The integrity model: working with men, their intimacy issues, and their search for community.

Nahon, Danielle ; Lander, Nedra R.

As we traverse our lives, we are each strangers in a strange land. Each man faces the existential challenge of assimilation versus integration as he ventures out of the trap of his comfort zone and dares to reach out to others. Based on our work as clinical psychologists working with men in tertiary care, community and academic settings, this article aims to provide a theoretical and clinical exploration of the ways in which men address the poignant issues of belonging, intimacy, and their sense of community with self and others as defined by Mowrer (1960, 1969; Lander & Nahon, 2005) within the context of their therapeutic work. This discussion is framed around the case studies of Paul and Tomas, two men from different walks of life presenting in therapy with a history of relationship issues and a deep sense of isolation and despair. Both men entered therapy with profound issues around intimacy and sense of community with self and others. Paul had a long history of estrangement from his wife and sons, and of withdrawing from others in times of conflict. His marriage was falling apart and he suffered from a plethora of mental health issues. Tomas had long-standing issues with regard to communication and dealing with anger in his relationships with women. He grappled with feelings of jealousy and issues around power and control. He too tended to shut down when angry; his girlfriend had left him and he presented in crisis with symptoms of depression.

Men, Intimacy, and Community: A Review of the Literature

"Intimate relationships are the principal arena within which adults live out their emotional lives" (Mirgain & Cordova, 2007, p. 983). Heller and Wood (1998) define intimacy as "a process in which people try to become close and explore their similarities and differences in feelings, thoughts, and behaviors" (pp. 273-274), and

   an experience that is the outcome of the disclosure of intimate
   topics and sharing intimate experiences, and an intimate
   relationship as two people who share intimate experiences over time
   ... expect continuity of the relationship and those experiences,
   (p. 274)

Hook, Gerstein, Detterich, and Gridley (2003) characterized intimacy as

   a multidimensional concept that means different things to various
   people. This is especially true for individuals from different
   cultural backgrounds, because other cultures do not view intimacy
   as a necessity or even in the same way as it is viewed in the
   Western world, (p. 462)

They suggest that most studies examine four major components of an intimate relationship: (a) love and affection, (b) personal validation, (c) trust, and (d) self-disclosure. They propose that intimacy is a key aspect of personal growth, harking back to Erikson's (1959) psychosocial stage of "intimacy versus isolation."

What does the literature tell us about men's capacity for emotionality, including their journeys in finding emotional intimacy and community with self and others? Land, Rochlen, and Vaughn (2011) pointed to the sustained thread in the literature regarding the strong correlation between men's traditional roles and men's ongoing challenges with achieving intimacy and community with others. This thrust is strongly linked to what O'Neil (1982) termed gender role conflict (Land et al., 2011). O'Neil (1982) proposed that men who experience gender role strain have adopted the values of "the masculine mystique" (p. 8), expressed through six patterns of gender role conflict and strain: (a) restrictive emotionality; (b) restrictive sexual and affectionate behaviour; (c) homophobia; (d) socialized control, power, and competition issues; (e) obsession with achievement and success; and (f) health care problems. Nahon and Lander (1992, 2008, 2010, 2011) suggested that this model has become deeply ingrained in current conceptualizations of men and their potentials--or lack thereof-for emotional expression, help-seeking, and positive therapeutic change. Fischer and Good (1997) pointed to men's "press for devaluation of emotional intimacy in romantic relationships" (p. 161). They concluded that men who are high on the variable of restrictive emotionality may consequently find it hard to access social networks necessary for daily living and suggested that counsellors working with men who hold traditional male gender role values should help these men to understand and address their impasses around intimacy. Mahalik, Coumoyer, DeFranc, Cherry, and Napolitano (1998) suggested that men who are emotionally restricted are fearful of appearing feminine and find it difficult to express their feelings and to appear vulnerable.

O'Neil's (2008) review of 25 years of research using the Gender Role Conflict Scale (O'Neil, Flelms, Gable, David, & Wrightsman, 1986) concluded that

   men struggle with intimacy and self-disclosure with women and other
   men because of their gender role socialization.... From the results
   of these initial studies, GRC [Gender Role Conflict] significantly
   relates to men's lack of intimacy, self-expressions, and connection
   with other men. (pp. 391-392)

   "RE [Restricted Emotionality] significantly correlates with lower
   self-esteem, anxiety, depression, stress, shame, marital
   dissatisfaction, and negative attitudes toward women and gay men
   and many other interpersonal restrictions" (p. 419).

O'Neil goes on to suggest that "therapists can become experts in helping men develop emotional vocabularies and ways of expressing feelings" (p. 420). Land et al. (2011) proposed that attachment theory provides a useful paradigm for understanding the genesis of "distinctive, stereotypical male styles of relating" (p. 65). Referencing Blazina (1997), they suggested that men's tendency to refrain from engaging in emotionally intimate relationships is linked with men's difficulties in regulating their emotions through appropriate "emotion regulation suppression and reappraisal" (p. 71). They pointed to the "potential benefits to incorporating explicit affect regulation strategies and interventions with existing gender-sensitive treatment approaches" (p. 72).

A number of authors have studied men's intimacy and emotional connection in the context of couple relationships and men's friendships. Mirgain and Cordova (2007) found that emotional skills were key in the process of a healthy marital relationship due to their impact on intimacy; although there were few gender differences in emotional skills, those noted pointed to women as being more skilled than men. Patrick and Beckenbach (2009) suggested that intimacy is key in couples achieving a sense of trust, and that without it the relationship may fail. They suggested that men and women may have a different conceptualization of what intimacy means. Heller and Wood (1998) suggested that for men, intimacy becomes the "transforming experience that brings the self back into connection with others and to an understanding of their perspectives" (p. 276). Heasley (2013) proposed that "the journey for men who experience isolation and maintain emotional distance from other men (and often, women as well) begins at an early age" (p. 345). He suggested that many men in Western culture experience a loss of intimacy as children, unlike earlier days where there were deeper bonds with boys and adult men. Examining same-sex male friendships, Bowman (2008) found that men with a higher gender role orientation were less willing to disclose negative information about themselves, but masculine gender role orientation was not inversely related to the quantity or extent of self-disclosure. The author concluded that "friendship behaviors are not easily categorized by masculine or feminine gender role orientations" (p. 326).

There is a paucity of published articles addressing working with issues around intimacy and men's sense of community in the context of therapeutic work with men. Richmond and Levant (2003) described a group intervention with seven boys, six of whom had been court-mandated for treatment, and one referred for depression. They conclude that the boys' willingness to explore the traditional male role "reflected on the psychologically harmful aspects of endorsing traditional masculinity. The awareness of the gender role strain became the first step in loosening strict gender role adherence" (p. 1243). Garfield (2010) described a therapeutic group program for men focusing on

   helping them to develop emotional intimacy skills while augmenting
   their work in couples therapy.... We emphasize the development of
   friendship skills, core attributes of friendship (connection,
   communication, commitment, and cooperation) that contribute to
   emotional intimacy in men's relationships, (p. 109)

The literature on psychotherapy with men warns of the limitations and difficulties that therapists face when contemplating working with men around emotional expression and their sense of personal vulnerability in the therapeutic process. For example, Englar-Carlson, Evans, and Duffey (2014b) stated that "common expectations of counseling, such as disclosing personal vulnerabilities, expressing emotions, and relying on a counselor for assistance, are not consistent with the ways many men are socialized to cope with problems" (p. xxiv). Referencing Good, Thomson, and Brathwaite (2005), they suggested that "some men actively work against connecting in counseling by avoiding counseling, remaining stoic in session, or acting out in order to unconsciously sabotage an emotional bond or connection" (p. xxiv). They reviewed the literature pointing to the lack of congruence between the way that men traditionally relate and the process of counselling, leading many authors to recommend "making male-friendly adjustments to their approach to fit with male socialization. These adjustments include changing the way counseling is presented to men by altering the therapeutic language and modifying the way counseling is conducted" (p. xxiv). Englar-Carlson (2014) suggested that

because of the prohibition against strong emotional expression and the difficulty many men may have identifying and expressing vulnerable and caring emotions (Brooks, 2010; Levant & Kopecky, 1995), some men may believe that feelings are better left unexplored (Mahalik et al., 1998). (p. 20)

This may result in early termination; the authors suggest that although most individuals are anxious about the therapeutic process, this is more marked in men.

Rabinowitz and Cochran (2002) suggested that therapists should appreciate the extent of the sense of shame that men will experience when they grapple with exposing their vulnerabilities and with the emotional relatedness in therapy. The authors stated that

   even when a man has crossed the threshold and entered
   psychotherapy, he often faces numerous obstacles to inner
   exploration ... Adherence to traditional male gender role rules of
   conduct will be challenged by the intimacy demanded in the
   interpersonal situation with the psychotherapist, (p. 51)

The authors suggested that men are uneasy with their vulnerabilities being exposed to the therapist, and consequently,

the task that lies ahead of the psychotherapist is not an easy one. He or she will need ... to be well versed in a wide range of deepening interventions in order to guide the man toward his emotional depth, (p. 51)

Sometimes therapy moves at a quick pace only to be interrupted by absences or a surprise termination.... Especially in initial sessions with male clients new to therapy, a slow pace is preferable to a fast one. (Rabinowitz & Cochran, 2002, pp. 129-130)

Challenging the Myth of the "Emotionally Defective Male"

A number of authors have suggested that the literature may utilize an inaccurate lens in examining intimacy in men through a tendency to feminize its nature. As previously discussed, Lander and Nahon (2008a) suggested that men's voices

   may not match the voices and metaphors of theoretical therapeutic
   models based on the feminine mode of emotional expression as the
   standard-bearer for appropriate emotional expression ..., placing
   potential male clients at risk of experiencing the historical
   wounds of "not being heard." (p. 143)

Heesacker and Prichard (1992) suggested that such phrases in the literature as "restrictive emotionality" and "fear of intimacy" serve as examples of what they termed the "flawed emotion" (p. 276) view of men, creating a perspective of men as defective not only in their capacity for emotional expression but also in terms of a generalized "male psychological defectiveness" or "denigration of the essence of men" (p. 277). Nahon and Lander (1998) have referred to this pessimistic and pejorative view of men in the literature with respect to men's capacity for emotional relatedness and their likelihood to seek psychological help when needed as the myth of the "emotionally defective male" (p. 16; Nahon & Lander, 2008). Nahon and Lander's (2008, 2010, 2011, 2014) reviews of the literature indicate that a number of empirical studies have pointed to the presence of a negative bias in the attitudes of therapists with respect to male clients. Englar-Carlson, Evans, and Duffey (2014a) suggested that

   a counselor's bias in working with men ... can be seen in gender
   stereotyping around assessment and diagnosis (Ali, Caplan, &
   Fagnant, 2010), holding stereotypes or having the expectation that
   all men should enact traditional gender roles in order to be
   healthy, (p. 348)

Hook et al.'s (2003) literature review suggests that research on intimacy and on therapeutic approaches in dealing with intimacy issues has been carried out from a female-focused perspective. They proposed that "if researchers and counselors have been listening to dialogues for indications of intimacy based on feminine relational strengths (i.e., verbal intimacy, empathie responding), they may have missed hearing or understanding the unique male voice of intimacy" (p. 465), and that "boys and men seem to feel that sharing activities and interests are just as important to experiencing intimacy as are self-disclosures. Moreover, silence, telling of stories, and other active forms of expression may be men's way of expressing themselves" (p. 465). Patrick and Beckenbach (2009) suggested that men's intimacy may be under-measured in research studies through the use of inaccurate measures that may not viably capture men's experience. Citing Cancian (1987), Davidson (2004) suggested that we tend to measure the "quantity and quality of social networks with a 'feminine ruler,' and we need to seek different ways of viewing intimacy and friendship patterns in the lives of older men" (p. 40). Examining men's friendships, Migliaccio (2009) proposed that although researchers are cognizant of differing kinds of intimacy, they isolate intimacy into masculine and feminine variables, leading to an artificial assumption about male-female differences in friendship patterns. Wong and Rochlen (2005) reviewed the literature challenging the view that men are less emotionally expressive than women, and suggesting instead that "men's and women's emotional behaviors are more similar than different. Moreover, when differences do emerge, they tend to be small, inconsistent, and limited to specific situational contexts" (p. 62).

We have been pleased to see the beginning of a theoretical shift away from the deficit view of men and masculinities reflected in O'Neil's (2008) suggestion that "one future direction for improving men's lives is to conceptualize healthy aspects of men's gender roles" (p. 434). Kiselica and Englar-Carlson (2010) summarized what they characterize as being 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). We have been saddened that the Integrity model, beginning with Mowrer's work in the mid-1940s, and with its long-standing history of advocacy for a positive view of men, has not been acknowledged.

Long before O'Neil's (2008), Kiselica and Englar-Carlson's (2010) and Englar-Carlson and Kiselica's (2013) calls for a positive perspective on men, results of a growing empirical and clinical literature based on what is now nearly five decades of work with men, teens, and boys have pointed to men's positive response to a values-based Integrity model of psychotherapy. For example, with reference to issues of intimacy and community for men, Nahon and Lander's (1992) report on an Integrity-based therapeutic group program for men grappling with relationship breakdown and marital separation concludes,

   Our clinical observations to date over the course of the groups
   stand in contrast with the predictions of the literature on
   self-disclosure and help seeking in men.... Although the men in the
   groups unanimously relate that they have not previously had the
   opportunity to share their feelings with other men, they readily
   open up to each other and rapidly come to form a sense of kinship
   and bondedness. This process of emotional sharing is spontaneous,
   intense, and powerful. All our leaders have been struck by the
   extraordinary openness and honesty of the men in the groups, (p.
   412)

Nahon and Lander's (2008, 2010) report on the results of the first randomized investigation of men's consciousness-raising groups and gender role re-evaluation psychotherapy groups for men points to significant changes in emotional expression, self- and other-orientation, and psychological well-being, maintained at 6-week follow-up. The majority of the variance noted for the self-and-other orientation cluster was accounted for by the Capacity for Intimate Contact (Shostrom, 1974). The authors concluded the following:

The fact that these facets of psychological functioning were able to undergo significant changes without either the need for a communication skills training program, or the necessary inclusion of an overt consciousness-raising component would suggest that these skills may be more accessible in men's behavioural repertoire than the bulk of the literature had previously considered. (Nahon & Lander, 2010, p. 121)

A number of authors (Evans, Carney, & Wilkinson, 2013; Miller, 2012; Shen-Miller & Olson, 2011) have pointed to the applicability of the Integrity model as a values-based therapeutic approach, and in working with men from a positive, strengths-based, and gender-sensitive perspective. Mowrer's early community-based Integrity groups from the 1950s 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, 1964). Beginning with Lander's group work with boys in the late 1960s (Lander, 1986), results of empirical and clinical research have indicated that the Integrity model provides a viable approach in working with boys and men in community practice, tertiary care, and academic settings through individual (Nahon & Lander, 2014), couple (Lander & Nahon, 2000a), and group psychotherapy (e.g., Lander, 1986; Nahon & Lander, 1992, 2008, 2010, 2013) in addressing a number of issues including relationship issues and marital breakdown, post-traumatic stress, work-related stress, severe mental illness and addictions, sexual identity, sexual dysfunction, spirituality, end of life issues, cultural diversity, and health promotion for men (e.g., Lander & Nahon, 2000b, 2008a, 2008b, 2010a, 2010b, 2015; Nahon, 1986, 1993; Nahon & Lander, 1992, 1998, 2008, 2010, 2011, 2012, 2013, 2014).

The current article aims to address the literature's call for a strengths-based and gender-sensitive approach in working with men. Framed around Paul's and Tomas's case studies, we will offer a theoretical and clinical exploration of the Integrity model--an existential, non-pathologizing, and values-based therapeutic approach, in working with men around issues of emotional intimacy and men's sense of community within the context of their therapeutic work.

Working With Men, Intimacy, and Community From an Integrity Model Perspective

Expanding on O. H. Mowrer's Integrity (Therapy) Group approach, formulated from the mid-1940s to mid-1980s, Lander and Nahon have evolved the Integrity model that offers the first wellness- and values-based model of psychotherapy. 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 (e.g., Lander & Nahon, 1992, 2000a, 2005; Mowrer, 1953, 1966; Mowrer & Vattano, 1976; Nahon & Lander, 2013).

An Existential Understanding of Men's Search for Intimacy and Community

As we have previously discussed, the Integrity model is an existential therapeutic framework both in terms of substance and form. It does not merely deal with existential issues--it is existential. The Integrity model stresses the client's equality to the therapist, and the client's role in the therapeutic process (Lander & Nahon, 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 Integrity model asks that the therapist use the language of the other, rather than have the other learn the jargon of therapy. 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; Mowrer, 1961, 1964).

As existentialists, in our understanding of the plight of being human, we work from Jean-Paul Sartre's dictum that to know oneself, one must first know another. Within this encounter with another, men begin to distinguish between the "me" and the "not me." It is at this juncture that the potential crisis of identity begins around issues of individuation, autonomy, and diversity. In facing the challenge of discovering the differences and the likenesses that they have with others, men must confront the difficult questions that arise as they dare to define what it is that comprises their self in its own right, as well as their self with or against others. Their answers to each of these existential decisions reflect their value systems and their value hierarchies, as one cannot either live or define oneself in a vacuum.

The search for intimacy and community is a challenging one for each human being as we live in a world which is often characterized by rules of engagement for how one relates to others that emphasize hierarchical placement instead of a deeper human encounter. For example, in social situations where people meet for the first time, such as a cocktail party, conversations often begin with a predictable pattern of a 20 Questions approach. These are aimed at sizing up the other and thereby figuring out the hierarchical relationship. If one listens closely, one can almost hear abacus beads sliding back and forth with lightning speed with each new piece of data as one's relative status is perceived. This manner of relating to others is often lacking in a genuine sense of interpersonal connection, as really little of the self is revealed behind the facade. How do men traverse the societal construct that impedes intimacy and thereby encourages a non-intimate encounter with another?

Our work with men around issues of intimacy and men's sense of community is framed around the four basic tenets of the Integrity model: (a) men's clarification of their values and value clashes, (b) men's ongoing mindfulness around the three legs of Integrity, (c) Buber's concept of the "I-Thou" relationship, and (d) the three stances of "movement towards, away from, or against others" in dealing with conflict.

Men's clarification of their values and value clashes

In beginning to address issues of intimacy and community by finding a meaningful and intimate sense of connection with self and others, men are invited to look at the values that they currently hold, and the behaviours that are the reflection of those values. They are invited to examine the price tags they pay for holding each of these values (Lander & Nahon, 2011). They are asked to list the values of a man of character, and to examine how these differ from the values that underlie their current choices and behaviours. Men begin to examine the value clashes that they have with important others in their lives; they reflect on the price tags that they would have to pay if they were to change these values. They also reflect on whether there may be alternative values of the self that they might value more because these would be unique to them, rather than valued by other individuals or groups.

In men's journeys of addressing issues of intimacy, this process of value analysis becomes critically important. Men may come to discover that they long for a deeper level of connection or community with others, but they have never known the path toward achieving this. This in turn challenges men to examine their values regarding altruism, power, and closeness to others. Through this process, men come to re-evaluate how they have dealt with conflict and anger in past relationships, and to discover the values that underlie their modes of conflict resolution. They are invited to reflect on whether these patterns have resulted in deepening their sense of commitment to their relationships, or, instead, in pushing others away.

Reviewer question. The portrait of the "existentially based" theory known as the "Integrity Model" is interesting, but not particularly original. All of these principles and interventions are reflected clearly in other orientations. The idea of focusing on men's strengths and showing respect for male values is not as novel as the authors portray it to be.

Author reply. To cite the 15th-century (English) proverb, "comparisons are odious" (Dryden & Mytton, 1999, p. 173; Lander & Nahon, 2005, p. 59). Values is a trendy word bandied about in most theoretical models in one way or another. However, no other model seems to focus on (a) values as the very essence of men's beingness, (b) how a man's values underlie all of his thoughts and actions, nor (c) values analysis and values ranking as the fundamental focus of therapy. Through the process of values exploration, the Integrity model enables men to discover their own strengths as a function of the values that underlie them. They come to discover that one's very self and one's identity arises as result of articulating and giving behavioural expression to their values, value systems, and value hierarchies. The focus on values allows men to reach a contextual understanding of both their selves and others, and provides a flexible and adaptable paradigm for daily living as it invites men to define their own values under differing and often challenging circumstances. In understanding both conflict within the self and with others as reflecting a clash of values, the Integrity model provides a wellness-based framework for resolving difficult impasses in men's relationships and in their sense of community with self and others--as both Paul's and Tomas's cases studies will illustrate.

The three legs of Integrity

As we have previously discussed, 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--which is the definition that we are focusing on in this article. This concept of community really is about relational attachments. The Integrity model requires all three components to be present for Integrity to exist at a given time in any given context (e.g., Lander & Nahon, 1992, 2005; Mowrer, 1953, 1964, 1966; Nahon & Lander, 2014).

Working with the three legs of Integrity becomes a key paradigm for men working around issues of intimacy and community. The honesty leg invites men to examine their values and behaviours with a sense of openness and candor. The responsibility leg, which in many ways embodies the essence of Integrity, invites men to take full account of their 50% in conflict situations, rather than explaining their behaviours as reactions to someone else's actions. The third leg of Integrity, which is that of closing the psychological space and increasing one's sense of community with self and others, is a critical therapeutic variable when men are examining their sense of intimacy with others. It invites men to look at the intentions underlying their actions, and whether these are aimed at moving closer by increasing their sense of community with others. The three legs of Integrity, culminating in the concepts of closing the psychological space and increased community, play a pivotal role in helping men to discover a new modus operandi for being-in-the-world, and in their relationships with self and others, as Paul's and Tomas's therapeutic journeys will illustrate. Men quickly come to implement this paradigm as a guide for living or a Global Positioning System (GPS; Lander & Nahon, 2000b) in dealing with the issues of daily living, including relational impasses.

Buber's concept of the "I-Thou" relationship

A key concept of the Integrity model is the emphasis on Buber's (1970) concept of the I-Thou (vs. the I--It) relationship:

Mowrer, while working independently from Buber although along parallel lines, was able to take Buber's great insights, and unknowingly translate Buber's sometimes esoteric philosophy into simple, everyday language as to how to conduct therapy and how to live daily life. (Lander & Nahon, 2005, p. 30)

Buber (1970) proposed that when an I-Thou relationship exists between individuals, "the Between"--or in our words, a sacred space or a moment of encounter--takes place. We see the third leg of Integrity--closing of the psychological space with self and others, or increased community, as a way of operationalizing the I-Thou relationship. This profound and simple concept encapsulates for men a different way of being that is able to bring together something that they have been yearning for, yet have found difficult to both conceptualize and achieve. Men in therapy respond immediately to the concept of the I-Thou relationship as a profound and palpable paradigm for building a more intimate and meaningful relationship with others and ultimately with themselves.

Reviewer question. The I-Thou description could benefit from a clear example to show what this looks like.

Author reply. The answer to the question of what an I-Thou relationship looks like is both simple and profound. If one considers one's day-to-day relationships, be it with loved ones, co-workers, health professionals, or a chance conversation with a stranger at a bus stop, one can pause and consider whether the sense of relatedness or encounter is one of what Buber would term an "I--It" or an "I-Thou." In the "I--It" relationship, there is a sense that one is being treated as object, or like a slide under a microscope; in other words, it feels like an impersonal transaction. In the "I-Thou" relationship, there is a sense of a deep and meaningful encounter or "Between" that occurs between two (or more) individuals. It is our contention that any viable therapeutic relationship in working with men encompasses an "I-Thou" encounter between the therapist and the individual in therapy, which will be critical in creating a sense of safety for men in therapy to express and explore both vulnerable emotions and unsavoury aspects of their lives.

The three stances of "movement towards, away from, or against" others in dealing with conflict

Men who are working toward achieving a deeper sense of an I-Thou relationship find it helpful to consider the Integrity model's concepts of "moving towards, away from, or against" others as a simple and profound paradigm for addressing conflict situations. Our use of these terms stands in contrast with Homey's (1942, 1945) definition of "moving towards, away from, or against others" as comprising coping strategies within what she viewed as 10 patterns of neurotic needs. The Integrity model conceptualizes Homey's three coping strategies as comprising three major existential choice points in any relationship, and particularly in dealing with conflict, while offering an entirely different understanding from Homey's concept of "moving towards people": We view "moving towards others" as a healthy and profound form of intimacy that reflects the third leg of Integrity--that of closing the psychological space with others or increasing a profound sense of community. Thus, a key concept of the Integrity model is that in any relationship, one can only take one of three stances: to move toward, away from, or against another at any given point in time (Nahon & Lander, 2014). Integrity is about daring to resolve value clashes with others in a manner that allows one to move toward them--especially when one is angry.

At a number of national and international conference presentations, the Integrity model has spontaneously been described by attendees as a peace model. Men in therapy have been profoundly receptive to this paradigm. The intention of "moving towards" allows men to discover a deep and meaningful new way to use the energy of their anger creatively and to resolve conflictual situations. This provides men with a new foundation for addressing relational impasses and for building a deepened sense of community with others based on a greater harmony within the relationship.

Case Examples: Paul and Tomas

Paul

A highly successful professional in his late forties, Paul had been diagnosed with depression and prescribed anti-depressant medication. Paul was living at home but separated from his wife Mary; he felt very disconnected from her and his three sons. An ongoing issue was a profound difference in their sex drives, with hers being described as virtually non-existent. Although Paul loved his kids, he had never felt connected to them. Paul disclosed to Mary that he had had a long-standing affair with Linda, a woman he could discuss his feelings with, and who he felt was the only person who pushed him to be honest with himself. Mary responded to this disclosure by "finding her sexual self," but for Paul it was "too late as though a switch had been turned off." Paul presented with symptoms of anxiety and burnout, and suffered from insomnia, panic attacks, labile moods, hypertension, and difficulty concentrating. He drank daily, could feel the wear and tear of stress on his body, and found it quite difficult to cope at work or home, necessitating an extended sick leave from his job. Although motivated, Paul appeared to be somewhat evasive, using jargon gleaned from self-help books and numerous leadership-training workshops.

Paul's goals for therapy were to find out who he was, what made him happy, and how not to repeat issues from the past. Paul composed the following contract which he signed with a handshake: "I will be open with [the first author] and myself in terms of being challenged on areas and on dimensions to really open myself up to find myself." Not once did Paul waver from this contract.

Paul liked the Integrity model and readily began to explore the discrepancies between his professed values and his daily life. He could see that he always focused on work as it was immediately rewarding and safe from the emotional challenges of deeper and intimate relationships. Even though he had a couple of lifelong male buddies, there were no deep connections with them. Paul found it safe to be "more inward" versus daring to "close the space" with others as he felt that this would make him more vulnerable to being judged. He explored his values of a man of character, especially his valuing of honesty versus a well-honed skill at creating a clever facade aimed at pleasing others. He saw how this facade had tainted his relationships, especially with Mary, and exacted a high price on his self-respect and on his very sense of self.

Paul said he appreciated being both understood and challenged as to his Integrity. He decided to focus on a new value of finding greater meaningfulness in his life and in his relationships and on becoming "more coherent and true" to himself. Paul began to work hard with the three legs of Integrity as a new modus operandi for his moment-by-moment actions and decisions. Almost immediately, he reported feeling better and was told by his family doctor that his blood pressure had greatly improved.

Paul explored his experience of having grown up as a "latchkey" kid, leading to feeling a rudderlessness that had become part of a lifelong sense of a nomadic existence without deep connections. He reported beginning to spend more time with his sons and to dare and strive for a greater sense of an I-Thou relationship with them.

Paul explored his relationship with Mary, and could see that he had dealt with his anger and hurt toward her sexual withdrawal by moving away from her. He found it very helpful to realize that similar patterns had occurred in previous relationships. He explored his blocks to communication, which were centered around the fear of appearing flawed, for example, from his lack of being handy around the house which he felt a man ought to be. He said he found it enlightening to realize that a bottom-line conflict--significant across his life span--was that of a clash of values between being a maverick versus a people-pleaser.

At our next meeting, Paul told me that he had decided to accept a job offer in Montana, and was planning to move there and further his relationship with Linda. He spoke about his fear of staying here and disappointing people if he were to really speak his mind and be true to his feelings. Paul was able to articulate the memories of attachments that had become more manifest as he explored being true to his values. He said he would further reflect on his attachments here, prior to going on a family holiday.

Our subsequent meeting marked a profound turning point in Paul's journey. Having moved to Montana, Paul found himself experiencing a renewed bout of panic attacks and migraine headaches. He understood that the return of his symptoms signified the fact that his current choices were "taking a toll on his body" due to an Integrity crisis. He reported feeling very uneasy when Linda had said to him that he should move on from his family, and that he could no longer be friends with Mary. Paul realized that he could no longer "move on" with the sense of relief that he had expected this would bring on. He said that therapy had helped him to own how much his wife was a part of his very essence, and how much of the turmoil had been caused by his sense of being cut off from special people in his life. He realized that the self-help book on separation that he had previously turned to had sold him a false bill of goods through its advice that "you should go with what feels good," only to discover that his body's organismic wisdom was greater than the pleasing cognitive constructs of the book. He stated, "It did not feel right; my body clearly said 'no.'" Paul told Mary that he had decided to reconcile with her, and flew out of town to end things in person with Linda.

Although he had surprised himself--not to mention Mary--with his decision, Paul felt good as he could see that he had behaved with complete Integrity and thus was earning a sense of deepened self-esteem. He was feeling happier with a new and positive sense within his family, was able to focus better at work and had a better joie de vivre. He was now focusing on taking the time to be with his sons, and committed to working on himself--physically and mentally. Although he had accepted the job in Montana, he planned to stay there for a limited time, was in constant contact with his family, and flew back home at every opportunity.

At our last meeting, Paul felt comfortable and anchored in his life. He was taking the time to understand himself and his situation, and to improve his communication with his family. He felt closer to Mary, was working on his emotions, and discovering a new language for them. He spoke of discovering new and meaningful ways of being up-front versus his previous pattern of "double-speak," and of working through issues rather than hiding from them.

Paul felt more serene and closer to himself versus his constantly searching for a "high." He was rebuilding his life by attending to the little things, such as honouring Mary's needs: making long-term plans, doing things together, and sharing experiences with her. He felt that this helped him to be and remain honest with her and with himself: "it feels nice; there is no extra baggage; it is what it is." He felt that this process had also helped Mary to own her 50%. He would always remain grateful that she did stay and allow him the space to go through this journey so that he could move back toward her.

Tomas

Tomas, a self-referred man in his mid-40s, came from a working-class background. He related that his girlfriend had recently left him due to recurring issues around communication and anger. Tomas said he felt devastated about this; he reported significant problems with sleep, loss of appetite with a 10 lb weight loss, and depressed mood. Tomas acknowledged that he had issues of jealousy in his relationships with women, and that he tended to shut down when angry. A first-generation Canadian with strong ethnic roots in his European culture of origin, Tomas presented as a "tough man," an imposing figure with tatoos and leather jacket. During the first session, it seemed that Tomas would shut down when he did not know how he felt on a given issue.

Tomas said he would really like to work on his issues of jealousy and anger in relationships with women: "I'll do whatever I need to do." Tomas related that he had sought help about 10 years before for a substance abuse problem and had remained abstinent. Despite Tomas's tough facade of leather jacket and tatoos, I (first author) was deeply touched by his candor, his profound sense of distress, and his genuine desire to seek help and work hard in his journey; I was also impressed by his previous help-seeking and sustained abstinence. Our rapport was excellent and I felt that Tomas would be a good candidate for Integrity-oriented work.

At our first meeting, Tomas acknowledged that he sometimes "snaps" when he does not know the answer to something; he accepted my invitation to really take the time to reflect on how he feels and to express these feelings. Tomas could see that, linked with his cultural roots, he had bought into the value of being dominant in relationships with women, but could see that this had become quite problematic in those relationships. Tomas became tearful as he faced a sense of sorrow, loss, and despair when he realized that some of this unhappiness could have been avoided. Tomas said that he would really like to accept the challenge of redefining who he was as a man and as the person who he would like to be, so that the rest of his life could be a happier one. Tomas was clear in asserting that he really was prepared to change and to give up old ways of being, for example his jealousy, reiterating: "I'll do whatever I need to do."

When I reviewed the Integrity model, Tomas listened intently, and it was almost as though a penny dropped for him. He said that he loved this approach that affirmed his deep sense of morality and wisdom, and that made excellent common sense to him. Tomas immediately focused on his need to deal with what had happened 10 years ago, when he had lost his family due to his substance abuse problem. He could see that, just like a house devastated by an earthquake, he needed to undertake the needed work of repair and reconstruction before being able to get on with his life. Tomas realized he needed to make amends without excuses.

Tomas continued to express astonishment at being deeply understood in the therapeutic relationship. He was able to catch himself when he was tempted to stop himself when unsure as to how he felt. Instead he courageously dared to begin to self-reflect and become attuned to his feelings. He found it quite helpful to articulate the values of the man who he wanted to be as someone who was honest and understanding, and decided that achieving this would be his blueprint for change. He liked the metaphor of becoming the potter remoulding the self in a new way. Tomas asked me how he could change his long-standing patterns of dealing with power and control in his relationships with women; he found it helpful to understand the process of change as comprising an existential fork in the road with important choice points as to which values would determine the path that he would choose to take.

Tomas related that he had spoken on the phone with Anne--his estranged girlfriend--and that to his surprise she had invited him to go out for dinner. Tomas began to explore ways of dealing with anger; he related that he had never before considered the option of "moving towards" others in this regard. We looked at ways of doing this through a role-play around a hypothetical conflict with a cousin. Through this process, Tomas was able to understand Mowrer's notion that one's vulnerability is one's best defense (Lander & Nahon, 2005), and to explore how to close the space while honouring the three legs of Integrity when feeling angry with someone who he was close to. This led to an important discussion of values, including (a) a past misuse of power, (b) Tomas's dislike of sharing as the basis for feelings of jealousy, and (c) how much he hated it when he saw kids being bullied on the hockey team that he coached. Tomas realized that he had been feeling angry for a long time, and was able to articulate how sad he felt about this, and the fact that he may have hurt others. He began to articulate a new value of using his anger in the service of good by being a kind and caring person as comprising the new foundation for his life.

At our next meeting, Tomas reported that he was feeling much better, and that he had a wonderful date with Anne. They spent the evening together, and ended up cuddling together for 2 hr--something entirely new for him. They saw each other on the weekend, and had a great time skating. Tomas said he had never done this before: focusing on something that she wanted to do. At the end of the skate, Tomas saw the light shining on ice sculptures at night, and told Anne how beautiful he found this. She phoned him the next day, and told him that hearing him say this "had blown her away."

Tomas wished to explore how to ensure the sustainability of the positive changes that he had made. He really liked the challenge of not resting on his laurels, and wrote the following words on a card: "What would a kind and caring man do?" He resolved to carry this piece of paper in his shirt pocket, and pledged that his new value would underlie his every behaviour, without exception.

Through a series of role-plays, Tomas explored how to find his unique and personal approach in dealing with feelings of anger by moving toward Anne around conflict situations that might arise in the future, for example, if he felt jealous about her going out with her friends or if he disapproved of her actions. Tomas related that a number of co-workers had commented on the fact that he had made positive personal changes.

Tomas continued to make remarkable progress. He had now seen Anne again many times, and felt much calmer. The couple had not yet been physically intimate as he wished to respect her personal space. Tomas continued with his staunch commitment to his Integrity work: "I'm here because I screwed up. I gotta keep going to be nicer, more understanding, better to talk to." Tomas related a delightful incident with the junior hockey team that he coached: One of the boys asked him "Coach, are you OK?" as he was wondering why Tomas was being so nice!

Tomas reported feeling a lot happier at home and work, more relaxed than before. He dealt well with the news that Anne was going on a trip with friends. Although he felt a bit jealous, he chose to be altruistic and generous; he felt happy that she was going to have a good time, and he wished her well. Tomas explored how to fine-tune his new sense of mastery over his anger, and found it very helpful to consider the values involved in choosing to move toward someone in situations of conflict versus choosing not to do so.

Tomas said he was communicating better, and not letting issues build up. It seemed that there were some aspects of Anne's life that he did not approve of. Tomas worked hard on the values surrounding how to deal with someone whose behaviour or values were clashing with his. He found the Integrity model's notion of 50/50 accountability was helpful in daring to let go and allow others to be responsible for themselves; he could see how this could be applicable across situations in his life.

Tomas reached closure at our ninth session. He said that he felt 100 times better than when he began therapy, and was feeling well across the arenas of his life. He was now formally back with Anne; she had told him that she was happy, with a new sense of faith in him and in the relationship. Tomas related that now, when feeling upset, he would talk about it, as he had come to value the merits of communication in a healthy relationship.

Discussion

Paul's and Tomas's case studies illustrate the Integrity model in action. Paul presented in therapy with significant anxiety, depression, and a sense of burnout as well as alienation from both self and others. He found it helpful to consider that his symptoms really were the hallmarks of an Integrity crisis. This offered him an immediate paradigm for both understanding the cause of his distress and a roadmap for the process of therapeutic work and change that would allow him to see a light at the end of the tunnel. Paul welcomed and worked hard on all challenges to his Integrity throughout our work. As Paul reviewed his values, he realized that he was not honouring his values of honesty, commitment, or Integrity to the important individuals in his life; he could see that he had focused on work as it was immediately rewarding and emotionally safe. This set the stage for Paul daring to define a new set of values for the man he wished to be.

Tomas's engagement in and receptivity to the therapeutic process was equally exemplary. At each of our meetings, his attitude was one of deep appreciation at being able to achieve new and often challenging insights into himself, so that he could learn to become the man who he wanted to be. He would poignantly express that he had never previously known of any other way of being and of relating to others, and that he now felt much happier with himself and with his life.

Buber's concept of the I and Thou was profoundly helpful to Paul in helping him to re-evaluate his pattern of emotional alienation from his estranged spouse and children, and from most others in his life. The I-Thou relationship offered Paul a tangible and profound metaphor toward which to aim in reclaiming a sense of community and emotional closeness first with his children and ultimately with his wife. Paul said that he found it illuminating to understand that he had handled his anger toward his wife and her sexual unavailability by "moving away" from her, and that this had become very costly, ultimately through the demise of the relationship. As most other individuals in therapy, he had never thought of "moving towards" as being a viable way to deal with his anger, and he liked this as a peace model that eventually helped him to rebuild a new relationship with his wife with a renewed and sustained level of emotional intimacy and community. The three legs of Integrity provided an ongoing paradigm for Paul to deal with the impasses of daily living, and a GPS for his daily decisions that allowed his previously dysfunctional emotions to lead the way to a sense of clarity and inner peace arising from living with Integrity and in accordance with his newly articulated set of values.

As soon as Tomas began to work with the Integrity model, he was able to articulate how much a life based on a misuse of power in interpersonal relationships had led to a pattern of unhappy or destructive relationships, and he mourned the lost opportunities for a more meaningful and joyful existence. This process of value clarification led Tomas to spontaneously challenge these values and choose instead to define himself as a man valuing altruism and a greater sense of community with others. Tomas immediately began this process by working on the amends that he needed to make for a past family break-up. He was then able to work on his relationship with his girlfriend Anne based on a new set of values that emphasized the three legs of Integrity: (a) honesty with himself and with Anne regarding his feelings, (b) accepting his 50% of the responsibility for issues and impasses that arose in the relationship, and (c) closing the psychological space and increasing his sense of community with her, and ultimately with others in his life space, as revealed by the touching anecdote of the little boy in the hockey team who was concerned about his well-being.

Anne was both startled and deeply touched by the changes in Tomas. Although her girlfriends encouraged her to be cautious and doubt Tomas's word, she was "blown away" by Tomas's new way of being with her, and by his sensitivity to her feelings and even to the beauty of the world around him.

Many aspects of Paul's case, from his initial "resistance" to therapy to his overinvestment in work and emotional detachment from his family, could be seen to fall into the trappings of traditional masculinity. Similarly, Tomas's presentation as a "gruff, tough man" with issues around power and dominance in relationships who initially seemed to find it hard to express his feelings, could have been seen as a cause of concern with regard to his ability to viably engage in therapy.

Both men's journeys in therapy were quite brief, and, coincidentally, of the same length--nine sessions. Paul's and Tomas's journeys provide a further clinical understanding of ways of working with men in therapy from a positive and strengths-based perspective in addressing issues of intimacy and in assisting men to address relational difficulties and emotional regulation. Paul's and Tomas's immediate and profound engagement in therapy and the emotional depth of their therapeutic journeys provide clinical support for (a) the results of Integrity-based clinical and empirical work with men indicating that men have been receptive to this existential perspective that honours men's profound and viable emotional voices and (b) the empirical findings in Integrity-based groups that men were able to show significant changes in the capacity for emotional contact in the context of a values-based encounter emphasizing a sense of community and a deep respect for men's emotional voices.

Reviewer Question

What was the gender of the therapist and how did the relational elements of the therapeutic alliance impact treatment? The article describes intimacy, but does little to reveal the intimacy within the therapeutic dyad. It describes application of ownership of problems in relationships, but describes very little in terms of the therapeutic encounter.

Author Reply

In my work with Paul and Tomas, I [first author] experienced a deep sense of a "Between" within the I-Thou relationship. I was deeply touched by both men's profound commitments to living with Integrity through the behavioural expression of their values of a man of character in their everyday lives. Tomas continually expressed amazement at how these concepts were helping him, and gratitude with how the sessions inevitably were able to address his most poignant impasses. Paul expressed respect for the therapeutic approach such that he considered follow-up sessions to comprise for him a form of Integrity checking-in. I felt privileged to be a part of this process and reminded both men to accept the credit for the positive changes that were occurring in their lives.

Both authors are female. We see men from all walks of life; we have no inclusion or exclusion other than our personal biases. In other words, although each of us has boundaries that she respects--for example, the second author does not feel comfortable working with (a) gang enforcers (unless they are "self-referred" and experiencing anxiety/depression, indicating an Integrity crisis) or (b) pedophiles--we believe that the Integrity model can be helpful to men across problem areas, including those that are beyond our own boundaries and comfort levels. There is a sense of intimacy in the therapeutic relationship that goes beyond the verbal face-to-face. As each man is unique, there is no script nor manual to guide or influence the relational encounter. The men describe themselves to us as to the pros and cons in their lives, and where they want to go; they quickly explore the price tags for getting there, versus the cost of staying in the status quo. To get into one's values with another requires a trustingness and a willingness to risk letting someone get close enough to see some of one's "scummy" values that need to be changed. It is men's willingness to do this that in our view comprises the true intimacy of the therapeutic encounter.

Reviewer Question

What was it about the short-term nature of the treatment that made it so successful? The author seemed surprised and pleased that it took 9 weeks in each case. Why?

Author Reply

The Integrity paradigm as a philosophical and reflective framework provides what many men refer to as "tools" for daily living. This model offers a man in therapy a new and profound sense of clarity as to (a) who he is, (b) what has caused the Integrity crisis or clash of values that has led to his current sense of distress, and (c) the needed repair work to address and resolve these Integrity crises and value clashes. Paul's and Tomas's therapeutic journeys illustrate how their daring to work with commitment and grit (the "root word" of Integrity; Lander & Nahon, 2005) around (a) the clarification and re-ranking of their values, (b) the three legs of Integrity, and (c) the willingness to "move towards" the significant others in their lives in creating a new sense of "Between" allowed both men to deepen the sense of intimacy in their significant relationships, and their sense of community with both themselves and with others.

Taken together, these four components of the Integrity model dovetail to comprise a holistic and accessible paradigm for men to (a) reflect on their values and on whom they wish to become as a man of Integrity, (b) begin to do the repair work needed in their lives and in their relationships with self and others by behaviourally expressing these values, and (c) deepen their relationships with the significant others in their lives, and with themselves in terms of increased self-esteem.

The short-term nature of the Integrity model, sometimes as brief as two or three sessions, never ceases to touch and amaze us, as it stands in such stark contrast to the literature's predictions regarding the challenges and limitations faced by therapists who work with men, with the likelihood of resistance, early termination, and/or the need for a slower pace in early sessions. In fact, it seems as though the deeper the pain, anguish, and angst, the faster that men "get" the Integrity model and run with it. Most men refer to further therapeutic sessions as comprising an opportunity for a "checking in" regarding (a) their thoughts and efforts between sessions and (b) their planned next moves regarding the values to be changed and the behaviours that will reflect these changes.

Reviewer Question

In this short-term described intervention, the authors share successful case examples, but what about talking of the "resistance to change" that is almost always present in many forms of psychotherapy? How did the authors identify resistance and how was it overcome? Or, are the authors suggesting that there is no resistance in the Integrity model? If that is true, then it needs to be stated and hopefully grounded in research and theory.

Author Reply

There is very little resistance when men engage in Integrity-based work. The men we work with are here because they are in distress, and they want to do their healing work. This existential model sets the stage for a reflective personal and existential framework for men to undergo this healing journey. Regardless of socioeconomic status, age, culture, sexual or gender orientation, men find an immediate resonance with the Integrity model. It speaks to their deep sense of morality and to their own past philosophical reflections about life and living.

The Integrity model invites men to take full responsibility for the therapeutic process and for their therapeutic journeys. The three legs of Integrity--(a) truthfulness with self and others, (b) taking responsibility for their 50% of their therapeutic journey, and (c) establishing a sense of community with self and others--quickly allow men to do the needed repair work in their lives. There is no homework; just the invitation to self-reflect and to apply the philosophical aspects of the Integrity model toward addressing the Integrity issues and value clashes in their lives. This entire process is under the men's control; thus, there is nothing and no-one for them to resist or act-out against.

Men immediately invest in doing the needed work to make the necessary changes in their lives. As they do this, they quickly gain a new sense of comfort in resolving conflicts, and begin to ameliorate their relationship with themselves and with others-- allowing for a new sense of well-being and personal mastery. This becomes highly reinforcing and motivating, and the men continue to invest in the therapeutic process.

We are initially up-front regarding our valuing of rage, anxiety, and depression--all of the so-called "negative" emotions, as they provide an internal feedback loop regarding the fact that there is "something rotten in the state of Denmark," in other words, that an Integrity issue or a value clash is brewing and needs to be addressed (Lander & Nahon, 2005). Furthermore, we present anger as a force that can be used for healing and "moving towards" others. Therefore, a seemingly angry man (implied by "resistance") is actually an ally in establishing a therapeutic rapport, as he learns to harness the energy of these so-called negative emotions into positive and creative channels.

Although we are very different from each other in our modes of being, while being integral in our work as therapists, we manage to convey an atmosphere of safety and of a man feeling valued. Furthermore, because as existentialists we are really focused on the n of 1, we find that it is hard to see men in a clustered manner based on research paradigms. Rather, we do view each man as a unique stimulus eliciting unique responses from us. Also, we have been anti -Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) long before this became a fad, which we feel is key to viewing each man as a unique individual who fully possesses the capacity to do whatever it is that needs to be done to work viably in Integrity-based therapy. We believe that this positive and affirming bias is also important in setting the stage for men's successful journeys through Integrity-based work. As a supervisor of psychology and psychiatry residents, I [second author] have always encouraged training therapists to be themselves and to discover their capacity to be therapeutic with any individual they are facing, independent of the model that they are learning. The Integrity model does not ask that clinicians forego what they have learned but to appreciate that what they have learned reflects a value system of understanding what it means to be human and to understand another view of why people get into distress.

Sometimes in the course of therapy, a different kind of resistance occurs when a man is reluctant to take the next step forward in his existential journey. We welcome this process as it validates the fact that a man is engaged, and is willing to work through a difficult impasse. Resistance at this point reflects a "spunkiness" as a man may not wish to do something on someone else's say-so. It is about a man deciding to make something his, and to move the locus of control (Rotter, 1966) from being external to internal. The Integrity model provides a paradigm to help a man decide whether or not it is worth paying the price for change versus maintaining the status quo. It is one of the most profound, intimate encounters that results when a man makes the decision to take a leap forward to commit all of his being to making the necessary changes to live a joyous, productive, and meaningful life.

Reviewer Question

It is not really clear how the Integrity model fits for men. The model presented is more general and related to human beings. What about men? What do they relate to? Are there aspects of male socialization, culture, social norms, and so on, that make the Integrity model applicable? If the authors are really presenting this model as for universal human beings only, then I struggle to understand if anything is unique about using this with men.

Author Reply

It is important to remember that men are first and foremost, members of the human race. This therapy works with men because it works with human beings. It offers a simple and profound paradigm that can be fleshed out regardless of circumstances, problem areas, diagnosis, gender orientation, and so on. Perhaps some of the hurdles and "resistance" that have been referred to in the literature regarding men's engagement in and viable response to therapy may be because there has been a thrust to alter therapy so that it can work with men--thus seeing men through the values-based lens of one's therapeutic model. Due to the universality of the Integrity model, an individual man is not trapped by being forced into an aggregate group defined by research protocols.

We are not saying that the Integrity model is unique to men; we are saying that it works with men, that men run with it with little or no resistance, and that it addresses men's issues and honours men's sense of Integrity and of being true to themselves. The Integrity model focuses on each man's struggle to be and to have a meaningful life as male human being. It does not pit men and women against each other; both can and have been victims, and both can and have been aggressors. What matters is for each man to decide who he is and whether he is the person who he wants to be.

The universality of the Integrity model has a profound impact on the theoretical understanding of the multiple cultural variables impinging on men. Because the Integrity model is existential, it focuses on each man as unique and struggling to define himself as a multifaceted being and to define what a meaningful life would be for him--daring to define the values that are to be reflected in his behavioural engagement with life. It is each man who leads and discovers himself--not any theory or therapist. As we note in Lander and Nahon (2015), "Because of the Integrity model's focus on the values of the other and not those of the therapist, there may be no need for expertise or specialization around the culture of the individual in therapy." The focus of the Integrity model in asking men to identify their values around all aspects of their lives including cultural variables allows men to work with the Integrity model from a wider and more existential perspective. This may provide therapists with a more nuanced understanding of ways in which to work with men in a culturally sensitive manner, ... mitigating the potential for impasses arising from clashes between differing client versus therapist cultural variables. (Lander & Nahon, 2015)

Although some of the recent literature on men and masculinities reflects a theoretical shift toward a more positive view of men, there is still a disquieting urging for counsellors and therapists working with men to find and utilize strategic interventions to alter therapy so that it can address the challenges and limitations faced by therapists who work with men--around variables including (a) men's engagement in therapy, (b) men's access and willingness to work with difficult emotions and to allow themselves to be vulnerable within the therapeutic relationship, (c) men's capacity for appropriate emotional regulation, and (d) men's ability to access appropriate social networks.

A key foundation for Integrity-based work with men is its strengths-based perspective. Nearly five decades of Integrity-based work with men in tertiary care, community and academic settings has hinged on a celebration of men's profound strengths in viably engaging in therapy and of men's profound emotional voices. We believe that the positive outcomes reported in this article are a function not only of the strengths-based foundation of this work, but also of its wellness- and values-focus, as well as its non-pathologizing view of men a la DSM. Furthermore, there is a direct theoretical link between the four tenets of the Integrity model in mitigating or addressing the limitations and challenges that the literature on men and masculinities raises with respect to men's viable engagement in therapy and to their therapeutic journeys. The process of values exploration is a key and fundamental reflective process that is needed before a man can make any substantive and sustained changes in those values that underlie those aspects of their behaviours and of their lives that have become problematic for them. For example, if one considers the literature's suggestion of (a) men's ongoing challenges with regard to achieving intimacy and community with others, or (b) the values of O'Neil's (1982) "masculine mystique," which underlie much of the scholarship on men and masculinities, the only way that a man can begin to change those values is through a process of personal reflection and values re-evaluation. This comprises the essence of the Integrity model and becomes the precursor for any viable therapeutic change along any other dimension.

The three legs of the Integrity model provide the core therapeutic paradigm through which men in therapy take responsibility for engaging in therapy and for making the necessary changes in their lives. It asks that men be truthful, responsible, and aim to close the space and increase their sense of community with self and others. The first requirement of being honest--first and foremost with oneself, and then with others-- is a challenge that each individual in therapy must face. The Integrity model invites each of us to identify the sense of fraudulence that may exist in our lives, whereby we may not be walking the talk of our professed values; this is part of the human dilemma. As men have the courage to identify the sense of fraudulence in their lives, they come to understand that it is the source of angst, anxiety, depression, rage, and of any other symptomatology that they may be experiencing. The second leg of Integrity provides men with an accessible paradigm for understanding what it is that they need to own--their 50% of the responsibility in dealing with conflict situations, both within the self and with others. It is also their 50% of doing the needed work within the therapeutic journey. Many men we have worked with have related that one of the concepts that they have found most helpful is that of discovering where the 50% line lies between owning less or more than their 50%--or using our terminology, between under-owning and over-owning (Lander & Nahon, 2005, 2008a).

Framed in the context of appropriate values re-evaluation and honest as well as responsible action, the third leg of Integrity--that is, aiming to close the psychological space and achieve a deeper sense of community with self and others--coupled with the intent of (a) moving toward others as well as (b) aiming for an I-Thou relationship and a "Between" with others, including the therapist, provides a profound theoretical and therapeutic vehicle for men to address the literature's predictions regarding,

* Men's ongoing challenges with achieving intimacy and community with others;

* The masculine mystique values of restrictive emotionality, restrictive sexual and affectionate behaviour, homophobia, socialized control, power and competition issues, obsession with achievement and success, and health care problems--as all impact on a man's ability to close the psychological space with self and/or others;

* Men's "press for devaluation of emotional intimacy in romantic relationships" (Fischer & Good, 1997, p. 161);

* Men's difficulties in accessing appropriate social networks;

* Men's difficulties in regulating their emotions through appropriate "emotion regulation suppression and reappraisal" (Land et al., 2011, p. 71);

* Men's difficulties in appearing vulnerable; and

* Men's lack of self-expression and connection with other men.

Furthermore, the focus on the I-Thou relationship and the "Between" within the therapeutic relationship are critically important in mitigating (a) the potential for a significant impasse in therapy as men explore their emotionally vulnerable sides within the therapeutic relationship and (b) "the intimacy demanded in the interpersonal situation with the psychotherapist" (Rabinowitz & Cochran, 2002, p. 51).

We hope that this article will encourage clinicians to dare to consider that most men do have (a) an accessible capacity for emotional intimacy and community as well as a desire to build a meaningful relational existence, coupled with (b) the ability to engage and viably work with an existential therapeutic framework focusing on personal reflection, personal integrity and value clarification. This article challenges the literature's hypotheses of (a) a lack of congruence between the way that men traditionally relate and the therapeutic process and (b) the potential for a sense of "shame" or humiliation that men may experience when they grapple with exposing their vulnerabilities and in dealing with emotional relatedness in therapy.

The Integrity model is about life and living, as Miller (2012) noted, in providing "a relational approach for helping people to live in conscious accord with their values ... [and] align their lives with values and purpose" (p. 5). The simple guidelines of the Integrity model provides a GPS for each man to find his way to making intimate relationships with partners, children, colleagues, and friends work. The men who we have worked with, across demographics, individually, in couples, and in groups, have run with this approach that focuses on allowing men to find their unique thumbprint in making daily life and daily functioning, including better relationships, more meaningful-- challenging the myth of the emotionally defective male.

DOI: 10.1177/1060826515600459

Acknowledgments

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 Dr. James A. Doyle and Dr. Diederik F. Janssen for their ongoing championing of scholarship in men's issues.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Danielle Nahon (1) and Nedra R. Lander (1)

(1) University of Ottawa, Ottawa, Ontario, Canada

Corresponding Author: Danielle Nahon, Suite 222, 250B Greenbank Road, Ottawa, Ontario, Canada K2H 8X4.

Author Biographies

Danielle Nahon, PhD, CPsych is a Clinical and Counselling Psychologist in community practice and an Associate Professor of Psychiatry, Faculty of Medicine, University of Ottawa. Danielle and her colleague Nedra R. Lander are deeply committed to working with men's and women's issues, and to fostering a respectful dialogue between the genders. She has collaborated with Nedra in (a) founding the Men's Clinic (1984 to 1994)-the first clinic for men in a tertiary care setting in North America-if not the world, recognized by the American College of Physician Executives; (b) organizing and hosting the first Continuing Medical Education men's health conference in Canada in 1993 at the Civic Campus of The Ottawa Hospital; and (c) organizing and hosting the First International Multi-Disciplinary Congress on Men in 1995 at Carleton University. For over four decades, Danielle and Nedra's empirical and clinical work has provided ongoing validation for a positive view of men and masculinities, and for men's viable, poetic and profound emotional voices. Danielle has received the Award for the Advancement of Equity, Diversity and Gender Issues from the Faculty of Medicine of the University of Ottawa.

Nedra R. Lander, PhD, CPsych is a Clinical, Counselling and Health Psychologist and an Associate Professor of Psychiatry, Faculty of Medicine, University of Ottawa, Canada. Furthering the work of her mentor O. Hobart Mowrer's Integrity (Therapy) Group approach, she has developed the Integrity model of existential psychotherapy, which has formed the basis of her and Danielle Nahon's Integrity-based therapeutic work with men in over four decades. Nedra has collaborated with Danielle in (a) founding the first clinic for men in a tertiary care setting in North America-if not the world; (b) organizing and hosting the first Continuing Medical Education men's health conference in Canada; and (c) organizing and hosting the First International Multi-Disciplinary Congress on Men. She has collaborated with Danielle in (a) teaching learners in medicine, psychology, counselling, education, social work, nursing and pastoral care through Integrity-based educational programs in the areas of counselling and psychotherapy, physician health, caregiver stress and wellness, and Continuing Medical Education for several decades; and (b) her co-authored book on an Integrity model perspective in working with the "difficult patient", published by Routledge, addressing issues of professionalism, values of the caregiver, and dealing with difficult issues and impasses in the therapeutic relationship. Nedra has received the Award for the Advancement of Equity, Diversity and Gender Issues from the Faculty of Medicine of the University of Ottawa.