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How do men deal with traumatic brain injury?

by Dr Ruth MacQueen & Dr Paul Fisher

Picture: famous brain injury patient, Phineas Gage.

contact: ruth.macqueen@nhs.net

 

Men are twice as likely to experience a traumatic brain injury (TBI) as women.  This suggests that aspects of masculinity, such as choosing risky jobs and sports, play an important role in how people acquire their brain injury. Research also suggests that masculine identity has an impact on how people manage the experience of illness.  Adjustment to traumatic brain injury can involve changes in cognitive, behavioural, emotional and physical functioning. Given the potential disruptive consequences of TBI, the day-to-day lived experience of being in the world can be, and often is, altered for the individual.

Our chapter in the Palgrave Handbook of Male Psychology and Mental Health summarises research which explores masculine identity in relation to how men experience these adjustments.  Individuals who have had a TBI can experience a changed sense of personal identity (Levack, Kayes, & Fadyl, 2010) and changes to the self tend to be viewed negatively in comparison to the pre-injury self (Carrol & Coetzer, 2011).  Identity as a man can be threatened by the changes in interactions and activity which can lead to a loss of traditional male roles such as being a provider, being strong, protecting others, having physical strength, and self-reliance (Addis & Mahalik, 2003;  Connell, 2005).  Roles which men have, for example within their occupation and relationships can therefore be lost or changed and men may face challenges in coping with this loss and adapting to the changing roles.  Masculine identity is therefore an important consideration for neuropsychological therapy and rehabilitation particularly because part of the process of rehabilitation concerns helping individuals with their sense of self.

Some evidence suggests that adherence to masculine ideals can be negatively associated with rehabilitation outcomes in TBI (Meyers, 2012).  Barriers to engaging in rehabilitation services may include that working with professionals is viewed as requiring help and therefore suggests that the individual lacks strength or self-sufficiency to be able to cope (MacQueen, Fisher and Williams 2018). Viewing the self as being reliant on others can lead to experiences of shame and the perception of the self as weak.  This can mean that developing therapeutic relationships may conflict with ideals of independence (Good et al., 2006; Sullivan, 2011).

However, aspects of masculine identity may also promote wellbeing in the context of adjustment to TBI for men. For example, there is evidence which suggests that adherence to dominant masculine ideals such as higher success, power and competition are associated with the perception of fewer barriers to community functioning (Good et al., 2006).  Similarly, Schopp et al. (2006) found that there was a positive effect on functional outcomes for men who adhered to ideals such as winning and seeking status and the authors suggest that therefore drawing on these values can promote positive outcomes after TBI.

It is important that gender identities are considered as part of rehabilitation and providing a gender-sensitive service can begin during initial discussions when men are referred to a service and should be considered throughout rehabilitation. In addition, given the higher prevalence of mental health problems in the TBI population (Seel et al., 2003) it seems particularly important to work with individuals in reducing the stigma of mental health problems after brain injury.   Within the context of masculine identity, the application of positive psychology constructs may be particularly beneficial.  Positive psychology has been applied within acquired brain injury (ABI) rehabilitation and these initial studies indicate that the application of positive psychotherapy may promote wellbeing following ABI (Andrewes, Walker, & O’Neill, 2014; Cullen et al., 2016).   The concepts of growth, strength and resilience within positive psychotherapy may particularly encourage flexibility in identity which may facilitate adjustment for men.

The implications arising from the research in relation to issues around engagement and outcomes in neuropsychological therapy and rehabilitation are further considered within my chapter in the Palgrave Handbook of Male Psychology and Mental Health.

Dr. Ruth MacQueen completed the Doctorate in Clinical Psychology at the University of East Anglia in 2016. Her doctoral thesis employed a

qualitative methodology to research men’s experiences of masculine identity following traumatic brain injury. She has presented her research as a poster

publication at the Neurological Rehabilitation Specialist Interest Group of the World Federation for Rehabilitation conference and published in

Neuropsychological Rehabilitation. Since qualifying, Ruth has continued to work within neurorehabilitation in Bath, UK.

 

Dr. Paul Fisher is a Clinical Psychologist and Senior Clinical Lecturer with significant experience working clinically with people with neurological

impairments across a range of settings and as an academic and researcher. Paul has worked in the UK and Singapore. He has a long-standing interest

in issues of identity and identity change and adjustment which he uses within his clinical work and has been a focus for his research using qualitative

research methods. Paul currently works at the University of East Anglia in the Department of Clinical Psychology and in Norfolk and Suffolk NHS

Foundation Trust.

 

References

Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. The American Psychologist, 58(1), 5–14. doi:10.1037/0003-066X.58.1.5

Andrewes, H. E., Walker, V., & O’Neill, B. (2014). Exploring the use of positive psychology interventions in brain injury survivors with challenging behaviour. Brain Injury28(7), 965-971.

Carroll, E., & Coetzer, R. (2011). Identity, grief and self-awareness after traumatic brain injury. Neuropsychological Rehabilitation, 21(3), 289-305. doi: 10.1080/09602011.2011.555972

Connell, R. W. (2005). Hegemonic Masculinity: Rethinking the Concept. Gender & Society, 19(6), 829–859. doi:10.1177/0891243205278639

Cullen, B., Pownall, J., Cummings, J., Baylan, S., Broomfield, N., Haig, C., … & Evans, J. J. (2016). Positive PsychoTherapy in ABI Rehab (PoPsTAR): A pilot randomised controlled trial. Neuropsychological Rehabilitation, 1-17.  doi:10.1080/09602011.2015.1131722

Good, G. E., Schopp, L. H., Thomson, D., Hathaway, S., Sanford-Martens, T., Mazurek, M. O., & Mintz, L. B. (2006). Masculine roles and rehabilitation outcomes among men recovering from serious injuries. Psychology of Men & Masculinity, 7(3), 165.

Levack, W. M., Kayes, N. M., & Fadyl, J. K. (2010). Experience of recovery and outcome following traumatic brain injury: a metasynthesis of qualitative research. Disability and Rehabilitation 32(12), 986–999. doi:10.3109/09638281003775394

MacQueen, R., Fisher P., & Williams, D., (2018) A qualitative investigation of masculine identity after traumatic brain injury. Neuropsychological Rehabilitation doi: 10.1080/09602011.2018.1466714

Meyers, N. M. (2012). The effect of traditional masculine gender role adherence on community reintegration following traumatic brain injury in military veterans. (Doctoral Thesis) American University, Washington, D.C

Schopp, H., Good, E., Barker, B., Mazurek, O., & Hathaway, L. (2006). Masculine role adherence and outcomes among men with traumatic brain injury. Brain Injury, 20(11), 1155.

Seel, R. T., Kreutzer, J. S., Rosenthal, M., Hammond, F. M., Corrigan, J. D., & Black, K. (2003). Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation. Archives of Physical Medicine and Rehabilitation, 84(2), 177-184.

Sullivan, C., Gray, M., Williams, G., Green, D., & Hession, C. (2014). The use of real life activities in rehabilitation: The experience of young men with traumatic brain injuries from regional, rural and remote areas in Australia. Journal of Rehabilitation Medicine, 46(5), 424–429. https://doi.org/10.2340/16501977-1788

 

 

 

 

Open post

Is there an alternative to the new APA guidelines for working with men and boys?

by Dr John Barry

The APA’s Division 51 (Men and Masculinities) recently released their guidelines for working with men and boys. While guidelines on this topic are much needed, the APA’s contribution leaves room for improvement. In this article I will outline issues with two of their 10 guidelines:

Guideline 1 of the APA guidelines suggests that “masculinities are constructed based on social, cultural and contextual norms”. However although it is true that masculinity is, in part, constructed, it is also partly innate.

What is the evidence that masculinity is, in part, innate? Well, sex differences in cognition and behaviour  are found worldwide, and their universality suggests something that transcends culture. Moreover, most of these clearly map onto masculinity. For example, the tendency to being more competitive, aggressive (physically), and interested in sports than women maps onto the male gender script of being a fighter and winner. The tendency to working longer hours, working in male-typical occupations, exploring the environment, more willing to take risks, maps onto the male gender script of being provider and protector.The tendency to show less fear, less crying, more inclined to substance abuse (self-medication) maps onto the male gender script of having mastery & control of one’s emotions.

The crucial point for therapy is that because some aspects of masculinity are innate, changing them is not a simple case of cognitive restructuring or behaviour change, any more than changing other deeply-held aspects of gender identity or sexual identity is straightforward or even desirable.

However we live in a culture steeped in the ‘gender similarities hypothesis’, telling us that there are ‘more similarities than differences’ between men and women. Of course this idea is not wholly untrue, but it typically deflects our attention away from the fact that it is the differences between men and women that ‘make all the difference’. Thus in many ways we are not encouraged to notice sex differences, and we might even experience cognitive dissonance if we are asked to focus on sex differences and consider the implications for, to take one example, treatment approaches in psychology.

Guideline 3 states that “in the aggregate, males experience a greater degree of social and economic power than girls and women in a patriarchal society”. This statement is an example of what we have identified as gamma bias in psychology, a type of cognitive distortion in which examples of male privilege are magnified and female privilege is ignored or explained away. Examples of male disadvantage are boys’ educational achievement and the high rates of male suicide. Examples of female advantage lighter prison sentences and gender quotas in science jobs. In fact recent evidence has found that men are disadvantaged in many countries worldwide, especially those with medium to high levels of development.

Therapists who believe that guideline 3 is true of their male clients might understandably struggle to find much empathy for them, and a male client might struggle to believe they will find much empathy from such therapists too.

As an alternative to guidelines 1 and 3, I would suggest that we recognise that masculinity is to some degree innate and potentially positive for mental health, and the vulnerabilities of male clients are more important to us, as therapists, than any hypothesised patriarchal power. We shouldn’t presume that the bad behaviour of the minority of men are representative of some underlying aspect of men in general, and we should recognise that negative views of men are a barrier to an appropriate level of therapeutic empathy.

I would encourage Division 51 to revise their guidelines to bring them in line with research evidence and common sense. I would also urge authors of any other guidelines relating to male mental health to make similar revisions. After all, men seek therapy less than women do even when suicidal, so we need to do what we can to make therapy more male-friendly.

Is there an alternative to the new APA guidelines for working with men and boys? Well the forthcoming Palgrave Handbook of Male Psychology and Mental Health offers practical advice to therapists and a more positive theoretical perspective on men’s mental health and male psychology in general. Guidelines based on this handbook will be issued soon, and I hope the 32 chapters offer therapists and academics a realistic and useful way of understanding and working with men.

 

About the author

Dr John Barry is a Chartered Psychologist and co-founder of the Male Psychology Network and Male Psychology Section of the British Psychological Society. He is one of the editors of, and contributors to, The Palgrave Handbook of Male Psychology and Mental Health

 

The Palgrave Handbook of Male Psychology and Mental Health will be released in April 2019.

From the back cover:

“This handbook brings together experts from across the world to discuss men’s mental health, from prenatal development, through childhood, adolescence, and fatherhood. Men and masculinity are explored from multiple perspectives including evolutionary, cross-cultural, cognitive, biological, developmental, and existential viewpoints, with a focus on practical suggestions and demonstrations of successful clinical work with men”.

https://doi.org/10.1007/978-3-030-04384-1

 

 

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