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End of Men: The "Feminization" of Psychotherapy

Are we witnessing the extinction of male psychotherapists?

This post is in response to
Is It Really the "End of Men?"

A New York Times article by Benedict Carey (May 21, 2011) titled "Need Therapy? A Good Man Is Hard to Find," highlights the fact that men have been abandoning the psychotherapy field in droves for decades. So much so that the profession has now become almost totally dominated by female practitioners. According to Carey, less than 20% of Master's degrees in psychology, clinical social work or counseling are being sought by men today. Women outnumber men in doctoral psychology programs by a ratio of at least 3 to 1. (See an article published by the American Psychological Association on this remarkable development.) But this has not always been so. Certainly not when I was a graduate student back in the mid-1970s. What's happening to the psychotherapy profession? Why have men gradually deserted the field? And does gender really matter in psychotherapists?

I personally witnessed this insidious shift to a predominantly female demographic during my twenty years of teaching psychotherapy to graduate students. The reasons for men fleeing the field of psychotherapy are many. First, and foremost, is financial. In recent decades it has become  increasingly difficult to earn a decent living as a psychotherapist of any discipline, be it psychiatry, clinical psychology, clinical social work, marriage and family therapy, or counseling. For men, who traditionally have a family to support or must support themselves, the mental health profession, especially private practice, no longer provides a viable source of steady income. Many male psychotherapists dropped out of the profession, finding work in other better paying venues. While this economic crunch equally affected female practitioners too, those women who were not the sole breadwinner for the family or were financially supported by their partners and therefore didn't need to earn as much money were better positioned to enter or remain in the field. But it is not just about money.

Since so many men in our society place such a high value on status and power, and since status and power are closely associated with money, some men choose to pursue status and power in more monetarily rewarding professions than psychotherapy. Psychotherapy was once a fairly lucrative vocation. But not so much now. Moreover, the mental health professions--especially clinical psychology--have significantly lost status and prestige overall. Whereas, at one time, clinical psychologists were seen as distinguished clinical specialists and uniquely qualified providers of treatment, today we are generically lumped together by insurance companies and consumers as merely one of a multitude of non-physician mental health providers who, unlike psychiatrists, cannot prescribe psychotropic medication to patients. (In a few states, clinical psychologists can, with additional post-doctoral training, prescribe such medications, but this is the exception rather than the rule. See my prior post.) Psychiatrists, in contrast to clinical psychologists, are still mostly males, but this too is slowly shifting. One reason that not as many male psychiatrists have fled their profession is that most, perhaps up to ninety percent, exercised their option as physicians to focus on psychopharmacology exclusively, a far more lucrative specialty than psychotherapy could ever be. Hence, their status and power--and income--was preserved. But most clinical psychologists and other non-medical clinicians don't have that dubious and, in some cases, cynical option.

But this alarming phenomenon goes deeper than any one of these single factors, far deeper than former American Psychological Association president Dr. Dorothy Cantor's simplistic assessment cited in Carey's piece: "Usually women get blamed when a profession loses status, but in this case the trend started first, and men just evacuated. . . . Women moved up into the field and took their place." While this is true, it must also be admitted that during that same period there was a pervasive devaluation of the archetypal "masculine" by women, both within and without the mental health profession. Much of this devaluation was a compensatory reaction against the prior denigration of the "feminine" in psychology and psychiatry, starting with Sigmund Freud. (Freud's famous male pupils, Rank and Jung, both tried to counteract this patriarchal prejudice in psychoanalysis by rehabilitating the "feminine" in their own approaches, as did pioneering psychoanalyst Karen Horney.) One manifestation of this devaluation and rejection of the masculine by women can be seen in the relatively recent trend toward females seeking treatment only from female therapists, a gender preference that presumably negatively affected the caseloads--and already plummeting incomes--of male practitioners, since women statistically comprise a greater portion of psychotherapy consumers. (See Chapter Two, "Sex Wars," in my book Anger, Madness, and the Daimonic. and also this excellent article, "Gender Issues in Psychotherapy.")

Does the sex of your psychotherapist really matter? As Carey's timely article notes, there is nothing in the rather limited mainstream scientific literature on gender and treatment outcome suggesting unequivocally that either males or females make better, more effective psychotherapists. (Having said that, the Helsinki Psychotherapy Study [2004] suggests some significant relationship between professional efficacy and personal qualities such as introversion and extraversion, self-confidence, and active vs. passive approaches to treatment.) So individual differences in personality style, some of which are inevitably linked to gender, do impact treatment. A male psychotherapist may be more effective for some patients than others; just as a female may have more success with certain cases than others. Part of this difference does have to do with gender and often unconscious gender psychology. Some male psychotherapists, for example, are fearful or out of touch with their "masculine" aggression, while others are estranged from their "feminine" side and feelings. Some female therapists either overidentify with the "masculine,"or devalue and dissociate it in their own personalities. This can all come into play during treatment, and commonly does so unconsciously in the form of what we call "countertransference" and other blindspots and biases on the psychotherapist's part. (For more on defining the archetypal "masculine" and "feminine" from a Jungian perspective, see my prior post. )

For instance, when women stepped into the void left by men in the field of clinical psychology and other mental health professions, many adopted men's "masculine" perspective and rational orientation to treatment. Cognitive-Behavioral Therapy (CBT) is a good example of such a highly "masculinized" approach today, one which imputes primacy to rationality and thinking over affect, the unconscious, and the so-called "irrational" (i.e., "feminine" or emotional) aspects of experience. The choice of this one-sidedly logical, mechanistic orientation to treatment represents an overvaluation of the "masculine" and devaluation of the "feminine" in psychotherapy itself. Paradoxically, given the vast popularity of CBT with today's female and few remaining male psychotherapists as opposed to more analytical, humanistic or existential approaches, it is clear that, unfortunately, the "feminization" of the psychotherapy field in terms of gender does not necessarily translate into a more truly "feminine" (i.e., compassionate, caring, affective and relational) orientation to psychotherapy. And, when it does, it tends to be a lopsidedly "feminine," nurturing, soft, passive, supportive approach to treatment in which firm limits, boundaries, diagnosis, structure and confrontation are sorely lacking. Balance between "masculine" and "feminine," between a focus on both feeling and thinking, intellect and experience, rational and irrational, is essential in psychotherapy, whatever the clinician's gender.

One key issue Carey's article touches on has to do with both male aggression and sexuality. Can a female therapist relate adequately to that which is archetypally and instinctually masculine? To the innate, primitive, often intimidating aggression, anger or rage of men? To the unique nature and primal power of male sexuality? Much of that depends, in my estimation, on how conscious and related she is to what Jung called her animus or inner masculinity. And on her own personal experiences with men. For male psychotherapists treating female patients, the same may be said regarding the awareness of and attitude toward their anima or inner femininity. Much like their patients, psychotherapists can suffer unconsciously from either "fear of the feminine" or "fear of the masculine." And unless they have faced that fear in themselves, and its psychological significance, it can be difficult to help others to deal with it.

Still, some men simply don't feel comfortable talking with a female therapist about these intimate matters. Just as some women feel uneasy with male therapists. Now the reasons for this discomfort, for either gender, can be--and, in my experience, often are--neurotic forms of negative transference, resistance or deep-seated distrust and dread of the opposite sex. Or, sometimes, of the same sex. Or one's own sexuality. In many such cases, it may be advisable for the male patient to, despite his reticence, courageously consult a female therapist and work through his anxiety with her as part of the treatment process. Or vice-versa for the fearful female patient. Or for the person who insists on only seeing an opposite sex psychotherapist to work with someone of the same sex. To choose to challenge the conscious or unconscious avoidance. But the fact remains that men and women clinicians have very divergent perspectives, psychologies and life experiences, and each bring something different to the therapeutic table. Not better or worse, superior or inferior. Just different, but equally valuable. This is why it is wisely recommended, and in some analytic training programs required, that therapy trainees undergo two courses of treatment--one with each sex.

Essentially, the best psychotherapy is not merely about eliminating some specific symptom, but confronting one's demons, facing one's fears, discovering one's true self, finding and fulfilling one's destiny. In this sense, psychotherapy is a type of spiritual mentoring and initiation into powerful secret wisdom for dealing with life's most perplexing problems. (See my prior posts.)  In the Arthurian legend of the Holy Grail, Perceval is mentored into knighthood by a wise hermit named Gurnemonz, who served as the model for the wizened and diminutive Yoda in Star Wars. Perceval, whose name means "innocent fool," is a young man destined to find the Holy Grail. But before he can fulfill his personal destiny, he must intensively prepare psychologically, physically and spiritually, a difficult, arduous, painstaking process requiring many years.

Luke Skywalker's secret initiation into Jedi knighthood by both Obi-Wan Kenobe and Master Yoda closely parallels both the psychotherapy process itself and psychological and spiritual development in general. There are similar archetypal examples of initiation of women into the feminine mysteries solely by females. In different cultures around the globe for millennia young men have been initiated into adulthood and the essential secrets of masculinity by men, just as young women have been initiated by women. The time-honored wisdom of such structured, socially sanctioned, transformative rituals suggests that it is crucial to acknowledge and honor the profound differences--both biologically and psychologically-- between men and women, and that there are certain initiatory tasks best conducted by specially prepared members of the same sex. Such painful yet healing  initations or rites of passage are not limited to children approaching puberty or adolescents entering adulthood, but occur also during later stages of psychological development like marriage, child-birth, parenthood, mid-life crisis and old age. ( See, for instance, my prior post "Staring at Sixty.")

Such existential crises and painful rites of passage can differ significantly for males and females. Becoming a mature man is not exactly the same task as becoming a mature woman, and sometimes demands a very different set of skills and values. But, given the current "feminization" of psychotherapy, with the number of female therapists and therapists-in-training far outnumbering males, where will men, already reluctant to seek psychological treatment, go for such much-needed assistance? And, if women dominate the field of psychotherapy completely, what will become of the sacred clinical secrets of masculinity? Who will be the cultural containers and teachers of this sacred masculine wisdom passed down traditionally from one generation of male psychotherapists to the next?  Because of our complementary polar differences, women will always need male psychotherapists, and men female psychotherapists. There are certain wounds inflicted by women on men that only women can help heal, as there are those inflicted on women by men that require a "corrective emotional experience" with a male.

Despite of, or really, because of our profound psychobiological gender differences, we still have a great deal to learn from each other. Female psychotherapists, as women, can provide precious therapeutic perspectives to male patients, and vice-versa. But men will always need mentoring and initiation into manhood mainly by men, and women by women. Now that there is a critical shortage of men remaining in or entering the psychotherapy field, coupled with the scarcity of psychodynamic practitioners in general (see my prior post), consumers have increasingly fewer choices--not only regarding the particular type of mental health treatment they receive, but what gender will provide it. Thie feminization of psychotherapy may be good for women. But can this gender imbalance be good for the profession? I wonder. Women make wonderful psychotherapists. But so do men.

My hope is that, as with the recent signs of renascence of psychodynamic psychotherapy (see, for instance, my forthcoming review of 2012's Psychodynamic Psychotherapy Research for PsycCRITIQUES) now in motion, eventually the gender pendulum will slowly swing back toward middle ground, with men once more being drawn to becoming psychotherapists alongside women. The practice of psychotherapy itself is dying. (See my prior post.) If the profession is to survive, we definitely need men's masculine energy and perspective in clinical psychology to complement that of female practitioners. And vice-versa. But how can we make the psychotherapy profession today more attractive, especially to men? Is it all about money? Prestige? Status? Power? Have men lost touch with their nurturing, giving, caring, compassionate side?  Have we brutishly become more materialistic and selfish than women? Too technical, mechanistic or mercenary? Have men lost their faith in psychotherapy? Or have men in the field of psychotherapy simply surrendered to women in the proverbial war of the sexes? Resolutely accepted defeat and withdrawn from the field of battle?

Is this really the "end of men" in general? Is what we are seeing in the mental health professions merely a symptom or sign of a much more pervasive trend in American culture? (See PT blogger Mark Sherman's review of a recent book by Hanna Rosin titled The End of Men here. See also a response by another PT blogger, Melissa Kirk here.) Reader comments, as always, are welcome on this particularly exquisitely sensitive subject.