Working with men in groups from an integrity model perspective.

Nahon, Danielle ; Lander, Nedra R.

This paper offers a theoretical and philosophical conceptual framework for both clinicians and researchers to understand ways of addressing impasses in working with men in groups. Framed in an Integrity model, values-based perspective, it examines the role of the clinician/researcher in the arena of men's groups. This paper will be of relevance in highlighting the role of values in: (a) the design and implementation of group membership and intake; (b) the therapeutic process within the group; (c) the formulation of a conceptual vehicle that allows men to understand themselves as a function of their value systems; and (d) the role of the group therapist or researcher with the potential for a hidden or masked bias in the therapist or the theory.

Since the 1940s and especially the 1970s, the Integrity model has been at the vanguard of a positive view of men. The 2012 American Men's Studies Association (AMSA) Annual Conference on Men and Masculinities, celebrating its 20th anniversary, featured new and emerging voices regarding men and their potential for a viable and sustained emotional voice, e.g., through Harper's (2012) invited address, and Adams's (2012) as well as Mandel and Justad's (2012) more positive portrayal of men in relationships.

PERCEIVED IMPASSES IN MEN'S PARTICIPATION IN THERAPEUTIC GROUPS

Beginning in the mid-1980s, we have consistently written about and presented the values underlying the literature on psychotherapy with men (e.g., Lander & Nahon, 2000a, 2011a; Nahon & Lander, 1992, 2010). There seems to be a continuing thread in the literature that highlights the unique challenges and impasses which must be addressed before men can viably engage in therapeutic and mental health services. For example, Good and Brooks (2005) indicate that "for some time, mental health professionals have recognized that men are reluctant to take on the client role. We have realized that men's help seeking is often tentative and complicated by conflicting motives, making it difficult for counselors to establish therapeutic alliances" (p. 8). Rochlen et al. (2010) point to the need for further research on treatment barriers for men. Ogrodniczuk and Oliffe (2009) point to the challenges that men encounter in moving beyond their cultural norms which discourage men from self-disclosure, leading to isolation, distress and decreased self-awareness. They suggest that therapists must become sensitive to these issues in order for men to engage in psychotherapy and address their gender-role constraints.

The literature on men and groups purports that similar constraints exist with respect to men's engagement and viable therapeutic work in men's counselling and psychotherapy groups. For example, Adams's (2011) review of the literature suggests that the influence of recurring hegemonic themes including avoidance of (a) appearing feminine; (b) vulnerability; (c) emotional expressiveness; and (d) having close contact with other men, conflicts with the demands of psychotherapy that men be vulnerable, emotionally expressive and subject to the direction of therapists. He suggests that although men have met in social and community-based groups for a long time, mental health services have not focused on men's needs to be with other men, and therefore there are few paradigms that describe how men can gather in a manner that aims to enhance men's psychological health. Akinsulure-Smith (2012) points to the need for clinicians to "increase their ability to work with diverse groups and use strategies and skills relevant to the client's cultural heritage" (p. 109) through viable group interventions that provide "sustainable ... ethical and effective culturally sensitive treatment" (p. 109).

There has been a paucity of publications that have addressed these issues in working with adult males in clinical, mental health and community settings. Results of a recent PsycINFO[R] (American Psychological Association, 2012) database search indicated that over half (58.3%) of the twelve studies indexed in the area of men and group counselling over the past five years addressed issues in working with men as either perpetrators or victims of abuse or dealing with addictions. Two studies (Boonzaier et al., 2008; Taylor et al., 2007) reported on psychoeducational approaches aimed at men undergoing cancer treatment. Only one study (Nahon & Lander, 2008) addressed group work with adult men in a clinical setting. Similarly, results of a recent PsycINFO[R] search indicated that nearly half (46.7%) of the thirty studies indexed in the past five years in the arena of men and group psychotherapy dealt with working with men as either perpetrators or victims of abuse, or dealing with addictions. Two studies reported favourable results for therapeutic retreats (Page, 2009) and for Adventure Therapy (Scheinfeld, Rochlen, & Buser, 2011) as an adjunct to traditional group therapy. Only eight studies (26.7%) addressed psychotherapeutic groups with men in clinical/mental health settings as follows: Rabinowitz and Cochran (2008) reported on a single-case study of a man taking part in individual and group therapy. Three international studies--Romero Gamero, Vucinovich, and Poves Onate (2010, 2011) working with six men diagnosed with depression through an Interpersonal Group Therapy approach, and Zhao et al. (2010) working with schizophrenic male inpatients using a structured group format in China-reported positive outcomes in working with men with (a) ICD (International Statistical Classification of Diseases and Related Health Problems) (World Health Organization, 1992), (b) DSM (Diagnostic and Statistical Manual of Mental Disorders) (American Psychiatric Association, 1994), or (c) CCMD (Chinese Classification of Mental Disorders) (Chinese Society of Psychiatry, 2001) diagnoses. Akinsulure-Smith (2012) reported on a group program for African refugees in a large US urban hospital. Seager and Thummel (2009) offered a clinical description of a group of seven men in a National Health Service environment in the UK utilizing a "psychoanalytically informed" (p. 254) group approach. Group members were described as being "generally withdrawn and isolated, with personality disorders/sociopathic tendencies" and "histories of repeated inpatient admissions" (p. 253). Nahon and Lander (2008, 2010) worked with a heterogeneous population of men and did not utilize a DSM diagnosis. Nahon and Lander (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. Their examination of the empirical literature on psychotherapy with men pointed to the presence of a negative bias in therapists' and researchers' attitudes towards male clients, resulting in a self-fulfilling negative prophecy regarding men's likelihood of engagement and sustainability in mental health/clinical treatment programs.

Nahon and Lander (2010) provided the results of the first randomized empirical investigation of men's consciousness-raising groups and gender role re-evaluation psychotherapy groups for men. Sixty-one men were randomly distributed into three Gender Role Re-Evaluation and three Non Gender-Focused groups. Results of a repeated-measures MANOVA revealed significant changes in emotional expression, self- and other-orientation, and psychological well-being, maintained at six-week follow-up. Taken together, these two studies point to the viability of a values-based, existential therapeutic model in viably engaging and working with men in group psychotherapy. Key values inherent in both studies 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 current article furthers this work in offering a clinical and philosophical exploration of the role of the group facilitator and the modus operandi of Integrity-based men's groups. This paper seeks to nurture the emerging zeitgeist of voices advocating for a more positive view and understanding of men and their masculinities in the context of men's psychotherapy groups.

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 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, 2005; Mowrer, 1953, 1964). 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, 2012).

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 fifty percent 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).

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).

Mowrer's early community-based Integrity groups from the late 1940s to the mid-1980s 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 authors' empirical and clinical investigations for over four decades beginning with Lander's group work with boys in the mid-60s 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).

THE INTEGRITY MODEL IN WORKING WITH MEN IN GROUPS

Through an examination of: (a) group composition; (b) the pre-group preparation phase; (c) the lack of emphasis on diagnostic labelling; (d) the role of the Integrity group leader; (e) the use of the three legs of Integrity in the group work; (f) the focus on value clashes in the group process; and (g) challenging the development of sub-groups, we will present the Integrity model in practice in working with men in groups: Why it works and why men like it.

The Heterogeneous Group Composition

Key to Integrity groups is the inclusive composition of the groups rather than being subject to the usual exclusionary criteria necessary in order to meet the requirements for research, even of a clinical nature. Due to the existential nature of the Integrity model, there are no a priori exclusionary criteria for group composition other than (a) those arising naturally as a function of the group's setting or institutional requirements and (b) the individual quirks/biases of clinicians/researchers.

Virtually all men's psychotherapy groups reported in the literature are homogeneous in nature, in terms of either (a) a DSM diagnosis (e.g., men and depression or men and schizophrenia), (b) culture or ethnicity, or (c) a focus on particular issues (e.g., men and abuse or trauma). An important value of Integrity groups is the heterogeneous nature of group composition across demographic variables and referral sources including physicians, other community-based sources and self-referrals.

Beginning with Mowrer's work (e.g., Mowrer, 1964, 1966; Mowrer & Vattano, 1976) and Lander's work in a tertiary care setting in 1973 (Lander, 1986), our focus on a heterogeneous group composition is based on two fundamental values/biases: (a) the perception, understanding and valuing of men's innate capability to be self-aware and poetically articulate about how they feel and how they experience the self in daily life and relationships, and (b) the value that men from differing backgrounds, cultures, and stations in life will find strength and enrichment in relating to one another. Both of these hypotheses/values have obtained significant validation across Integrity groups in clinical, academic and community settings.

The impact of the heterogeneous nature of Integrity-based groups for men has been therapeutic and profound. Integrity groups have consistently shown that men can bond despite differences in sexual orientation, race, religion, socio-economic status, or educational level. These demographics are not the barriers that clinicians and researchers perceive them to be. Men have shown that it is not problematic for them that another man may differ from him on any external variable. What is relevant to them is that there is another human being who, en passant, happens to be male, and who is able to care, to feel compassion for their plight, and to step into the breach with suggestions rather than advice for their consideration in problem-solving. Across groups and populations, including the tertiary care environment, Integrity-based men's groups in academic medicine (Lander & Nahon, 2011b) and Integrity groups with men's studies scholars (Lander & Nahon, 201 la), we have found a universal phenomenon that occurs when, for example, the Southern European bricklayer with grade 10 education, the Asian corporate executive officer, the elderly French Canadian university professor, the young man who comes out in the group, and the African immigrant discover that their plights and humanity make them brothers with a deep capacity for caring and emotional intimacy. This boggles their minds and brings about an immediate component of gender role re-evaluation as they realize that their demographic facade, their educational level, ethnicity, sexual orientation, etc. are only artificial barriers from society that had masked them from seeing themselves as well as seeing other men in terms of their true selves. Men can relate to one another as fellow human beings and discover that their humanity and their masculinities become unifying variables. Another case in point is that of a physician who had provided us in his pre-group needs assessment with a scenario that poignantly described his current plight. This brief scenario captured his angst as he felt torn apart between his obsession with perfection and career success versus his unfulfilled dreams of being a good father and spouse. When we anonymously presented this scenario at an Integrity workshop comprising men's studies scholars including graduate students, academics, and counsellors (Lander & Nahon, 2011 a), one man wept openly as he could relate so much to this scenario as well as to others provided by group attendees.

The Pre-Group Preparation Phase

This phase plays a key role in setting the stage for men's successful journeys through Integrity groups, and is part of the preparation for groups that are of an ongoing nature or will meet for a period of time, for example, 10 sessions in the groups for men dealing with relationship crises (Nahon & Lander, 1992, 2008), and Lander's Integrity groups in a tertiary care setting from 1973 to 1986 (Lander, 1986) which were of an ongoing nature. The pre-group meeting is presented as a mutual eyeballing, which means that the men have an opportunity to "check us out" and be able to make an informed decision about whether or not they would like to take part in the group.

The group contract. O. H. Mowrer spearheaded the development of contract psychology. Critical to the Integrity group process is the group contract, based on Mowrer's (1970) original work with group contracts and further elaborated in Lander and Nahon (2005). The terms of the contract include the following:

* To agree to refrain from any physical violence in the group, but to allow verbal expression of feelings of anger and frustration.

* To agree to remain in the group room during the group sessions and not leave, but rather communicate feelings, whatever they might be, that may be creating the desire to leave.

* To inform another member of the group (not the leaders) should unforeseeable and unchangeable circumstances arise necessitating missing a group session. Respecting this clause is vital....

* To call someone in the group should circumstances seem very difficult before making any hasty decision on one's own; that is, to not undertake unilateral decisions without cross-validation by the group, and to report this outside contact. (Nahon & Lander, 2008, p. 236)

Honouring of this contract is key to the pre-group selection process as it begins the dialogue about the process of therapeutic change that every member agrees to be responsible for. Both the leader and the group members sign and/or seal the contract with a handshake. Men have responded well to this contract. Because the Integrity model is existential, it is about the other and the other's voice and not ours as therapists, nor that of a given therapeutic model. Consequently, the contract is very specific and comprises rules of order as to what are and are not acceptable behaviours for group membership. It is clear-cut and allows men to feel that they are making an informed decision as to whether or not to join the group. That very decision is motivational and helps unfold the existential aspect of the group work. The handshake is important to men; to this day, a man's handshake is so highly valued as to be his bond. It is a simple gesture that symbolically seems to resonate deeply within men, furthering our writings regarding men's honour as being a previously unrecognized therapeutic strength (Lander & Nahon, 2008; Nahon & Lander, 2010, 2011). The Integrity model's perception of the symbolic importance of a handshake for men is further supported by Seager and Thammel's (2009) observation that: "quite early in the group, participants began shaking hands at the end of the session. We wondered about the various levels of meaning: sealing a contract, trust ... status, mutual appreciation or gratitude" (p. 268).

Our emphasis on the importance of the pre-group preparation phase provides clinical support for Rabinowitz's (2005) and Vinograd, Cox and Yalom's (2003) focus on the importance of pre-group screening and preparation (Nahon & Lander, 2008). Akinsulure-Smith (2012) notes that group members are offered the chance to be part of a contact list. The only guideline is that members must let the group know about any outside contact. This echoes the Integrity model's notion of group contracts.

Pre-group preparation for brief men's Integrity groups. When men's Integrity groups are offered through a one-shot encounter, for example, in a faculty wellness or personal growth workshop (Lander & Nahon, 2010, 2011b), there is no opportunity for a pre-group screening session. However, there are two important points of contact with participants prior to the group: (a) the program description and (b) the pre-group needs assessment. We always emphasize the importance of a qualitative description of (a) the philosophy underlying the Integrity model in working with men, (b) the focus on confidentiality, and (c) the expectations of both leaders and participants for involvement and responsibility for the success of the group. This allows potential participants to make an informed choice as to whether they would like to invest in joining the group. We ask group participants to complete a needs assessment in order to identify some of the issues that they would like to discuss in the group. This allows us to dialogue with participants by email, thus beginning to develop rapport, and welcome the men to the group. Furthermore, it invites participants to begin to take responsibility in shaping the group format and content around their issues and needs.

De-Emphasizing Diagnostic Labelling

Be it in the tertiary care or the community clinical/mental health setting, men who find their way to us are usually in deep distress. They readily welcome the reframing of their plight, angst, anguish, pain and traumas as reflecting Integrity crises (Lander & Nahon, 2005). For us, the use of labels is a form of name-calling that is quite devaluing of another. For example, as existentialists, we are non-fans and non-users of the DSM and ICD nomenclatures. In our view, the literature on men includes several insidious sources of name calling which depict men through labels and characterizations that are devaluing, pejorative, and perpetuate the deficit model of being male, such as:

* The use of DSM/ICD terminology, nomenclature or diagnostic labels, such as referring to the "psychopathic" or "narcissistic" male; and

* The concept of the alexithymic male, characterized by Levant (2001) as occurring "in garden-variety or mild-to-moderate forms; these forms are very common and widespread among men. I have come to term this condition normative male alexithymia" (p. 424, emphasis in original).

Furthermore, Kimmel (2008) depicts young men in Guyland: The Perilous World Where Boys Become Men through characterizations such as the following:

   Guyland is the world in which young men live.... In this
   topsy-turvy, Peter-Pan mindset, young men shirk the
   responsibilities of adulthood and remain fixated on the trappings
   of boyhood, while the boys they still are struggle heroically to
   prove that they are real men despite all evidence to the contrary.
   (p. 4)

We view this description as being of reflective of popular culture's negative portrayal of men. As a point of contrast to Kimmel (2008), an existential approach has allowed for a more positive and respectful portrayal of young men: Woodman (2011) found that both high school and college males were extremely receptive to a course focusing on a "philosophical consideration of identity construction and social values" (p. 52), framed around an existential perspective.

The Integrity Group Leader

In an Integrity group, the leader also honours the contract of being honest, responsible and behaving in a manner which closes the psychological space with self and others. The leader must be willing to dare to be challenged by group members, and meet these challenges with complete integrity and without hiding behind the title. Leaders must also be courageous in facing the narcissistic injury of really being just members but with the added responsibility of therapeutic accountability to the institution where appropriate (Lander & Nahon, 1999).

We have found that the male leaders need to be comfortable in dealing with their own anger, and

... in being nurturing to the other men in the group. This may act as a therapeutic agent both by virtue of its role-modeling potential and by allowing for a healing bond to occur. With regard to self-disclosure, we have found that a lack of self-disclosure by the mental health counselor is less problematic than prematurely terminated and/or inconsistent disclosure. In other words, if the mental health counselor initially self-discloses and then withdraws-perhaps because of ambivalent feelings about intimacy with men-the members of the group will feel rejected and betrayed. (Nahon & Lander, 1992, p. 411)

The most effective leaders are open and comfortable with their personal levels of self-disclosure, and behave with integrity in respecting these boundaries. What we find most critical is that when leader self-disclosure occurs, it is relevant, and not in competition with the group members for airtime or attention. Rather, it must be offered with the intent of closing the space and increasing the sense of community within the group. These disclosures, offered in a spirit of integrity, further contribute to keeping the group circle complete. In doing so, the shamanic healing powers of the group in which each person is critical in preserving the continuity of the whole-is nurtured and preserved (Lander & Nahon, 2005; Nahon & Lander, 1992).

The therapist's willingness to be an equal player within the group, openly accepting challenges from the members, is critical in circumventing impasses in the group, especially in dealing with authority battles or confrontations.

The Integrity model's focus on a seeking of counsel reinforces the notion that one is ultimately responsible for one's values, one's decisions and one's choices, thus creating a vehicle for an existential process of self-work and self-exploration. It also stresses one's autonomy in choosing how one is going to handle the thoughts, feelings and wisdom offered by other group members. This atmosphere of a democratic and egalitarian group process "avoids the image of the wheel in which everything is connected through the axle of the leader, thus keeping the circle from being broken" (Lander & Nahon, 1999, p. 10). It offers an alternative way of dealing with group impasses. For example, resistance is dealt with by the group through a challenge to all members, including the leader, to be willing to be held accountable to the group. Members may call into question one another's excuses or rationalizations. Again what is encouraged here is a seeking of counsel. Because only the self can determine whether or not one has honoured or violated one's value system, this prevents or minimizes the taking up of group time with those control battles or impasses which might be viewed as resistance.

The Three Legs of Integrity in Men's Groups

The three legs of Integrity are a major focus of our group work with men. Honesty means daring to have an openness with others and truthfulness with self and other. Responsibility means that one must be careful about how one uses one's honesty, and be willing to dare to be accountable for one's deeds and misdeeds. It also means that one must make amends wherever necessary. The focus on closing the psychological space with others in the group is a key one; this means that the men in the groups must care deeply, and share the gamut of their emotional reactions to one another ranging from warm affirmation to angry disgust.

In an Integrity group, this sense of community really comes alive, as the men in the group are able to identify with one another based on their angst, their pain, and their commitment to discovering a greater sense of meaning in their lives. They have a deep respect for one another's voices and unique paths. All group members are therapists for themselves and for one another, based on their ability to be radically honest with themselves, to self-disclose, to be compassionate in understanding each other's situation, and to offer support as each man undertakes his journey of repair and healing based on his values as a man of honour.

The seeking of counsel honours Mowrer's concept of religare (Mowrer, 1961), or return to community through improved communication with others and a commitment to a more responsible and mature lifestyle (Lander & Nahon, 2005).

As each man shares his journey and his integrity violations, past and present, there is a sense of full knowledge of one another. The men are peers to each other, and their deep acceptance of each other is palpable and real. This deep sense of openness, comradeship and community are key therapeutic factors in the group.

In her work with African refugees, Akinsulure-Smith (2012) found that the group provided members with a sense of family; they referred to each other as "my brothers." Our Integrity-based group work with men shows that Akinsulure-Smith's results are far more universal. In the Integrity groups, the bond between members is immediate, involving a respect for one another's voices and differences.

Working With Value Clashes in the Group

Like Mowrer, we view the group as providing a microcosm of the daily lifestyle of the members. For us, this means that who we are and how we behave reflect a value system. It is this sense of self as a value system that allows men to have a sense of meaningfulness as they live out their daily lives, or not as is often the case when men seek us out. As they reflect on the values they are operating with, they often discover that these values are not their own or that if they were, they would rank them differently. Now the real work begins as men start to quickly articulate their values and how they would rank them. Then comes the challenge of walking the talk by behaviourally translating their value system into their daily lives-for to have a value system and not honour it is the best way to create what Mowrer called a sense of "dis-ease" (O. H. Mowrer, personal communication, 1969), stress, anxiety, angst and a host of other symptoms.

When value clashes arise, members and leader alike are asked to examine the personal values and value hierarchies which govern their decision-making and behaviours, not only in the context of the group but also in daily life and daily relationships with others as well as the prices they pay for these values, and whether or not these prices are worth it.

Challenging the Development of Sub-Groups

From the Integrity model perspective, the functioning of the group as a whole is ultimately the responsibility of each member. This means that there is an ongoing sense of scrutiny by all members including the leader of the level of integrity of the group. This has a powerful impact on mitigating the likelihood of alliances and sub-groups forming. If the group becomes aware of a sub-group forming, this is immediately examined as to its level of integrity by the group. In other words, the individuals involved in the sub-grouping are asked to look at their levels of honesty, responsibility, and closure of the psychological space with the group at large by their formation of a sub-group. They are invited to look at the values that underlie this covert alliance. The group may provide useful feedback in helping these members to understand both patterns from the past and current difficulties with daily living that may be connected with this dynamic of sub-grouping (Lander & Nahon, 1999).

CLINICAL AND EMPIRICAL FINDINGS ON INTEGRITY-BASED GROUPS

The Integrity model served as the treatment modality in Lander's Integrity groups from 1973-1986 in a tertiary care setting, and in the Men's Clinic at The Ottawa Hospital, 1984-1994, the first tertiary care clinic for men in the world (Nahon, 1993; Nahon & Lander, 1992, 1998). As summarized earlier, results of the first empirical study of an Integrity-based group psychotherapeutic intervention with men (Nahon & Lander, 2010) has provided a positive re-framing of men's accessible potential for engagement and positive therapeutic change. The high participant self-referral to the program, low group drop-out rate, as well as the pre-group/post-group improvements in psychological functioning provide support for the viability of an Integrity-based group approach in engaging and working with men in groups.

At an Integrity workshop offered to men's studies scholars (Lander & Nahon, 2011a) we found that heterogeneity in terms of theoretical backgrounds, disciplines, languages, and culture of participants became a source of richness in the group. Participants found the Integrity model's focus on contracting and value exploration to be helpful in providing new frameworks for addressing personal and professional impasses.

From the mid-90s to the present, we have worked with men in both same-gender and mixed-gender groups for faculty members in a medical school. The Integrity model has provided a positive perspective towards self-care and the care of others. Men in these groups have openly shared their sense of profound distress emerging from (a) the untenable demands of academic medicine, and (b) the deep-seated conflicts between professional success and a meaningful life (Lander & Nahon, 2009, 2011b).

Anecdotally, we recently found out that one of our colleagues had left a copy of Lander and Nahon (2005) lying around her home. She was amazed that her teenaged son not only found it, but actually read it, and she wanted to let us know that he felt it really turned his life around. She also related that he had passed it on to his father, feeling that this would be helpful. His Dad read it, passed it on to a good friend, and they decided to start their own Integrity group. This is a peer-led group of men with a history of significant trauma and addictions, retired from high positions of leadership, who have been working on their recoveries via weekly meetings utilizing the Integrity model as a guide for discussion. It seems that the men have found it helpful and transformative in many ways.

DISCUSSION

Celebrating AMSA's 20 years in the trenches advocating for a positive view and understanding of men and masculinities, this paper comes full-circle in supporting men's positive voices in a group context. In our respective 30- and 40-plus years of group therapeutic work with men in varying contexts and across demographic and diagnostic categories, men have resonated with the Integrity model.

The greater the crisis, the more powerful the simplicity of the Integrity model in making sense out of a seeming morass of meaninglessness and chaos. According to chaos theory, even the smallest and most minute change creates far-reaching impacts. So too with the Integrity model; because of its existential nature, it provides a philosophical understanding of self and self in the universe. Because of their new awareness of the values underlying their behavioural choices, men discover new ways of understanding themselves and how their values influence their choices and provide them with a sense of meaningfulness in their daily lives. The Integrity model, with its emphasis on values, allows men to make profound characterological changes resulting in an increase in self-esteem.

While women have fought for professionals to be sensitive to the feminine voice in therapy, this voice does not seem to be very effective when working with men. Feminism made huge inroads in changing the antiseptic, neutral and sterile voice of psychology, psychiatry and psychotherapy to be more feminine and feminine-sensitive. This great milestone and victory for women to have their voices valued reflects a journey that men must also undergo in order to have their voices valued, because men's journeys through the vicissitudes of daily life and socialization are different. Hence, men's vocabulary and metaphors are also different. We let men know that it is not our voices as clinicians that they must emulate; rather, it is their own voices that they must discover and claim, as men, and their own voices that they must speak in the groups.

There is something about a man's voice that reaches other men, and that is far more effective than what theory or models can do. In an Integrity group, men are basically told: "This is your group. You are responsible for your 50% of the successful outcome of the group (the second leg of Integrity). You bear a responsibility for the degree to which you are able to profit from this encounter and from this opportunity to be with other men."

Rochlen et al. (2010) call for the need for further research on treatment barriers for men. Taken as a whole, the findings from 40-plus years of Integrity groups offer a different vantage point from which to address some of the perceived issues that are raised in the literature on working with men. This ever-growing body of knowledge suggests that treatment barriers are actually a function of either the therapeutic model or the clinician's or researcher's biased perception in their view of men and masculinities.

Similarly, in addressing the literature's focus on the challenges that men encounter in moving beyond their cultural norms which discourage men from self-disclosure, leading to isolation, distress and decreased self-awareness (Ogrodniczuk & Oliffe, 2009), we believe that the literature's perceived barriers reflect a theoretical and clinical bias. Our biases do influence the ways that men perceive us. For example, the philosophy and perspective of male and female group leaders towards men's capacity and ease of access to their emotional voices act to either enhance or create impasses in the group. Furthermore, as we have presented in this article, the non-pathologizing of life's dilemmas by reframing them as value clashes allows men to become aware of their 50% of the accountability in doing the necessary repair work in addressing and resolving their sense of isolation and distress through a paradigm that is (a) accessible, (b) in their own voices, and (c) fully individualized in its focus on their values.

The Integrity model addresses the literature's call for a viable paradigm for ways in which (a) men can gather in a manner that aims to enhance men's psychological health (Adams, 2011) and (b) clinicians can "increase their ability to work with diverse groups" (Akinsulure-Smith, 2012, p. 109). Because the Integrity model focuses on the values of the other and not the therapist, there is no need for expertise or specialization around the values of the other. For example, in her clinical work with men whose ethnic/cultural backgrounds vary from her own in the national capital cultural mosaic, Lander has found that, ironically, not being of the same culture or demographic variables is an asset rather than a liability. As they explore facets of their identities and masculinities, the men voiced their view that a therapist from a similar background would have generated a resistance for them and a pressure to conform to cultural norms while exploring their potential for individuation and change.

In crisis, with horrific his-stories and diagnostic labels attached to them, men have shown us that they have the most amazing poetic emotional voice, and that they are able to honour and value their vulnerabilities and to view these as the source of their greatest strengths, addressing Seidler's (2009) call for a positive model of masculinity, anchored in what Seidler referred to as (a) a "connection between the personal and the therapeutic", (b) allowing for inter-cultural dialogue, and (c) aiding men to find ways to like themselves as men. (Nahon & Lander, 2011, p. 28, emphasis in original)

DOI: 10.3149/jms.2102.162

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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. They are deeply grateful to James P. Maurino and Jeff W. Cohen for their helpful assistance, and to Men's Studies Press for its ongoing championing of scholarship in men's issues.

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