting programs to the needs of adolescent fathers and employed supportive, nonjudg-mental, and nontraditional approaches. Because these studies were conducted with hun-dreds of teen fathers from many different areas of the United States and included extensivesamples of African American, Hispanic, Native American, and White, non-Hispanic males,they are likely to have strong external validity for working with other boys.

Male-Friendly Practices

Using Flexible Time Limits for Sessions and Informal Settings

Although the so-called “50-minute hour” has become the standard time frame and prac-tice for psychotherapy sessions for many clinicians, it is an odd and artificial concept formany boys, especially young men who come from particular ethnic groups, such as NativeAmericans and Puerto Ricans, whose orientation to time emphasizes the present anddeemphasizes rigid deadlines. Furthermore, the 50-minute hour is an arbitrary and, attimes, clinically inappropriate time frame. For some boys, 50 minutes is too long a periodto sit around talking. For others who are in an acute crisis, 50 minutes may be too shorta span of time to address the crisis adequately.

Another problem with the 50-minute hour is that it is usually held in formal settingsand is filled with interpersonal demands foreign to the ways that boys conduct socialexchanges. Across different ethnic groups, boys tend to form close friendships with otheryoung men by hanging out and playing sports or electronic games. Although they mightnot sit down and have heart-to-heart, face-to-face conversations, they do get to knoweach other quite well, including an understanding of each other’s psyche and the interestsand concerns that are important to them, by sharing information about their lives while

1226 JCLP/In Session, November 2003

playing a game, while tinkering with a machine, or while eating. Through these non-rushed forms of sharing, significant friendships are formed that are often characterized bystrong bonds. Expecting boys who are accustomed to bonding in this way to enter anenvironment that demands extensive and quick self-disclosure about difficult issues isunrealistic and places unfair demands on boys. Doing so “is analogous to asking an operasinger to perform an inspired rendition of an aria in a tool shed without the support of anorchestra. The setting is just not conducive to the production of one’s best performance”(Kiselica, 2001, p. 47).

A more realistic and therapeutic approach is to use flexible time schedules and infor-mal settings where boys feel more comfortable. The times for meeting with boys shouldbe convenient for them, and the length and location of a session should be adjusted to fitthe individual needs and personality of the client. With some boys, the initial sessionmight be brief, perhaps just 15 or 20 minutes, and held outside or in a gymnasium, wherethe clinician and the youth take turns tossing a football while they talk about each other’sfavorite team. Or they might chat about the young man’s interests while playing checkersor chess, walking down the street, hiking or fishing in a park, working together on aproject (e.g., building a shed or model airplane), or enjoying a meal together in a restau-rant. Engaging a boy through these types of activities can promote his trust and comfortwith the practitioner and open the door to his gradual exploration of clinical material.

Expressing Humor and Self-Disclosure

Although it is true that some males avoid intimacy by attempting to joke every time asignificant issue is raised, many young men use humor as a vehicle to achieve intimacy.For example, it is quite common for teenage boys to begin a conversation about a seriousmatter by joking about it. Periodic humorous responses by the therapist to this sort ofentrée relieve the client’s tension associated with his problems, thereby facilitating greaterexploration of his concerns. Therefore, it behooves a therapist to inject a little humor intohis or her conversations with the client.

Timely self-disclosure is another practice that can facilitate therapeutic movementwith young men who find it difficult to reveal personal matters directly. Boys who arescared to open up about themselves find it easier to talk to others who take the lead withand model self-disclosure. For example, I sometimes show my young male clients pic-tures of my family members and tell them a little bit about where I was raised and whereI now live. These disclosures often prompt my clients to tell me about the significantpeople in their lives and their relations with those people.

Employing a Variety of Rapport-Building and Facilitative Tactics

A variety of tactics are effective for developing and maintaining rapport with adolescentboys. These include the following:

• If you are meeting the client in your office, display magazines with which a teen-age boy can identify, especially sports publications, and have all calls held duringthe interview.

• Sit side by side, rather than face to face, in order to reduce suspiciousness andself-consciousness.

• Help the boy to relax by offering a soft drink or snack prior to the start of thesession or by discussing his interests or events in the community.

Male-Friendly Psychotherapy With Boys 1227

• If you are wearing a long-sleeved shirt, roll up your shirtsleeves to convey to theyouth your readiness to work with him.

• Be knowledgeable about the slang he may use. However, if the boy uses slangexpressions you do not understand, ask him to explain the expressions to you,rather than pretend you understand him.

• Avoid using open-ended questions such as “How are you feeling?” because theytend to be ineffective with this population. Instead, conduct content-specific dis-cussions centered on helping the client with his most pressing concern.

• Take it slow, follow the boy’s lead, and carefully monitor the client’s cues regard-ing his comfort level with topics.

• Be prepared to do a lot of listening and avoid asking too many questions so as toavoid being too intrusive.

• Toss a miniature football or a Nerf ball back and forth as the client talks with youabout his concerns.

• Be empathic, available, and honest.

• Explore with the boy his expectations about psychotherapy and clear up any mis-conceptions he might have about you and your role.

• Respect the young man’s autonomy by scheduling appointments with him, ratherthan through his parents, and by giving him your business card.

• Focus on practical matters (e.g., finding a job, getting a car license) that are fore-most on the young man’s agenda.

• Keep initial interview sessions brief (a maximum of 45 minutes) unless the clientshows a keen interest in extending the session.

Working With Boys in Groups

Group therapy is a powerful treatment modality with boys because males are accustomedto relating, bonding, and cooperating in groups, such as sporting teams, military units,work groups, scout troops, and gangs. Group activities with boys are particularly effec-tive when they are incorporated into holistic programs that include health services, psy-choeducational and recreational activities, and job placement counseling. For example,over the course of the past 12 years, several colleagues and I have developed an approachto group therapy that has been successful with boys because it has been provided as partof a multifaceted program that appeals to the interests and needs of boys (e.g., Kiselica,1999; Kiselica, Rotzien, & Doms, 1994).

In brief, our approach involves incorporating informal, rapport-building strategies(such as participating in recreational events) into group psychoeducational activities. Forexample, we have developed after-school programs for expectant teenage fathers in whichthe participants introduce themselves and then play basketball for approximately a halfhour. Afterward, while having a drink or a snack, the boys watch and react to educationalvideos that are designed to help them clarify their attitudes about fatherhood and toexpress their feelings about becoming a parent. Other sessions are focused on teachingthe participants important life skills, such as childcare, financial, and time-managementskills. This approach taps the instrumental, group-oriented relational style of traditionalboys, while capitalizing on the support of a therapeutic group.

A group approach also is an efficient means of helping because it allows practitionersto reach large numbers of boys at one time. Group therapy with boys may be particularlynecessary in school settings, where the average student-to-counselor ratio is 513:1(Kiselica, 2001).


Reexamining Professional Constraints

Historically, mental health practitioners have been taught to maintain a professional dis-tance from their clients in order to preserve objectivity about their clients’ problems andto avoid engaging in exploitive dual relationships. Although these considerations cer-tainly have merit, strict adherence to these conventions can pose problems in the client–therapist relationship. For example, Lazarus (1990) warned that maintaining rigidboundaries between the therapist and the client can shackle the therapist’s humanity,thereby impairing the therapeutic relationship. In addition, a disengaged method of con-ducting psychotherapy is alien to many ethnic minority clients who prefer relationshipscharacterized by a high degree of familiarity, warmth, and accessibility (Carrera, 1992).

In short, we must reexamine our professional constraints in order to be more effec-tive with many of the populations we intend to serve, including boys. Empirical evidencesuggests that helpers who are willing to get out of their offices and address a boy’sconcerns while taking him out to lunch, visiting him in his home, playing with him inschool yards and gymnasiums, assisting him with practical matters, and working withhim on a project are more effective than those practitioners who limit their practice todiscussing a boy’s problems with him in an office setting (e.g., Hendricks, 1988; Sander& Rosen, 1987). Effective helpers manage to establish healthy, therapeutic boundariesthat allow them to be active, involved, and caring mentors of troubled young men.

A key guideline in this work is to make sure that the boundaries are healthy. Goodtherapists self-disclose without revealing too much personal information. They visit theirclient’s home, yet they respect the client and his family’s personal space and autonomy.They extend themselves to their client and help him with practical matters, while chal-lenging him to take responsibility for his actions and his destiny. They recognize thatsome young men, such as those with a budding personality disorder, have problemsrespecting other people’s boundaries and therefore should be handled more cautiously.Overall, the therapist must make sound clinical judgments and define professional bound-aries on the basis of what is therapeutic for the client.

Reexamining Stereotypes About the Emotional Lives of Boys

Over the past several years a number of writers have claimed that most boys suffer fromserious deficits in the ability to access, identify, and describe feelings—a condition referredto as alexithymia. Unfortunately, the popular influence of these writers has created thewidespread impression that alexithymia is normative for males. Although it is true thatsome boys do experience alexithymia, there is no empirical support for the claim thatboys are significantly more likely than girls to suffer from alexithymia. On the contrary,the best available data indicate that there are no consistent, systematic gender differencesin alexithymia (see Kiselica & O’Brien, 2001). For example, in the most geographicallyextensive study of the subject, Levant and colleagues (2001) found no gender differencesin clinical and subclinical alexithymia in samples of adult men and women from SanJuan, Puerto Rico (N � 373); Gainesville, Florida (N � 416); Detroit, Michigan (N �250); and New York, New York (N � 162). Furthermore, when gender differences arefound, they tend to be slight and reveal that most people, both females and males, are notalexithymic.

In spite of this evidence, widespread misconceptions about alexithymia have con-tributed to stereotypes depicting boys as emotionally mummified creatures. These stereo-types have been shown to cause practitioners to view male clients as being more


pathological than they actually are (Heesacker et al., 1999). If professionals continue toembrace these stereotypes, they are likely to see boys as flawed and treat them as unwholebeings who need to be fixed, rather than as people who want to be helped.

A more accurate portrayal of boys arises when one understands that boys are notemotionally constricted but that they tend to express their emotions differently from mostfemales and most therapists. Furthermore, if we really intend to help boys with theirproblems, then we must build upon their strengths and adapt our counseling methods tofit the natural relational styles of boys by practicing a male-friendly approach. An illus-tration of this approach is provided in the following case study.

Case Illustration

Presenting Problem/Client Description

Charlie W. was a 15-year-old African American boy who was referred for psychotherapyby his mother to help him cope with the aftermath of his father’s suicide. His father, Mr.W., had died from a self-inflicted gunshot wound to the head about a year prior to thecommencement of therapy. Clinical records and consultations with other professionalsrevealed that Mr. W. had suffered from a psychotic depression characterized by commandauditory hallucinations telling him to kill himself.

Charlie was one of five siblings. Three older siblings, Reggie (age 23), Loretta (age21), and Anthony (age 19), lived outside of their mother’s home at the time of Charlie’sreferral. Charlie resided with his mother, Mrs. W. (age 43), and his younger brother,Frankie (age 12), in a single-family home in a middle-class neighborhood.

Prior to his father’s death, Charlie had been functioning well at home and at school.Although the entire family had experienced difficulties adjusting to the ups and downs ofMr. W.’s psychiatric illness, Charlie had good relationships with his siblings, especiallyAnthony and Frankie, and with his parents. Charlie particularly had enjoyed workingwith his father in his part-time business as a carpenter at those times when Mr. W. hadbeen functioning well. The two enjoyed talking about sports, music, and woodworking.Before his father’s suicide, Charlie had earned A’s and B’s in school and demonstratedgood peer relations and an overall good deportment at school. After his father’s death,however, Charlie withdrew from family members and friends, spent a great deal of timelistening to loud rap music in his bedroom, stopped doing his homework, experienced adecline in grades to a B and C level, began smoking cigarettes, and had periodic verbalexplosions directed toward his teachers and his mother.

Charlie had been referred to two other practitioners for help with his depression. Thefirst, an outpatient psychotherapist, made no progress with Charlie through three ses-sions, which were held at her office. The therapist reported to Mrs. W. that Charlie “avoideddeep emotional connection” because he was immediately “resistant” to discussing thedetails of his father’s death with her. When work with this practitioner got nowhere, Mrs.W. took Charlie to a psychologist in private practice for two sessions, who limited hiscontact with Charlie to the one hour each week that Charlie was brought to his office.Although the psychologist proposed to Mrs. W. that the death of Charlie’s father hadprovoked the reliving of a prior trauma of a forced premature emotional separation fromhis mother, she considered this hypothesis to be implausible. Nevertheless, the psychol-ogist continued to view Charlie’s “resistance” to working with him as a defense againsthis fully reexperiencing this alleged prior trauma. Charlie refused to see the psychologistfor a third session.


Case Formulation

Mr. W.’s suicide was a cataclysmic loss for Charlie, prompting Charlie to slide into amajor depression. Although Charlie’s adjustment had declined significantly the past year,his prior high level of functioning at home and at school indicated that he had manystrengths, which could be utilized through psychotherapy designed to assist him with thegrieving process. However, clinical records and Mrs. W.’s reports indicated that two priortherapists had tended to ignore these strengths, probably because both had viewed Char-lie’s personality from a deficit perspective. Although he had good relationships withfamily members and peers, including a strong bond with his father, with whom he hadshared many interests, the psychotherapist erroneously concluded that Charlie lacked thecapacity for deep emotional connection because Charlie had difficulty taking about hisfather’s horrific, violent death. And although Charlie needed help with the immediatetragedy of losing his father, the psychologist had focused on an alleged prior trauma.Both therapists expected Charlie to adopt their ways of relating, rather than trying tomatch their methods to his relational style. Therefore, Charlie desperately needed assis-tance from a caring adult who would help him to mourn his father’s death through theapplication of a male-friendly approach that capitalized on Charlie’s many strengths.

Course of Treatment

Charlie had all but given up on mental health professionals because of his experienceswith the first two practitioners. Nevertheless, he agreed to meet a new therapist after afriend of his had reported liking this therapist. Charlie’s new therapist immediatelyemployed a warm, open, and psychoeducational approach with Charlie. The therapistintroduced himself to Charlie and showed Charlie photos of his family members thatwere placed around his office, including a photo of the therapist’s father. The therapistthen assured Charlie that he realized Charlie had been through a major ordeal, expressedhis sympathy regarding Mr. W.’s death, and assured Charlie that he would not have to talkabout difficult things until he was ready to do so, even though the therapist might askCharlie from time to time how he was doing with regard to his father’s passing.

The therapist also explained to Charlie that he was “not the type of shrink who willmess with your head or think funny things about you.” Instead, the therapist assuredCharlie that he would let Charlie know exactly what he was thinking as he was thinkingit so that Charlie would be certain that there were no secrets or games on the therapist’spart. During this explanation, Charlie listened attentively and responded with body lan-guage communicating that he appreciated the therapist’s straightforward style.

The therapist then asked Charlie if he liked football, which he did, so the therapistasked him if he would like to go outside and toss a football around for a while. Charlieaccepted the invitation, and the two went into the office complex parking lot, where theytook turns throwing the football back and forth to each other for about 20 minutes whilethe therapist asked Charlie a few questions about his interests and about where he livedand went to school. As a result of this exchange, the therapist discovered that Charlie wasa Philadelphia Eagles fan, that he had played football in junior high school but no longerdid, that he had liked classic rock music before switching to rap music, and that he hadonce enjoyed fishing and working with wood but had not done either in a long time. Thetherapist also learned that Charlie had quit football, turned to rap music, and stoppedfishing and woodworking because of his father’s death. Thus, although much of theconversation had been focused on other subjects, talking while actively playing helped


Charlie to introduce the subject of loss and its impact on him, even though he did not talkextensively about these issues.

When the two went back inside, the therapist thanked Charlie for talking with himand asked him whether he would be willing to return for another “visit,” purposely usingthis word instead of the word “session.” When Charlie agreed to come for a second visit,the therapist scheduled the appointment with Charlie and asked him to make arrange-ments with his mother about getting a ride back to the office. The therapist also askedCharlie for his permission to contact Charlie’s mom to let her know how things had gonebetween them, explaining that it was understandable that a caring, worried mother wouldwant a progress report. Charlie granted his approval for the phone call.

Recognizing that the death of a parent, a history of suicide by a family member, andmajor depression are all predictors of suicide, the therapist made sure to broach thesubject of suicide briefly but supportively and assertively with Charlie prior to his leav-ing. The therapist explained to Charlie that it was perfectly understandable that he mightbe depressed over his father’s death and that people sometimes have thoughts of hurtingthemselves when they feel down. He gently asked Charlie whether he had any thoughts orhad made plans to harm himself. Charlie responded by admitting that he had had momentswhen he wished he were dead, but he denied having any serious suicide intentions orhaving made any suicide attempts, explaining that he “could not do that” to his motherand siblings. The therapist thanked Charlie for sharing this information and assured Char-lie that it was safe to talk about suicide with him and to call him if Charlie ever feltoverwhelmed by his feelings. Finally, the therapist gave Charlie a copy of his businesscard and asked Charlie if he wouldn’t mind keeping it in a safe place, just in case he everwanted to give the therapist a call. Charlie immediately said, “Cool,” took the card fromthe therapist, reached into his back pocket, pulled out his wallet, and placed the cardinside of it. The two shook hands, and Charlie went outside where he was met by hismother, who drove him home.

Between the first and second sessions, the therapist called Mrs. W., summarized thesession, and listened to her concerns about her son’s behavior. The therapist empathizedwith Mrs. W.’s worries, urged her to call him at any time, and explained to her that hethought it would be beneficial to hold future sessions with Charlie over a meal at a localpizzeria or in a park next to a lake. She agreed with this suggestion, convinced that herson would respond well to this informal approach. The therapist then introduced thenotion of having family sessions with Charlie at some point in the future, but only afterthe therapist had built up a strong rapport with Charlie and had received Charlie’s consentto move in that direction. Mrs. W. concurred, stating that she felt hopeful after noting thatCharlie had seemed somewhat less angry after his first session, commenting that Charliehad offered to help her with the dinner dishes for the first time in months.

Charlie returned for the next visit and for 12 more sessions over the course of approx-imately a year. Although some of these visits were held in the therapist’s office andincluded some periods of the two playing with the football, most were held in othersettings. One session was held in a pizzeria, and two others were held in a park, the firston a picnic bench under a comfortable shaded area, and then along the shore of a lake,where the therapist and Charlie fished and talked together. The two also made a specialtrip to visit a local woodworker, whom the therapist had recruited to talk with Charlieabout his interest in the craft. In addition, Charlie agreed to visit his father’s gravesitewith the therapist.

Each session began with the therapist engaging Charlie with conversations about theEagles (and later other Philadelphia sports teams) or music while the two engaged insome sort of physical activity (e.g., playing catch, eating, walking, fishing, driving in the


car). During these conversations, Charlie would talk about his week, bringing up what-ever was important to him. Gradually, he volunteered more information about what hisfather had meant to him, including his fondness for his father, his resentment about hisfather’s mental illness and death, and how much he missed his dad. He quickly acceptedthe therapist’s probes about how he was doing and readily switched to filling the therapistin on his emotional state in response to these probes. The two settled into a nice flow,sensing cues from each other about when it was time to talk about serious matters andwhen it was right to talk about less emotionally charged topics.

Across these settings and sessions, the therapist recruited peer groups, adult menfrom the community, and family members to help Charlie. For example, the therapistrevealed that his father was a talented woodworker, too, which led Charlie to reminisceabout his father and the many times they had worked together in the evenings and onweekends, with Charlie assisting Mr. W. with his special projects. Charlie missed thesetimes dearly and often became teary-eyed as he recalled them, stating that working withwood seemed to have been therapeutic for his father.

These exchanges of self-disclosure were often punctuated by expressions of humor,with both the therapist and Charlie joking about each other’s father’s idiosyncratic workhabits. Sometimes, Charlie expressed dark forms of humor that became the grist forvaluable analysis. For example, during several sessions, Charlie cracked, “It’s no wondermy dad killed himself—if I had to live with his standards of perfection, I would havekilled myself too.” In response to this comment and others like it, the therapist wouldmake a fond joke about his own father and enjoy a laugh with Charlie, but he wouldfollow it up with an exploration of what it had been like for Charlie to live and work witha man who had, on the one hand, high perfectionistic standards and, on the other hand,such difficulty coping with life. Discussing these issues served as segues for psychoedu-cation on depression, suicide, and perfectionism with Charlie. The therapist gave Charliesome lay readings on these subjects, thereby capitalizing on Charlie’s intellectual strengths,and discussed his reactions to the readings, particularly as they related to Charlie’s feel-ings about his father.

On three occasions, Charlie participated in family sessions through which the familymourned their father’s death together. The family meetings allowed the therapist to pro-mote a renewed bonding between Charlie and his brothers, who decided to build a treehouse in their backyard as a memorial to their father.

Family sessions were supplemented by the referral of Charlie to a local minister whoran a community-based mentoring program for African American boys. His participationin this group program gave Charlie the support of a peer group, which helped him easeout of his social isolation and rekindled his interest in football, through which he found ahelpful outlet for the anger associated with his father’s death. Last, the therapist hookedCharlie up with Mr. C., an acquaintance in the community who was a kind, elderly manwho loved to tinker with wood in his toolshed. The old man and Charlie hit it off, andCharlie began to hang out with the gentleman on a regular basis.

The session held at Mr. W.’s gravesite warrants a separate discussion because it wasparticularly powerful and therapeutic. Prior to the session, the therapist had encouragedCharlie to write a note to his father, expressing all of the things he might like to say to hisdad were his father still alive. The therapist also suggested that Charlie bring somethingto leave at his father’s resting place. Charlie followed through with this assignment andbrought the letter and a memento with him to the gravesite. As the therapist drove Charlieto the cemetery, he told Charlie that he appreciated having the privilege of joining Char-lie, admired Charlie’s courage, and would leave with Charlie if the task they were aboutto do became too difficult. But Charlie forged ahead and sat down on his father’s grave,


facing his father’s tombstone as soon as they arrived at the gravesite. The therapist sat onthe grass next to Charlie and encouraged Charlie to express what was on his mind. Atfirst, Charlie responded by talking about his dad, stating that he still found it hard tobelieve that he was gone. Then, he began to choke back tears, as he expressed how muchhe missed his father and how angry he was that his father was no longer there for him.Throughout this entire time, he never pulled out his letter, explaining that he felt betterjust saying things as they came to him. But he did place a small woodcarving of a bear onthe grave, stating that his father had been a big, bearlike man, so he thought his dad wouldenjoy having this memento. When the therapist sensed that Charlie had said all that hehad needed to say, he expressed his admiration to Charlie for his love of his father andthen said a few words out loud, as though he was talking directly to Mr. W. and reportingto him that Charlie was a fine young man about whom he would be proud. He then saidgood-bye and asked Charlie if he was ready to leave. Afterward, the two went down to thelake where they had once fished together, and took turns feeding bread to the fish andducks, sharing in the process of nurturing other living creatures.

Outcome and Prognosis

By the end of the year, Charlie’s mother reported that Charlie had improved dramatically,stating that he was much less confused and angry than he had been the year before. By theend of his last marking period, his grades had improved and he was no longer causingproblems at school. He still visited Mr. C. from time to time and had obtained a jobworking as a carpenter’s assistant with a contractor on weekends and during the summer.He remained a participant in the community-based program for youth, and he had triedout for and made the junior varsity football team at his school. He still had some bad daysdealing with his father’s death, especially near the anniversary of his father’s suicide andduring the Christmas season, but he had learned to use his family members, his peers, histherapist, Mr. C., and activities to help him cope with the lingering sad feelings associatedwith the loss of his father. He and his brothers completed their construction of the treehouse, and he placed two framed photos of his father in it. He reported that he consideredthe tree house to be a source of comfort to him, especially when he looked at his father’sphotos and tried to recall the good times they had shared. During the second year follow-ing his father’s death, Charlie had appointments with his therapist about every two tothree months and used the therapy effectively to discuss the ongoing developments inhis life.

Clinical Issues and Summary

Charlie’s positive response to a male-friendly psychotherapy illustrates how psychother-apists can adjust the process of helping in order to utilize the relational style of a youngman. What is instructive about this case is that the therapist recognized Charlie’s strengthsand focused on meeting him where he was, rather than viewing Charlie as flawed andtrying to fit Charlie into an unrealistic model for how boys should be. Charlie’s responseand the findings from prior empirical research verify that boys respond well to clinicianswho adopt such a male-friendly posture.

Although the therapist assisting Charlie went beyond the traditional boundaries ofthe client–therapist relationship by driving Charlie in his car to a pizza parlor, a cemetery,a park, and an acquaintance’s toolshed, the therapist was careful to maintain a healthy,nonexploitive relationship with the client and to obtain the permission of both Charlie


and Charlie’s mother to go this route. An important guideline in doing nontraditionaloutreach with clients is to be certain that such activities remain professional and fo-cused on the client’s needs. Moreover, practitioners should refrain from straying fromtraditional boundaries with young men who show symptoms of personality disorders,such as antisocial personality and borderline personalities, because respecting bound-aries between themselves and others is a major difficulty for them. In other words, withcertain clinical populations, more, rather than less, adherence to traditional conventionsmay be called for.

Although sporting activities were effective rapport-building tactics with Charlie,different activities might be a better fit for other boys. For example, some boys haveadjustment difficulties because they are not very coordinated and cannot play sports well.Some of these boys may have a strong dislike of “jocks” and sports. The challenge for thetherapist is to remain flexible and to identify activities that work for each unique client.With some boys, shooting baskets and talking about sports work fine. With other boys,playing checkers or chess or a video game may be the key to success. And with others,artwork and music may hit the mark, whereas engaging in intellectual discussions mightbe fruitful with some other boys. The overarching point is that the therapist must discoverhow a particular boy relates to the world and adjust the process of counseling and therapyaccordingly. By doing so, practitioners are likely to help more troubled boys to feel andto invest themselves in the difficult work of confronting and mastering their difficulties.

Select References/Recommended Readings

Achatz, M., & MacAllum, C.A. (1994). Young unwed fathers: Report from the field. Philadelphia:Public/Private Ventures.

Biddulph, S. (1998). Raising boys: Why boys are different and how to help them become happy andwell balanced men. Berkeley, CA: Celestial Arts.

Brindis, C., Barth, R.P., & Loomis, A.B. (1987). Continuous counseling: Case management withteenage parents. Social Casework, 68, 164–172.

Brown, S. (1990). If the shoes fit: Final report and program implementation guide of the MaineYoung Fathers Project. Portland: Human Services Development Institute, University of South-ern Maine.

Carrera, M.A. (1992). Involving adolescent males in pregnancy and STD prevention programs.Adolescent Medicine, 3, 1–13.

Gurian, M. (1997). The wonder of boys: What parents, mentors, and educators can do to shape boysinto exceptional men. New York: Jeremy P. Tarcher/Putnam.

Heesacker, M., Wester, S.R., Vogel, D.L., Wentzel, J.T., Mejia-Millan, C.M., & Goodholm, C.R.(1999). Gender-based emotional stereotyping. Journal of Counseling Psychology, 46, 483–495.

Hendricks, L.E. (1988). Outreach with teenage fathers: A preliminary report on three ethnic groups.Adolescence, 23, 711–720.

Kiselica, M.S. (1988). Helping an aggressive adolescent through “The Before, During, and AfterProgram.” The School Counselor, 4, 299–306.

Kiselica, M.S. (1995). Multicultural counseling with teenage fathers: A practical guide. ThousandOaks, CA: Sage.

Kiselica, M.S. (1996). Parenting skills training with teenage fathers. In M.P. Andronico (Ed.), Menin groups: Insights, interventions and psychoeducational work (pp. 283–300). Washington,DC: American Psychological Association.

Kiselica, M.S. (1999). Counseling teen fathers. In A. Horne & M.S. Kiselica (Eds.), Handbook ofcounseling boys and adolescent males (pp. 179–197). Thousand Oaks, CA: Sage.


Kiselica, M.S. (2001). A male-friendly therapeutic process with school-age boys. In G.R. Brooks &G.E. Good (Eds.), The new handbook of psychotherapy and counseling with men (Vol. 1,pp. 41–58). San Francisco: Jossey-Bass.

Kiselica, M.S. (2003). Parenting with the experts series: Parenting boys [video]. Boston: Allyn &Bacon.

Kiselica, M.S., & O’Brien, S. (2001, August). Are attachment disorders and alexithymia charac-teristic of males? In M.S. Kiselica (Chair), Are males really emotional mummies: What do thedata indicate? Symposium conducted at the 109th Annual Convention of the American Psy-chological Association, San Francisco, CA.

Kiselica, M.S., Rotzien, A., & Doms, J. (1994). Preparing teenage fathers for parenthood: A grouppsychoeducational approach. Journal for Specialists in Group Work, 19, 83–94.

Kiselica, M.S., & Sturmer, P. (1993). Is society giving teenage fathers a mixed message? Youth andSociety, 24, 487–501.

Lazarus, A.A. (1990). Can psychotherapists transcend the shackles of their training and supersti-tions? Journal of Clinical Psychology, 46, 351–358.

Levant, R.F., Majors, R.G., Inclan, J.E., Rossello, J.M., Heesacker, M., Rowan, G.T., & Sellers, A.(2000, August). A multicultural investigation of masculinity ideology and alexithymia. Paperpresented at the 108th Annual Convention of the American Psychological Association, Wash-ington, DC.

Sander, J.H., & Rosen, J.L. (1987). Teenage fathers: Working with the neglected partner in adoles-cent childbearing. Family Planning Perspectives, 19, 107–110.


transforming psychotherapy in order to succeed with adolescent boys: male-friendly practices

Documents