Approvals

This course is accepted/approved by the following for continuing education credits/contact hours: 

The California Board of Registered Nursing # CEP 14462

The National Board for Certified Counselors (NBCC) # 6412
The Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling #50-14000 
The California Consortium of Addiction Programs and Professionals: CCAPP-IE Provider # 1N-16-256-0726

The California Associations of Alcohol and Drug Educators (CAADE) #CP40 977 H 0425

1)Recognize the ways in which male gender roles influence men’s psychosocial adaptation, substance use/abuse, and help-seeking behaviors.
2)Identify areas of screening and assessment of substance use disorders.
3)Define three parts of a comprehensive screening and assessment process.
4)Explain the treatment issues for Men.
5)Define co-occurring Physical health problems,behavioral and mental disorder in men from different age groups,diverse culture and geographic groups.
6)Define men’s treatment needs in the context of different modalities and settings and strategies.

What is a TIP?

This course is part of the “Treatment Improvement Protocols (TIPs) [that] are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). TIPs are best practice guidelines for the treatment of substance use disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts to evaluate the quality and appropriateness of various forms of treatment. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://kap.samhsa.gov.

Although each TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that the field of substance abuse treatment is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey front-line information quickly but responsibly. If research supports a particular approach, citations are provided. “

Recommended Citation

Substance Abuse and Mental Health Services Administration. Addressing the Specific Behavioral Health Needs of Men. Treatment Improvement Protocol (TIP) Series 56. HHS Publication No. (SMA) 13-4736. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

1. Creating the Context

Introduction

This Treatment Improvement Protocol (TIP) examines the history and theories of male socialization, changes in perceptions of masculinity and male roles, fatherhood, and other factors related to men’s substance use, abuse, and treatment. It emphasizes the fact that there is no single concept of masculinity or male identity appropriate for all men. Many factors besides gender status influence men’s identities—age and cultural background, for example, affect how men view what it means to be male. While recognizing that there is tremendous variation among men, this TIP also discusses how American cultural norms shape the way many men evaluate themselves and how this relates to patterns of substance use or abuse and to treatment provided by behavioral health counselors.

Historically, substance abuse treatment services were developed with male clients in mind because most admissions to substance abuse treatment programs were—and are—men. More recently,though there are still more specialized programs and interventions for women than for men (Substance Abuse and Mental Health Services Administration [SAMHSA], Office of Applied Studies [OAS] 2007d), the gender studies and men’s studies fields have begun to identify possible improvements in treatment services for men.

Men and women abuse substances for many reasons—some gender-related, some not. Reasons overlap in many areas but markedly diverge in others, necessitating different treatment options. This TIP and TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women (Center for Substance Abuse Treatment 2009c), explore gender-specific treatment needs and services that can address those needs. Note: TIPs referred to in this and subsequent chapters are available at the Knowledge Application Program Website (http://kap.samhsa.gov).

This chapter explains key issues, such as gender, sex, gender role conflict/stress, and conceptual frameworks relevant to behavioral health services for men with substance use disorders. It also describes concepts of masculinity and associated beliefs. It concludes with discussions of specific patterns of male substance use and abuse and how certain substances affect men differently than women; the current state of male-specific substance abuse treatment; and how this TIP is useful for various audiences of behavioral health service providers.

Although this TIP focuses on men with substance use disorders who are receiving treatment in substance abuse treatment settings,much content is directly applicable to clients with other behavioral health problems and disorders or who have a substance use disorder and a co-occurring mental disorder. The content of the TIP is directly applicable in various settings beyond substance abuse treatment programs, including mental illness treatment programs; criminal justice, vocational, and social rehabilitation programs; settings that primarily address physical health or family issues;and housing programs.

Defining Sex and Gender

One’s sex is generally assigned according to biological markers. Individuals are typically classified as male or female based on their reproductive organs, but assigning sex based on observable physical or biochemical traits leaves some individuals unassigned due to genital,chromosomal, or hormonal ambiguities.

Gender , on the other hand, is a sociocultural construct that defines expected characteristics of men and women. Femininity refers to characteristics ascribed to women, whereas masculinity refers to characteristics ascribed to men. Gender is not absolute; masculine behavior in one culture can be the opposite in another.

Moreover, notions of gender-appropriate behavior change over time and according to context. For example, in the 19th and early 20th centuries, it was considered appropriate for young boys to wear dresses. Notions of gender-appropriate occupations have also changed. For example, when the typewriter was first invented, male clerks were thought to have innate typing abilities far surpassing those of women. However, those stereotypes changed and in a few decades, working as a typist was considered a female occupation.Nursing, long considered a feminine job, has attracted more men in recent years.

[Question #1. A sociocultural construct that defines expected characteristics of men and women]

In this TIP, masculinity is defined broadly to include commonly accepted expectations for men in the United States. A number of variables can alter accepted ideas about masculinity: economic status, occupation, geographic location, religious affiliation, education, race,ethnicity, and sexuality, among others. Some men are at odds with dominant notions of masculinity; others embrace such notions. Regardless of individual definitions of masculinity, ideas about gender roles and expectations can affect substance abuse treatment for men.

A person’s gender identity must also be considered in discussions of masculinity. Gender identity is usually defined as a subjective, continuous, and persistent sense of oneself as male or female, but the importance of gender identity varies from one individual to another.

Defining Substance Abuse and Dependence

Unless otherwise noted, in this TIP, substance abuse and substance dependence refer to all varieties of substance use disorders described in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSMIV-TR; American Psychiatric Association[APA] 2000). The DSM-IV-TR states that “the term substance can refer to a drug of abuse, a medication, or a toxin”—alcohol is included as a substance as well (p. 191). The text also notes that “many prescribed over-thecounter medications can also cause a sub-stance-related disorder” and that “a wide range of other chemical substances can also lead to the development of substance-related disorders” (p. 191).

Substance dependence is “a cluster of cognitive,behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems…[in which] there is a pattern of repeated self-administration that can result intolerance, withdrawal, and compulsive drug-taking behavior” (APA 2000, p. 192). Though not a criterion, “craving (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with substance dependence” (p. 192).

[Question #2. A pattern of repeated drug self-administration that can result in tolerance for the drug , withdrawal, and compulsive drug-taking behavior is]

According to the DSM-IV-TR (APA 2000),the essential feature of substance abuse is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” (p. 198). The text notes that, “unlike the criteria for substance dependence, the criteria for substance abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated use” (p. 198). It specifies that “the term abuse should be applied only toa pattern of substance use that meets the criteria for this disorder; the term should not be used as a synonym for ‘use,’ ‘misuse,’ or ‘hazardous use’” (p. 198). Although there is general agreement that intensive substance abuse treatment is best provided in specialized substance abuse treatment programs, many men with substance use disorders enter and may continue care in a variety of other behavioral health settings. As a result, in both specialized substance abuse treatment programs and other settings, clients may be seen by behavioral health service providers from a number of disciplines, including substance abuse counselors, mental health counselors, psychologists, social workers, professional counselors, ministers and chaplains, physicians,and persons working in criminal justice settings. The general principles discussed in this TIP will be informative for the broader range of behavioral health specialists who work with men who have substance use disorders.

Conceptual Frameworks of Masculinity and Male Roles

Although no one set of behaviors or traits defines masculinity, certain characteristics or expectations are associated with masculinity in abroad range of cultural contexts and across different age groups. Brannon (2005) reviews research on the cross-cultural applicability of gender stereotypes and notes that although diverse cultures label certain characteristics differently as masculine or feminine, there are generally more similarities than differences in gender stereotypes across cultures.

The stereotypical roles that define men with in a culture are referred to as masculinity ideologies (Good et al. 1994). Ideologies are systems of values, beliefs, or ideas shared by a social group and often presumed to be natural or innately true. Masculinity ideologies, then, are a body of socially constructed ideas and beliefs about what it means to be a man and against which men are measured by their societies (Addis and Mahalik 2003; Good and Sherrod 2001).

Masculinity ideologies also affect how men think and feel about themselves, and they influence male roles in a society (Pleck 1981,1995). Men internalize these concepts from a nearly age. Through a process of “masculine role socialization,” boys learn how they are expected to act, feel, and think, and they often face negative consequences if they fail to meet those expectations (Addis and Mahalik 2003;Eisler 1995; Good and Sherrod 2001).

Scholars have built upon Brannon’s blueprint for masculinity (1976) to classify common,socially accepted male roles (e.g., Levant et al.1992; Mahalik et al. 2003b; Mahalik et al. 2005; Pollack 1998b; Smiler 2004). Individual men may identify with several roles or none and may place more emphasis on some roles than others. The next sections examine specific masculinity concepts and their potential relation to substance abuse; these concepts exist on a continuum and may change over time.

[Question #4. Which contributes to a shared and necessary sense of belonging?]

[Question #6. The inability to experience and communicate feelings?]

[Question #8. Gender roles do not vary according to social role. True/False?]

Gender Role Conflict and Masculine Role Stress

Several models attempt to explain how men become socialized. Among these are the theories of gender role conflict (O’Neil et al. 1995) and masculine role stress (Eisler and Skidmore 1987; Eisler et al. 1988), which focus on the negative consequences experienced by men who endorse particular beliefs regarding masculinity (Addis and Mahalik 2003; Good and Sherrod 2001; Pederson and Vogel 2007).

Gender role conflict occurs “when rigid, sexist,or restrictive gender roles result in personal restrictions, devaluation, or violation of others or self ” (O’Neil et al. 1995, pp. 166–167). This conflict can be experienced at a cognitive,emotional, or behavioral level, and may be conscious or unconscious.The Gender role Conflict Scale developed by O’Neil and colleagues (1986) gauges gender role conflict in four areas: success, power, and competition issues; restrictive emotionality; restrictive sexual and affectionate behavior between men; and conflict between work and family relations.

As with gender role conflict, the theory of masculine role stress views the socialization of men from a cultural lens. Eisler (1995) notes that:

Masculine gender role stress may arise from excessive commitment to and reliance on certain culturally approved masculine schema that limit the range of coping strategies employable in any particular situation…. Masculine gender role stress may also arise from the belief that one is not living up to culturally sanctioned gender role behavior. Men may experience stress if they feel that they have acted in an unmanly or feminine fashion. Many men are doubly stressed by experiencing fear or by feeling that they did not appear successful or tough enough in situations requiring masculine appearances of strength and invincibility (p. 213).

Masculine role stress has been refined to include links to shame (discussed in Chapter 3),depression, and anxiety (Liu and Iwamoto 2006; Liu et al. 2005; Wong et al. 2006).

Men’s Substance Abuse

Regardless of age or race, men use alcohol and drugs more frequently and in greater quantities than women. Similarly, young adults are more likely to use substances than are their older counterparts. The highest rate of illicit drug use is among young adult men, and the most common illicit drug used is marijuana. According to SAMHSA’s 2008 National Survey of Drug Use and Health (NSDUH),young adult men 18 to 25 years of age are also more likely to drink alcohol (64.3 percent)than their female counterparts (58.0 percent)(SAMHSA 2009). Binge drinking (a pattern of alcohol use that is more likely to result in alcohol-related problems) is likewise more prevalent among men. An earlier NSDUHstudy (SAMHSA 2005) indicated that eventhough 32.9 percent of men ages 21 and older reported prior-month binge alcohol use, only 14.7 percent of women in the same age group reported binge drinking in the prior month.People who binge drink have a higher incidence of alcohol-related problems (than those who do not binge drink), and men are more likely to binge drink than women, so counselors need to be aware, particularly when working with younger male clients, that binge drinking may be part of the individual’s drinking pattern.

[Question #10. The most common illicit drug used is :?]



[Question #11. The substance used more frequently and in greater quantities is :]

Perhaps reflecting these differences in use,American men are two to five times more likely to develop a substance use disorder than women (Brady and Randall 1999; Johnson and Glassman 1998; SAMHSA 2008;SAMHSA, OAS 2004a). In fact, in developed nations around the world, men experience greater mortality and morbidity from alcohol and tobacco use than women, due in part to greater rates of use (Lopez 2004). Worldwide,the health burden for substance use disorders is more than three times greater for men than women (World Health Organization 2004).The economic cost of men’s substance abuse is greater as well; men who abuse substances have more criminal justice system involvement than women who abuse substances, and because men are more likely to have jobs, they more often require disability payments (Harwood et al. 1998; Oggins et al. 2001; Timko etal. 2009). When men receive substance abuse treatment, taxpayers benefit: For every dollar spent on treatment, an estimated $9.00 is saved in criminal justice, healthcare, welfare,and disability costs (Harwood et al. 1998).

Given the chance, men and women are equally as likely to use substances. However, men may be more likely than women to use and abuse them largely because they have more opportunities to do so (van Etten et al. 1999). This could, in part, account for higher rates of abuse and dependence among men. Men also generally begin using alcohol and drugs at an earlier age than women (SAMHSA 2005).

Understanding how socially constructed gender role expectations affect some men’s choice of substances and attitudes toward treatment can help behavioral health service providers choose more effective strategies. Alcohol consumption, in particular, can be tied to ideas about masculinity and appropriately masculine activities. For young men, a first drink or first episode of drunkenness is often a rite of passage (Blazina and Watkins 1996; Hunt et al.2005), and drinking is commonly seen as a form of male bonding (West 2001). Such traditional ideas linking masculinity to drinking are prevalent across cultures (Heath 2000) and are associated with greater alcohol consumption among college men (Blazina and Watkins1996; West 2001) and military person-nel/veterans (Burda et al. 1992; West 2001).

Men also respond differently than women to certain substances, and some substances have effects in men that they do not have in women(see Chapter 3). For example, when men and women think about cocaine cravings, their neural responses differ (Kilts et al. 2004); men who use cocaine are also more likely than women to state that cocaine increases their sex drive and that they have more sex when using cocaine (Washton 2009). Findings such as these suggest the possible usefulness of gender-specific treatment approaches for cocaine dependence and other substances of abuse. As with cocaine, there are differences between the sexes in both methamphetamine and opioid dependence. Men show greater loss of mental faculties relating to executive function and memory than women, and these effects persist even after abstinence (Ersche et al. 2006).

Men may use or start to abuse substances for different reasons than women, and male institutions (e.g., fraternities, amateur sports teams) often encourage alcohol use (Brooks 2001). Men who cannot talk about their feelings or manage them constructively sometimes use substances to deal with difficult emotions. Shame, especially, can limit help-seeking behaviors for substance use and mental disorders (Brooks 2001; Pollack 1998b).





SAMHSA’s 2008 NSDUH established rates of lifetime use of substances for men and women (Exhibit 1-1); it found that 12 percent of menages 18 and older met criteria for a substance use disorder in the past year compared with 6.3 percent of women (SAMHSA 2009).

SAMHSA’s 2006 Treatment Episode DataSet (SAMHSA, OAS 2008b) revealed differences in substance abuse patterns and preferred substances of abuse between men and women who entered substance abuse treatment programs funded through State agencies (Exhibit 1-2). For all drugs listed save sedatives and tranquilizers, most treatment-seekers were male. However, data reported in the exhibit are for the primary substance of abuse,which was not necessarily the only substance a person abused.

State of the Field

Substance abuse treatment was designed for a largely male client population, and greater numbers of men than women continue to be treated in a variety of behavioral health settings.Additionally, much of the research on substance abuse treatment has been conducted with male participants; nevertheless, it has not examined the specific, unique issues of men (e.g., their health, psychological, cultural, and social needs)as related to substance abuse and its treatment. There is a difference between designing a substance abuse treatment intervention for a population—the majority of whom are men—and designing one specifically to address factors that distinguish male from female clients.The study of men’s issues is a growing field, and as researchers focus on issues specific to men, our knowledge base—and thus our ability to design treatment interventions for men—will increase.

In 2006, 68.2 percent of admissions to substance abuse treatment programs receiving State agency funds were men (SAMHSA,OAS 2008b). However, data from 2005 show that only 25 percent of programs offered any type of specialized services for adult men (OAS2007a). These data exclude treatment programs for incarcerated clients, an even greater percentage of whom are male.

In 2003, the Addiction Technology Transfer Centers (ATTCs) began offering two trainings related to men’s issues in treatment: “Men in Therapy” and “Anger Management”(http://www.attcnetwork.org/learn/education/dasp.asp). Trainings in substance abuse treatment specific to men are also available from other sources, such as the “Counseling Alcohol and Drug Dependent Men” training from the Distance Learning Center for Addiction Studies (http://www.dlcas.com). Men in general,regardless of age or cultural background, are less likely than women to seek treatment and more likely to leave treatment early, so motivational interviewing and treatment engagement skills should be a primary focus when training staff members who treat men.

Audience for This TIP

Because men who have substance abuse problems are a large and diverse group of people,this TIP will be useful to a broad audience of behavioral health service providers, including:

• Substance abuse treatment providers.
  This TIP will help providers reevaluate treatment programs for men and the assumptions on which treatment is based.Providers who understand current social expectations, how clients view themselves vis--vis these expectations, and the role that substances of abuse currently play in men’s lives can improve men’s engagement in and outcomes for treatment.
• Substance abuse prevention programs. Substance abuse prevention efforts that focus on men’s and boys’ issues can use this TIP to help clients learn to interact with one another without using substances and to encourage help-seeking for substance abuse problems.
• Primary care physicians and primary care providers. Hospital workers will find resources and suggestions for improving the screening of men for substance abuse,mental health, violence, and related problems.
• Psychiatrists, psychologists, counselors,social workers, and other behavioral health workers.
  This TIP is a useful tool for modifying screening, assessment, engagement, referral, and treatment approaches when working with men who have substance abuse problems.
• Educators.This TIP can help students modify and/or challenge how men are viewed, to dispel misconceptions about men who abuse substances, and to encourage critical thinking and discourse about men who have substance abuse problems.
• Criminal justice professionals. Professionals associated with courts, prisons, probation and parole systems, and other criminal justice settings can use this TIP as a resource when urging programs to address the multiple needs of men as related to substance abuse, physical and mental health,violence, and other concerns, including vocational and parenting programs.
• Faith-based organizations. Content from this TIP can be incorporated into the work of faith-based programs to help men address issues related to substance abuse.
• Researchers. This TIP summarizes some of the central issues relating to men’s treatment currently being studied and suggests directions for future research.
• Administrators. Administrators of agencies, provider organizations, treatment and prevention programs, medical facilities,and businesses can use this TIP to better inform community members not currently involved with the problems of substance use and abuse.