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A TreATmenT ImprovemenT proTocol Addressing the Specific Behavioral Health Needs of Men TIP 56 A TreATmenT ImprovemenT proTocol Addressing the Specific Behavioral Health Needs of Men TIP 56 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Addressing the Specific Behavioral Health Needs of Men Acknowledgments This publication was produced by The CDM Group, Inc. (CDM) under the Knowledge Appli cation Program (KAP) contract numbers 270-99-7072, 270-04-7049, and 270-09-0307 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier served as the Contracting Officer’s Representatives. Disclaimer The views, opinions, and content expressed herein are those of the expert panel and do not nec essarily reflect the views, opinions, or policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software, or resources is intended or should be inferred. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be repro duced or distributed for a fee without the specific, written authorization of the Office of Com munications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered from or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877 726-4727) (English and Español). Recommended Citation Substance Abuse and Mental Health Services Administration. Addressing the Specific Behavioral Health Needs of Men. Treatment Improvement Protocol (TIP) Series 56. HHS Publication No. (SMA) 13-4736. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Admin istration, 1 Choke Cherry Road, Rockville, MD 20857. HHS Publication No. (SMA) 13-4736 First Printed 2013 ii Contents Consensus Panel ............................................................ v KAP Expert Panel and Federal Government Participants ........................... vii What Is a TIP? ............................................................ ix Foreword ................................................................. xi Executive Summary ........................................................ xiii Chapter 1: Creating the Context ............................................... 1 Introduction ...............................................................1 Defining Sex and Gender .....................................................2 Defining Substance Abuse and Substance Dependence .............................2 Conceptual Frameworks of Masculinity and Male Roles .............................3 Gender Role Conflict and Masculine Role Stress ..................................8 Men’s Substance Abuse .......................................................8 State of the Field...........................................................10 Audience for This TIP ......................................................11 Chapter 2: Screening and Assessment .......................................... 13 Introduction ..............................................................13 Screening and Assessment of Men .............................................13 Comprehensive Screening and Assessment ......................................14 Chapter 3: Treatment Issues for Men ........................................... 27 Introduction ..............................................................27 Treating Men for Substance Abuse: General Considerations ........................27 Counselors’ Gender: Some Considerations ......................................31 Counseling Men Who Have Difficulty Accessing or Expressing Emotions .............40 Counseling Men Who Feel Excessive Shame ....................................44 Counseling Men With Histories of Violence ....................................46 Counseling Men About Sexual Issues ..........................................52 Family Issues ..............................................................59 Spirituality and Religion .....................................................65 Chapter 4: Working With Specific Populations of Men in Behavioral Health Settings ..... 67 Introduction ..............................................................67 Men With Co-Occurring Disorders ...........................................67 Men With Physical Health Problems ..........................................82 iii Addressing the Specific Behavioral Health Needs of Men Men From Different Age Groups .............................................86 Gay and Bisexual Men ......................................................89 Men With Employment or Career-Related Issues ................................90 Men With Systems-Related Needs ............................................92 Men From Diverse Cultural and Geographic Groups ..............................95 Conclusion ..............................................................100 Chapter 5: Treatment Modalities and Settings ................................... 101 Introduction .............................................................101 Detoxification ............................................................101 Treatment Modalities ......................................................102 Treatment Strategies .......................................................111 Treatment Settings ........................................................115 Mutual-Help Groups ......................................................118 Community Influences .....................................................122 Helping Men Live With the Residual Effects of Substance Abuse ...................124 Appendix A—Bibliography ................................................. 125 Appendix B—Glossary ..................................................... 197 Appendix C—Resource Panel ............................................... 201 Appendix D—Field Reviewers ............................................... 203 Appendix E—Acknowledgments ............................................. 206 Index .................................................................. 207 Exhibits Exhibit 1-1: Lifetime Substance Use in the General Population Ages 12 and Older (2008) ...10 Exhibit 1-2: Treatment Admissions by Primary Substance of Abuse ..................10 Exhibit 3-1: Node-Link Map .................................................32 Exhibit 3-2: Anger Management Counseling Techniques ...........................43 Exhibit 4-1: Assumptions and Adaptations Used in M-TREM ......................72 Exhibit 4-2: Rates of Co-Occurring Personality Disorders Among Men With a Substance Use Disorder ...................................................80 Exhibit 4-3: Age-Adjusted Rates of Suicide per 100,000 Individuals in 2006 by Race/Ethnicity ........................................................82 Exhibit 4-4: Primary Substance of Abuse According to Cultural/Ethnic Group Among Men Admitted for Treatment ........................................96 Exhibit 5-1: Time Out! For Men .............................................105 Exhibit 5-2: Goals and Techniques for Working With Male Clients in Couples and Family Therapy ........................................................110 iv Consensus Panel Chair Glenn E. Good, Ph.D. Associate Professor Patrick Reilly, Ph.D. Department of Educational, School and Associate Chief Counseling Psychology Mental Health Service University of Missouri–Columbia Community-Based Outpatient Clinic Columbia, MO Santa Rosa Veterans Affairs Associate Clinical Professor Panelists Department of Psychiatry Louis E. Baxter, Sr., M.D., FASAM University of California San Francisco Executive Director Santa Rosa, CA Physicians Health Program Co-Chair Medical Society of New Jersey Lawrenceville, NJ William S. Pollack, Ph.D. Assistant Clinical Professor Rodger L. Beatty, Ph.D., LSW Department of Psychiatry Assistant Professor Director University of Pittsburgh Harvard Medical School Pittsburgh, PA Centers for Men and Young Men McLean Hospital Terry Beartusk, B.A., CAS III Executive Director Belmont, MA Thunder Child Treatment Center Workgroup Managers Sheridan, WY Gary R. Brooks, Ph.D. Harold O. Braithwaite, Jr., Ph.D. Professor Associate Professor and Chair Department of Psychology and Neuroscience Department of Psychology Baylor University Morehouse College Temple, TX Atlanta, GA Thomas E. Freese, Ph.D. John P. de Miranda, Ed.M. Director Executive Director University of California–Los Angeles National Association on Alcohol, Drugs and Integrated Substance Abuse Programs Disability, Inc. Pacific Southwest Addiction Technology San Mateo, CA Transfer Center Los Angeles, CA v Addressing the Specific Behavioral Health Needs of Men Robert K. Edmundson, M.A., M.S.W. Jerry Pattillo, Ph.D. Assistant Professor Chief, Chemical Dependency Services Department of Behavioral Medicine and Department of Psychiatry Psychiatry Kaiser Medical Center West Virginia University San Francisco, CA Morgantown, WV Thomas A. Peltz, M.Ed., CAS Natarajan Elangovan, M.D., M.P.H. Therapist/Licensed Mental Health Counselor Clinical Director Private Practice Meadowview Psychiatric Hospital Beverly Farms, MA Secaucus, NJ David J. Powell, Ph.D. Thomas L. Geraty, Ph.D., LICSW President Jamaica Plain, MA International Center for Health Concerns, Inc. East Granby, CT Jan Ligon, Ph.D., LCSW Associate Professor Luis B. Rosell, M.A., Psy.D. School of Social Work Licensed Clinical Psychologist Georgia State University LBR Psychological Consultants Atlanta, GA Mount Pleasant, IA William M. Liu, Ph.D. Eddie B. Sample, Jr., M.S.Ed. Assistant Professor in Counseling Psychology Research Associate Division of Psychological and Quantitative Rehabilitation, Research and Training Center Foundations on Drugs and Disability University of Iowa Wright State University Iowa City, IA Trotwood, OH Irmo Marini, Ph.D., CRC, CLCP, FVE Bernard Segal, Ph.D. Professor, Graduate Program Coordinator Director Rehabilitative Services Program Center for Alcohol and Addiction Studies College of Health Sciences and Human University of Alaska–Anchorage Services Anchorage, AK University of Texas–Pan American Addiction Technology Transfer Edinburg, TX Center Representative Thomas J. McMahon, Ph.D. Assistant Professor John Porter Yale University School of Medicine Technology Transfer Specialist West Haven, CT Northwest Frontier Addiction Technology Transfer Center Michael Mobley, Ph.D., M.Ed. Salem, OR Assistant Professor in Counseling Psychology Department of Educational, School and Counseling Psychology University of Missouri–Columbia Columbia, MO vi KAP Expert Panel and Federal Government Participants Barry S. Brown, Ph.D. Jerry P. Flanzer, D.S.W., LCSW, CAC Adjunct Professor Chief, Services University of North Carolina–Wilmington Division of Clinical and Services Research Carolina Beach, NC National Institute on Drug Abuse Bethesda, MD Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS Michael Galer, D.B.A. Professor of Clinical Psychiatry Chairman College of Medicine Graduate School of Business University of Cincinnati University of Phoenix– Greater Boston Cincinnati, OH Campus Braintree, MA Deion Cash Executive Director Renata J. Henry, M.Ed. Community Treatment and Correction Director Center, Inc. Division of Alcoholism, Drug Abuse, and Canton, OH Mental Health Delaware Department of Health and Social Debra A. Claymore, M.Ed.Adm. Services Owner/Chief Executive Officer New Castle, DE WC Consulting, LLC Loveland, CO Joel Hochberg, M.A. President Carlo C. DiClemente, Ph.D. Asher & Partners Chair Los Angeles, CA Department of Psychology University of Maryland Baltimore County Jack Hollis, Ph.D. Baltimore, MD Associate Director Center for Health Research Catherine E. Dube, Ed.D. Kaiser Permanente Independent Consultant Portland, OR Brown University Providence, RI vii Addressing the Specific Behavioral Health Needs of Men Mary Beth Johnson, M.S.W. Everett Rogers, Ph.D. Director Center for Communications Programs Addiction Technology Transfer Center Johns Hopkins University University of Missouri–Kansas City Baltimore, MD Kansas City, MO Jean R. Slutsky, P.A., M.S.P.H. Eduardo Lopez, B.S. Senior Health Policy Analyst Executive Producer Agency for Healthcare Research and EVS Communications Quality Washington, DC Rockville, MD Holly A. Massett, Ph.D. Nedra Klein Weinreich, M.S. Academy for Educational Development President Washington, DC Weinreich Communications Canoga Park, CA Diane Miller Chief Clarissa Wittenberg Scientific Communications Branch Director National Institute on Alcohol Abuse and Office of Communications and Public Alcoholism Liaison Bethesda, MD National Institute of Mental Health Kensington, MD Harry B. Montoya, M.A. President/Chief Executive Officer Consulting Members Hands Across Cultures Espanola, NM Paul Purnell, M.A. Social Solutions, LLC Richard K. Ries, M.D. Potomac, MD Director/Professor Outpatient Mental Health Services Scott Ratzan, M.D., M.P.A., M.A. Dual Disorder Programs Academy for Educational Development Seattle, WA Washington, DC Gloria M. Rodriguez, D.S.W. Thomas W. Valente, Ph.D. Research Scientist Director Division of Addiction Services Master of Public Health Program New Jersey Department of Health and Department of Preventive Medicine Senior Services School of Medicine Trenton, NJ University of Southern California Alhambra, CA Patricia A. Wright, Ed.D. Independent Consultant Baltimore, MD viii What Is a TIP? Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). TIPs are best practice guidelines for the treatment of substance use disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts to evaluate the quality and appropriateness of various forms of treatment. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://kap.samhsa.gov. Although each TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that the field of substance abuse treatment is continually evolving, and re search frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey front-line information quickly but responsibly. If research supports a particular ap proach, citations are provided. ix