Working with men in individual psychotherapy from an integrity model perspective: the unsung heroes.

Nahon, Danielle ; Lander, Nedra R.

For over four decades, there has been a continuing thread in the literature emphasizing the unique challenges and impasses in psychotherapy with men. For example, Rochlen's (2005) review of the literature indicates that many studies point to the difficult hurdles facing therapists working with men (or potential male clients), most particularly the incongruity between the "culture of therapy and the rules (cultures) of masculinity" (p. 628). Rochlen points to the discrepancies between (a) "ideal clients" who are able to express their emotions, feel at ease with being vulnerable, and ask for help, and (b) "men's socialization process as one that promotes the avoidance of emotional expression, the absence of weakness or vulnerabilities, and the need to solve problems without the help of others" (Rochlen, 2005, p. 628). Similarly, Ogrodniczuk and Oliffe (2009) suggest that therapists must address men's gender role constraints that impeded their viable engagement in therapy. Good, Thomson and Brathwaite (2005) indicate that entering therapy means becoming willing to seek assistance, expressing one's vulnerabilities, and surrendering a sense of control, which may conflict with what men had learned to do earlier on. Consequently, men may be resistant to developing working relationships with therapists by "avoiding entering therapy, by being stoic, or by acting out in order to unconsciously prevent or sabotage an emotional bond. Men are also likely to have less experience and fewer skills associated with understanding and expressing their vulnerable emotions (Good, 1998)" (Good, Thomson & Brathwaite, 2005, p. 701).

CHALLENGING THE "MYTH OF THE EMOTIONALLY DEFECTIVE MALE"

Nahon and Lander's (2008, 2011) reviews of the literature on psychotherapy with men indicate that a number of authors have identified a negative bias in the attitudes of therapists towards men in therapy. For example, as previously discussed (Nahon & Lander, 2008, 2011), Heesacker and Prichard (1992) suggested that such phrases in the literature as "restrictive emotionality" and "fear of intimacy" characterize a "flawed emotion" (p. 276) view of men, creating a portrayal of men characterized by "psychological defectiveness" or "denigration of the essence of men" (p. 277). Lander and Nahon (2008a) suggested that positive qualities of character in men, for example honour and integrity, seldom mentioned in the literature on psychotherapy in general (du Plock, Lander & Nahon, 2008; Hoffman, 2005) and in working with men, provide fundamental resources in men's therapeutic work and in reaching men across individual and cultural differences. Nahon and Lander (1998) referred to this negative and devaluing view of men as the "myth of the emotionally defective male" (p. 16).

Nahon and Lander (2011) indicate that the notion of men's purported difficulties in help-seeking and emotional relatedness stems back to early research, beginning with Jourard and Landsman's (1960) research on self-disclosure in men. Although this early work is subject to a number of serious methodological limitations, it is cited in virtually all early writings on male gender role strain and has shaped the literature's understanding of men's emotionality. There has been little change in the portrayal of the deficit model of male emotionality. "Reviewing the earliest writings, some of these pioneering therapists' initial clinical observations remain highly relevant today" (Wade & Good, 2010, p. 273). Nahon and Lander (1992) suggested that this pejorative view of men may have created a self-fulfilling prophecy "in that the measured behavior of help seeking may ultimately reflect the attitudes of health professionals rather than those of potential male help seekers" (p. 413, emphasis in original). Nahon and Lander (2008) stated:

   Our experiences invite researchers and therapists working with men
   to reflect on the possibility of a figure-ground reversal. What
   would the picture look like if we were to ask not what men cannot
   do, but rather what men can do in the arenas of help-seeking and
   utilization of group therapeutic services, and what our roles and
   stewardship can be in facilitating this process, offering new
   encouragement for therapists to dare to reach out to the men in
   need of help in their communities? (p. 232, emphasis in original)

A MORE HOPEFUL VIEW OF MEN'S CAPACITY FOR HELP-SEEKING AND EMOTIONAL EXPRESSIVENESS

In parallel with the literature's focus on the constraints facing therapists who work with men, results of empirical and clinical research over the last four decades has shown men's positive response to a values-based Integrity model of psychotherapy. For example, Nahon and Lander (1992, 2008) found that the Integrity model--an existential, values-based approach, provided a viable theoretical vehicle for the design and implementation of a tertiary care group treatment program for men grappling with relationship issues, resulting in a three-month waiting list of self-referred men. Results of the first randomized empirical investigation of men's consciousness-raising groups and gender role re-evaluation psychotherapy groups for men (Nahon & Lander, 2010) revealed significant changes in emotional expression, self- and other-orientation, and psychological well-being for men dealing with marital separation, maintained at six-week follow-up. Key values inherent in the Integrity-based therapeutic approach were: (a) the positive view of men and their ease of access to a viable emotional voice; (b) the use of a non-pathologizing therapeutic approach in both program design and implementation; and (c) the use of an existential, Integrity-based therapeutic approach in the design and implementation of the group treatment program. The Integrity model has been shown to provide a viable approach in working with men in community practice, tertiary care and academic settings across a wide spectrum of issues including: (a) relationship issues and marital breakdown (Nahon & Lander, 1992, 2008, 2010); (b) post-traumatic stress (Lander & Nahon, 2005, 2010a; Nahon & Lander, 2012); (c) work-related stress (Lander & Nahon, 2008a, 2010a); (d) severe mental illness, and addictions (Lander & Nahon, 2005, 2008b); (e) cultural diversity and gender orientation (Lander & Nahon, 2005, 2008b); (f) finding harmony between work and home life (Lander & Nahon, 2011a, 2011b); (g) spirituality (Lander & Nahon, 2000b; 2010a, 2010b); and (h) end of life issues (Lander & Nahon, 2010a, 2010b) through individual, couple, and group psychotherapy (Nahon & Lander, 2013).

Our review of the literature points to a dearth of published articles that examine individual psychotherapy with men. Good and Robertson (2010) address ways in which therapists can address the "daunting tasks" (p. 306) that therapists face with reference to both (a) men seeking therapeutic help, and (b) once men do present for therapy, to "get them to trust therapists sufficiently enough to share their issues and to form an effective working alliance" (p. 306). Through the use of a case study, they offer the metaphor of the good therapist as the good pilot who "demonstrates that he can help a captain successfully navigate some challenging psychological waters" (p. 313), and thus is more likely to be consulted in the future by the male client-as-captain. Schermer (2013) proposes narrative therapy as an alternative approach for counsellors to work with men. He suggests that counsellors should "take special considerations for the narrating of men's problem-saturated stories, externalizing men's issues, challenging masculine metaphors, and constructing a unique masculine team" (p.136) in order to implement this approach with men.

Two recent studies have considered a more positive perspective towards men and masculinities, comprising a shift that is more congruent with Nahon and Lander's Integrity-based work with men. Kiselica and Englar-Carlson (2010) suggest that "the [New Psychology of Men] model has largely emphasized deficit models of male development 22and a remedial approach to psychotherapy that is designed to help men recover from the damaging effects of constricted masculinity" (p. 276). They summarize what they term a new perspective for "a positive psychology of boys and men, which accentuates positive aspects of masculinity, male development, and the male socialization process, and the application of positive psychology principles in psychotherapy with boys and men" (p. 277) and encourage other therapists and researchers to "develop and refine an approach to studying and helping boys and men that is based on male strengths" (p. 285).

Hammer and Good (2010) found that the endorsement of traditional male norms in Western society such as risk-taking and seeking greater status were associated with higher autonomy, endurance, courage and resilience. In contrast, they found that conformity to norms including self-reliance and pursuing status were associated with lower levels of courage, personal control, grit, autonomy and resilience, and call for qualitative studies that further explore these variables. They suggest that "there is some utility in continuing to explore the healthy aspects of traditional masculinity" (p. 314) and that this increased knowledge may enhance the "appeal and utility of counseling for more therapy-resistant men ... and respond to the call of positive psychology to acknowledge and consider the utility of a strengths-based, gender-sensitive approach with men" (p. 314).

The current article addresses this call in furthering the focus on a strengths-based and gender-sensitive approach in working with men. Through the use of three clinical case studies of men in individual psychotherapy in both tertiary care and private practice settings, this paper will offer both a theoretical and a clinical exploration of the Integrity model--an existential, values-based theoretical approach in working with men in individual psychotherapy.

PHILOSOPHICAL UNDERPINNINGS: THE INTEGRITY MODEL

As we have previously discussed, expanding on O.H. Mowrer's Integrity (Therapy) Group approach, formulated from the mid-1940s to the mid-80s, Lander and Nahon have evolved the Integrity model which offers the first wellness and value-based model of psychotherapy (e.g., Lander & Nahon, 1992, 1995, 2000a, 2005; Mowrer, 1953. 1961, 1964, 1966, 1970; Mowrer & Vattano, 1976). This model is based on the assumption that the human being is a valuing animal; its basic inviolate principle is that the degree of distress or angst in one's life reflects the degree of personal violation of one's very own values (Nahon & Lander, 2013).

Integrity is operationally defined as a three-legged stool: (a) Honesty means being open and truthful about one's feelings, and acknowledging past or present wrongdoings; (b) responsibility means taking 100% ownership of one's 50% in conflict situations; and (c) emotional closure refers to the intent of any actions as "closing the psychological space" or increasing one's sense of community with self and others. This concept of community really is about relational attachments. Integrity requires all three components to be present in order for Integrity to exist at a given time in a given context. Hence any interaction (verbal or behavioural), any decision by a person, institution, or government, any product or service can be analysed as to its level of Integrity by the presence or absence of the three components (Nahon & Lander, 2012).

Stress and distress are understood as reflecting a clash of values, and an Integrity crisis as occurring when any one of the three components of Integrity--honesty, responsibility and emotional closure/community--are absent. Guilt comprises a critical component of the Integrity model. We see it as arising from the violation of one's values and their discrepancies with one's actual deeds done rather than feared. What psychotherapy calls for is not new or different values, but rather for an increased fidelity to one's present values (Lander & Nahon, 2000a, 2000b; Nahon & Lander, 2012, 2013).

THE INTEGRITY MODEL IN WORKING WITH MEN IN THERAPY

Mowrer's early community-based Integrity groups from the late 1960s to the mid-80s with men grappling with addictions and relational crises, as well as with impaired male physicians revealed that men were profoundly self-aware, expressive and insightful (Mowrer, 1953, 1964). Results of the current authors' empirical and clinical investigations for over four decades beginning with Lander's group work with boys in the mid-60s (Lander, 1986) indicate that men have been receptive to this therapeutic approach that honours men's innate sense of wisdom, morality, relationality and Integrity as key therapeutic resources--challenging the "myth of the emotionally defective male" (e.g., Lander & Nahon, 2011a; Nahon & Lander, 1992, 2013).

As we have previously discussed, the Integrity model is perhaps the only true existential therapeutic framework both in terms of substance and form. It does not merely deal with existential issues--it is existential. The existential framework emphasizes the uniqueness of individuals, their values, and the search for meaning in their lives (Coleman, 1976). Following its existential basis, the Integrity model views the process of therapy as being unique to each individual and to each context, and thus as one which cannot be "manualized"--in other words, cannot be presented in a cookbook approach. The Integrity model stresses the client's equality to the therapist, and the client's role in the therapeutic process (Lander & Nahon, 1992, 1995). The process of change in therapy is seen as being the task and responsibility of the individual in therapy, rather than that of the therapist. The aim of Integrity-based psychotherapy is to challenge individuals to examine and enhance their level of Integrity within their relationships with both self and others, being sensitive to the context in which they occur. Each situation and each individual is viewed as unique and the level of Integrity of each encounter is viewed as reflecting the existential moment. There is no Integrity jargon, no "Integrity-speak". The Integrity model asks that the therapist use the language of the other, rather than have the other learn the therapeutic jargon. Rather than using an artificial lexicon and destroying individuals' own voices by asking them to adopt the voice of the therapist, the Integrity model adopts everyday simple language in the context of therapy (Lander & Nahon, 2000b).

Case Examples

Francois, Mark and Peter--three men from very different walks of life--were seen for brief individual psychotherapy. We feel that these three men represent the men who have crossed our thresholds, and whom we see as the unsung heroes facing crises of alienation and in search for meaning through their identities as men.

Francois. Francois, a former Catholic priest in his late 70s, presented to the hospital emergency room with a severe suicide attempt. He related that he had been sexually abused by a female superior in the Church when he was a young priest; the abuse lasted several decades. For many years, Francois had been plagued with a sense of guilt about the abuse. Despite the numerous Novenas and other prayers of absolution that he was asked to recite, he had been unable to experience a sense of atonement.

Francois had resigned from the priesthood rather than retiring as a priest, as he felt that he had been unable to walk the talk. He felt alienated, abandoned, and with a sense of loss of his religion and of his colleagues who could not understand his leaving the priesthood. Francois found himself in a moral dilemma, because he had believed in a G-d from whom he now felt alienated in terms of his religious affiliation and his transgressions, but with whom he still felt a personal connection; he found himself in a no-man's land where the only solution was to leave, propelling him into the existential abyss. For a Catholic priest, or even a former priest, to contemplate suicide was almost unthinkable, as it is one of the most egregious acts according to his religious values; for Francois, the suicide attempt comprised an ultimate sign of his despairing anger.

Francois explored the fact that, from an Integrity model perspective, his symptomatology reflected the moral dilemma of a clash of values and a conflict between his values and his behaviours. Francois really liked this as a clear and profound paradigm which provided him with (a) an understanding of why he had gotten into trouble within himself resulting in his current untenable crisis and (b) a new roadmap for the work of repair and healing needed in order to resolve his crisis.

As Francois explored the Integrity issues that he was facing in his current life, he related that although embarrassed to articulate this in talking with a (then) young lady, he could acknowledge that sex was still important and highly valued for him. Francois was relieved and delighted when I (second author) affirmed the fact that although he may be older, he was certainly not dead, and therefore he could still find a way to honour these values in his current life. Marguerite was a widow who had a very active and supportive social network. Their relationship began to flourish. Francois found a new religious home in a Protestant sect; the pastor's teachings resonated with him and he felt a new sense of community and belonging. Also, Marguerite was quite religious. Francois felt that he had to walk the talk and convert in order to marry her, and proceeded to do both. However, a new wrinkle occurred in their relationship; Francois developed erectile dysfunction. He realized that in his past sexual relationship with his abuser, there had been a highly erotic appeal to the secrecy and to the risk of being found out. In his current consensual sexual relationship, there was a lack of excitement and so he found himself unable to perform.

Francois was able to see that he was now involved in a loving and mutually caring relationship, and that sex when not "on demand" had its own comfort and allure; he was able to reclaim his sexuality in tandem with his spiritual and psychological journey of healing, and at last, was able to live a meaningful life.

Mark. Mark's case provides an interesting counterpoint to Francois'. Mark was a successful professional in his late 40s. A father of two young adult children and a long-standing member of Alcoholics Anonymous (AA) with 20 years' sobriety, Mark had been separated from his wife for three years. After the separation, Mark felt socially isolated and faced an empty nest.

Mark related that he had dated quite a few women since his separation, but found that the relationships had never worked out. He had often been drawn to women whom he described as "controllable as they needed rescuing." He reported panic attacks in recent years, leading to hospitalization to rule out cardiac involvement. Mark disclosed a history of intermittent premature ejaculation. He had seen a sex therapist once who gave him exercises and lotions, but the premature ejaculation continued to be a problem.

Mark's goals for therapy were to gain a sense of control over his feelings of anxiety, and to explore how to have healthy relationships. He said that although he found A A helpful and had long-standing sobriety, he was looking for a greater depth of help in addressing his current problems and sense of crisis. Mark found that the Integrity model opened the door for him to begin exploring his role in his relationships with women and whether he was being true to his values; he realized that he was a "people-pleaser".

Mark was invited to articulate his values as a man of honour; he characterized this as being someone who keeps his word, is trustworthy, dependable, kind versus cruel and petty, has inner strength and self-confidence, and stands up for his values. A key part of Mark's Integrity work was his decision to implement these values in his relationships with women, via kindness and inner strength. At the next session, he related that upon reflection, he no longer valued success and doing well at work as top values, focusing instead on relationships and on enjoying life more.

Mark acknowledged that he did not show his emotions much of the time and would like to learn to do this. He poignantly revealed that as a child, he had endured bullying at school, and that his mother's advice had been to "keep on smiling."

Mark decided that he would work on no longer wearing a mask, as he could see that the price he had paid for wearing it had been too high. Mark discovered that contrary to his own mythology about his emotional inexpressiveness, he had in fact been very emotionally expressive and involved over the past 20 years.

Mark entered into in a new relationship with Mary which was different from all previous relationships. He could see that prior to this, he had been drawn to women whom he described as having been more flirtatious than he felt comfortable with, because he felt that there was safety in the fact that they were emotionally unstable and needy. With Mary, Mark had a new I-Thou relationship (Buber, 1970; Lander & Nahon, 2005; Nahon & Lander, 2008); he was sincere and real, and felt more at ease with this way of being with another.

Mark could now see that in his marriage, he had been "strong and silent" when upset. He began to discuss his sexual dysfunction, and to note that he had not been able to perform sexually when the sexual connection was not coupled with an emotional connection, and he understood that this reflected a clash of values for him.

Mark reported feeling deeply disappointed when he was told by Mary that she really did not want to get involved, and was not attracted to him. He was invited to own the sense of rage and outrage behind the disappointment (Lander & Nahon, 2005, 2010a), and to realize that she was the target of his anger, not himself. He said that this helped him not to embrace the "L" word--that of concluding that he was a loser. He realized that he needed to take it slower in relationships with women. He redefined his long-standing values of what it meant to be a man. These had included the following: being strong (physically and in character), a leader, dependable, sexually aggressive and successful--i.e., having regular sex and multiple partners, and being able to "get sex easily" as well as performing well at any time, being able to fight physically, to handle all of his problems on his own, to always be in control of his emotions, to be less sensitive to others and less in touch with himself. His newly defined value of a man was that of an honourable man: To keep his word, to be kind, fair, honest, dependable, and faithful in a relationship. He now felt that being physically strong had nothing to do with character. A man of character would handle sex in a sensitive manner, would be able to handle his emotions with Integrity, while at the same time being able to express his feelings. Mark felt that he had learned the values of being a macho man from peer groups, movies and peer pressure, especially at ages 14-16. He could see that his father--a blue collar worker--had been a man of character.

Mark decided to work on developing friendships with women first, and finding ways to work on a courtship rather than his usual pattern of becoming sexually involved right away. At the ninth and last therapeutic session, Mark reported feeling consistently well, joyous and with the sense that life was opening up for him. Mark was now dating a new woman and working on a courtship. He found that they had a lot of values in common. He said: "I used to look for a woman whom I could sleep with; I am now looking for a woman I can wake up with." Mark was now relating entirely differently within his social circle, being open, initiating. He said that he was feeling better than he had in years, and that this reminded him of the time he joined AA and felt that everything had fallen into place for him. He felt that life was wonderful; he was now recapturing the joys of childhood, such as summers spent camping.

Mark said that he found it so helpful to realize that his issues had been linked to issues of Integrity, and that he now had clear insights into this. Referring to his previous lack of Integrity, he stated: "I need to change those patterns to get to be who I really am"--realizing that it was a fundamental principle of the Integrity model: In order to improve how one feels one must first change one's behaviour to one that has more Integrity (Lander & Nahon, 2005). Mark could understand his panic attacks from the vantage point of Integrity--realizing he had developed them when in relationships where he was feeling deeply unhappy, but staying as he feared being alone. Mark contacted me (first author) some months later; he informed me that his relationship with his girlfriend was now solid and strong. They had moved in together and were building a home and a life as a couple; his sexual performance continued to be non-problematic. He said that he was now happier with his life than he had ever been and he had exceeded his wildest dreams.

Peter. Peter, a man in his mid-40s, was referred to me (first author) right after I attended a conference of the American Men's Studies Association. At first glance, Peter appeared somewhat brusque; however, I was impressed with Peter's courage and sincerity in seeking help and his candor in putting all of his cards on the table, and thus invited him to come in for a "mutual eyeballing".

Peter presented with a recent history of financial problems, causing major turmoil at home. He felt locked into a job that he hated. Peter described feeling sad, stressed, and wanting to "escape in his head". There were many home stresses with a blended family; he felt that it was his home and that the kids were "boarders"--a concept I felt initially uneasy

with. At this first meeting, Peter spontaneously acknowledged that he was "stubborn and rigid" which was a new insight for him; he felt that his wife was too lenient and that he "ran the roost". He said that his wife found it hard to express herself as he was "a big guy" who could be intimidating.

At our next meeting, Peter told me that he had gone home and shared with his family his discovery that he was a "control freak". We reviewed the Integrity model, and discussed the model's three basic stances that in any relationship, and especially in dealing with anger, one can only "move towards, away from, or against another" (Nahon & Lander, 2014). Peter said he had never conceptualized the "moving towards" stance before, i.e. the notion that one could move closer to someone as a way of resolving a conflict. He felt that the idea was "gold" but that he would never do that as "men don't confront". Peter described a past conflict situation with a friend; Peter had pulled away in anger and was now estranged from this man. I asked Peter to list the qualities of a man of character. He replied: "Honesty, trust, loyalty, and fun." I suggested that pulling away from someone with no discussion, as he had done with his friend, would not be loyal; he agreed with this. He also explored how to better communicate with his teenage son.

At our third and final meeting, Peter said that he had worked with all of the concepts that we had discussed, and felt that all were "of gold". He said he discussed with his kids the fact that he is "the bit-h"; by this he meant that he did have 50% of the accountability for the conflicts in his relationships with them. Peter told me that when he said this to his kids, they immediately offered to help with dinner, the laundry, etc.

Peter related that he felt proud and happy; he even shared with his family the concepts of Integrity, for example, the notion of the three fingers pointing back in one's direction when one is pointing the finger and blaming another. He said: "I'm a learner, not a pursuer" and "my bark is worse than my bite". He said he had acquired a new concept of power, a different kind of power: Team versus solo. I told him about an article I was writing with my colleague on men's issues regarding good versus evil. Peter said: before, "I came across as an ogre", yet "yelling does not get you anywhere". He said he had acted in the only way that he had known. He now could see the "power in being good" versus his previously aggressive stance.

Peter said that he found these concepts helped as well in difficult social situations. When he sat down and told his family about the Integrity model, he also told them that he was seeing a therapist and they said "good for you"; he did not try to hide this. Peter also contacted the friend from whom he had been estranged for many years, and made amends with him; he felt proud of himself and for having been "the bigger person". His family told him: "If you are not yelling, we will listen!" He said to me: "I'm not your prototypical male; I'm loud but not an aggressor." He added: "I've seen the light; I will be teaching it to all that I know." He spoke of how much he respected his wife: "She's my hero; I would die for her." He told me that he discussed our sessions with her and that he had begun to "move towards" her; he felt that if he continued his Integrity work, she would "let her guard down." He told his friends at the pool hall about his therapy and suggested to them that they seek help if needed. He felt a new "bounce in his step" and was talking to people more honestly. He was ready to terminate with the proviso that he would contact me if needed.

DISCUSSION

Mark, Francois, and Peter's journeys illustrate our Integrity-based work with many men in community practice and tertiary care settings, adding further support to our clinical and empirical findings of: (a) Men's immediate engagement in the therapeutic process; (b) men's deep willingness to be radically honest without defensiveness; (c) men's positive response to a wellness versus pathologizing perspective; (d) the Integrity model as a theoretical vehicle for men to articulate their values of being male and the value clashes between traditionally socially prescribed values versus their personal values of being a man of honour; (e) the connection between issues of Integrity and symptoms of distress or physiological symptoms; and (f) the fact that therapy is often quite brief as men are able to run with the Integrity model as a philosophical perspective for daily living (Lander, 1986; Lander & Nahon, 2000b, 2005, 2008a, 2008b, 2010a, 2011a; Mowrer, 1953, 1961, 1964, 1966; Mowrer & Vattano, 1976; Nahon, 1993; Nahon & Lander, 1992, 1998, 2008, 2010, 2011, 2012, 2013). As these men were able to work through this process and acquire the understanding of the connections between symptoms and living with Integrity, they discovered a sense of resilience that allowed them to gain a new sense of mastery over their lives.

The journeys of all three men offer a conceptual challenge to the literature's purported challenges faced by men in addressing "the restrictive components of masculinity within a clinical context" (Rochlen, 2005, p. 628), through both engaging in and viably working in therapy. Mark, Francois and Peter--three men from widely differing walks of life, had no difficulty engaging in therapy and were profoundly receptive to the existential nature of the Integrity model, in its stress on (a) the client's equality to the therapist, and (b) the client's role in the therapeutic process, such that the process of change in therapy is seen as being the task and responsibility of the individual in therapy, rather than that of the therapist. The existential nature of the Integrity model allows men to dare to use their own individual voice with its male metaphors and historical journey that has its own vibrato that is unique and can harmonize with other men and of course the vibrato and voices of women.

Francois and Mark's journeys are typical of our work with men who are grappling with sexual dysfunctions including premature ejaculation and erectile difficulties. There is a dearth of recent published articles in the arena of psychotherapy with men around sexual dysfunctions. Several authors (Anson, 1995; Crowe, 1995; O'Donohue, Swingen, Dopke, & Regev, 1999) have called for a greater focus on: (a) Individual rather than couple treatment; (b) a focus on under-represented populations, including men without partners and older men; and (c) a greater understanding as to why the interpersonal rather than the sexual therapy components of therapy may be effective. Our work with Francois and Mark addresses this call, adding to the theoretical and clinical understanding of factors underlying their sexual dysfunctions in terms of an Integrity crisis based on a values violation and how this can be addressed. The Integrity model quickly allowed both men insight into this; their ensuing fidelity to a newly articulated value system enabled them to access their potential for resilience, allowing them both to resolve the sexual issues in a sustainable manner, and to build a sense of self-worth and a more meaningful and joyous life.

This article further addresses the literature's call for a focus on a strengths-based and gender-sensitive approach in working with men from a positive psychology perspective. It adds to the body of empirical and clinical knowledge regarding the viability of a values-based, existential perspective in engaging and working with men in therapy (e.g., Lander & Nahon, 2000b, 2008a, 2011a; Nahon & Land er, 1992, 2008, 2009, 2010, 2011, 2012, 2013), challenging the "myth of the emotionally defective male". The "unsung heroes" that we have sung about today are the men who have crossed our thresholds for over four decades. These are the men who have defied the still-negative dominant literature, daring to pursue meaning in their lives, their love of family and their courage to seek out therapy, or even if court-mandated, stay in therapy for their own sake and for that of others. They are the men who have defied the diagnostic labels that often shunted them into revolving doors, drug regimes, and research programs, with their failed outcomes confirming their diagnosis a la The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) and for having a "Y" chromosome. The Integrity model encourages men to engage in a rebellion of non-acceptance of the values of (a) society, including the media, (b) significant others, and (c) their own fragmented selves that had been cobbled together as a function of the man they thought they ought to be.

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Danielle Nahon * and Nedra R. Lander *

* Faculty of Medicine, University of Ottawa.

The authors would like to thank Stephen West for his editing assistance, Emil Lander for his gift of time, and both Stephen and Emil for their Integrity, love and support. The authors are deeply grateful to James A. Doyle, Diederik F. Janssen, and Men's Studies Press for their ongoing championing of scholarship in men's issues.

All correspondence regarding this article should be addressed to Danielle Nahon, 250B Greenbank Road, Ottawa, Ontario, Canada K2H 8X4.

DOI: 10.3149/jms.2203.194