TIP 56

A TreATmenT ImprovemenT proTocol

Addressing the Specific 

Behavioral Health 

Needs of Men
A TreATmenT ImprovemenT proTocol

Addressing the Specific

Behavioral Health

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

TIP 56

Needs of Men
Addressing the Specific Behavioral Health Needs of Men 

Acknowledgments 

This publication was produced by The CDM Group, Inc. (CDM) under the Knowledge Application 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 necessarily 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 reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, 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 Administration, 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 

Patrick Reilly, Ph.D.

Associate Chief 

Mental Health Service 

Community-Based Outpatient Clinic

Santa Rosa Veterans Affairs 

Associate Clinical Professor 

Department of Psychiatry 

University of California San Francisco

Santa Rosa, CA 

Co-Chair 

William S. Pollack, Ph.D. 

Assistant Clinical Professor 

Department of Psychiatry 

Director 

Harvard Medical School 

Centers for Men and Young Men

McLean Hospital

Belmont, MA 

Workgroup Managers 

Gary R. Brooks, Ph.D. 

Professor 

Department of Psychology and Neuroscience 

Baylor University

Temple, TX 

Thomas E. Freese, Ph.D.

Director 

University of California–Los Angeles

Integrated Substance Abuse Programs

Pacific Southwest Addiction Technology

Transfer Center 

Los Angeles, CA 

Glenn E. Good, Ph.D. 

Associate Professor 

Department of Educational, School and

Counseling Psychology 

University of Missouri–Columbia

Columbia, MO 

Panelists 

Louis E. Baxter, Sr., M.D., FASAM

Executive Director 

Physicians Health Program 

Medical Society of New Jersey 

Lawrenceville, NJ 

Rodger L. Beatty, Ph.D., LSW

Assistant Professor 

University of Pittsburgh

Pittsburgh, PA 

Terry Beartusk, B.A., CAS III 

Executive Director 

Thunder Child Treatment Center 

Sheridan, WY 

Harold O. Braithwaite, Jr., Ph.D.

Associate Professor and Chair 

Department of Psychology

Morehouse College

Atlanta, GA 

John P. de Miranda, Ed.M.

Executive Director 

National Association on Alcohol, Drugs and

Disability, Inc.

San Mateo, CA 

v 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Robert K. Edmundson, M.A., M.S.W.

Assistant Professor 

Department of Behavioral Medicine and

Psychiatry 

West Virginia University

Morgantown, WV 

Natarajan Elangovan, M.D., M.P.H.

Clinical Director 

Meadowview Psychiatric Hospital

Secaucus, NJ 

Thomas L. Geraty, Ph.D., LICSW

Jamaica Plain, MA 

Jan Ligon, Ph.D., LCSW

Associate Professor 

School of Social Work 

Georgia State University

Atlanta, GA 

William M. Liu, Ph.D.

Assistant Professor in Counseling Psychology

Division of Psychological and Quantitative

Foundations 

University of Iowa

Iowa City, IA 

Irmo Marini, Ph.D., CRC, CLCP, FVE

Professor, Graduate Program Coordinator 

Rehabilitative Services Program

College of Health Sciences and Human

Services 

University of Texas–Pan American

Edinburg, TX 

Thomas J. McMahon, Ph.D.

Assistant Professor 

Yale University School of Medicine

West Haven, CT 

Michael Mobley, Ph.D., M.Ed.

Assistant Professor in Counseling Psychology

Department of Educational, School and

Counseling Psychology

University of Missouri–Columbia

Columbia, MO 

Jerry Pattillo, Ph.D.

Chief, Chemical Dependency Services

Department of Psychiatry

Kaiser Medical Center 

San Francisco, CA 

Thomas A. Peltz, M.Ed., CAS

Therapist/Licensed Mental Health Counselor

Private Practice 

Beverly Farms, MA 

David J. Powell, Ph.D.

President 

International Center for Health Concerns, Inc.

East Granby, CT 

Luis B. Rosell, M.A., Psy.D. 

Licensed Clinical Psychologist

LBR Psychological Consultants 

Mount Pleasant, IA 

Eddie B. Sample, Jr., M.S.Ed. 

Research Associate 

Rehabilitation, Research and Training Center

on Drugs and Disability

Wright State University 

Trotwood, OH 

Bernard Segal, Ph.D.

Director 

Center for Alcohol and Addiction Studies 

University of Alaska–Anchorage

Anchorage, AK 

Addiction Technology Transfer 

Center Representative 

John Porter 

Technology Transfer Specialist

Northwest Frontier Addiction Technology

Transfer Center 

Salem, OR 

vi 
KAP Expert Panel and Federal 

Government Participants 

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina–Wilmington

Carolina Beach, NC 

Jacqueline Butler, M.S.W., LISW, LPCC,

CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, OH 

Deion Cash 

Executive Director 

Community Treatment and Correction

Center, Inc.

Canton, OH 

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, CO 

Carlo C. DiClemente, Ph.D.

Chair 

Department of Psychology

University of Maryland Baltimore County

Baltimore, MD 

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, RI 

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research 

National Institute on Drug Abuse

Bethesda, MD 

Michael Galer, D.B.A.

Chairman 

Graduate School of Business 

University of Phoenix– Greater Boston

Campus

Braintree, MA 

Renata J. Henry, M.Ed.

Director 

Division of Alcoholism, Drug Abuse, and

Mental Health 

Delaware Department of Health and Social 

Services 

New Castle, DE 

Joel Hochberg, M.A.

President 

Asher & Partners 

Los Angeles, CA 

Jack Hollis, Ph.D.

Associate Director 

Center for Health Research 

Kaiser Permanente 

Portland, OR 

vii 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Mary Beth Johnson, M.S.W.

Director 

Addiction Technology Transfer Center 

University of Missouri–Kansas City

Kansas City, MO 

Eduardo Lopez, B.S.

Executive Producer 

EVS Communications 

Washington, DC 

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC 

Diane Miller 

Chief 

Scientific Communications Branch 

National Institute on Alcohol Abuse and 

Alcoholism 

Bethesda, MD 

Harry B. Montoya, M.A.

President/Chief Executive Officer

Hands Across Cultures 

Espanola, NM 

Richard K. Ries, M.D.

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, WA 

Gloria M. Rodriguez, D.S.W.

Research Scientist 

Division of Addiction Services 

New Jersey Department of Health and

Senior Services 

Trenton, NJ 

Everett Rogers, Ph.D.

Center for Communications Programs

Johns Hopkins University

Baltimore, MD 

Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst

Agency for Healthcare Research and

Quality

Rockville, MD 

Nedra Klein Weinreich, M.S.

President 

Weinreich Communications 

Canoga Park, CA 

Clarissa Wittenberg

Director 

Office of Communications and Public 

Liaison 

National Institute of Mental Health 

Kensington, MD 

Consulting Members 

Paul Purnell, M.A.

Social Solutions, LLC

Potomac, MD 

Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development

Washington, DC 

Thomas W. Valente, Ph.D.

Director 

Master of Public Health Program

Department of Preventive Medicine

School of Medicine 

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 research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is 

to convey front-line information quickly but responsibly. If research supports a particular approach, citations are provided. 

ix 

H. Westley Clark, M.D., J.D.,

M.P.H., CAS, FASAM

Director 

Center for Substance Abuse 

Treatment 

Substance Abuse and Mental 

Health Services 

Administration 

Frances M. Harding

Director 

Center for Substance Abuse 

Prevention 

Substance Abuse and Mental 

Health Services 

Administration 

Paolo del Vecchio, M.S.W. 

Director 

Center for Mental Health 

Services 

Substance Abuse and Mental 

Health Services 

Administration 

Foreword 

The Treatment Improvement Protocol (TIP) series fulfills the Substance Abuse and Mental 

Health Services Administration’s (SAMHSA’s) mission to improve prevention and treatment of

substance use and mental disorders by providing best practices guidance to clinicians, program 

administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and

health services research findings, demonstration experience, and implementation requirements. A 

panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best

practices. This panel’s work is then reviewed and critiqued by field reviewers. 

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of

practicing clinicians and administrators to serve, in the most scientifically sound and effective

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field. 

Pamela S. Hyde, J.D.

Administrator 

Substance Abuse and Mental Health Services Administration 

xi 

 

 

 

Executive Summary 

Executive Summary 

This Treatment Improvement Protocol (TIP)

is a companion to TIP 51, Substance Abuse 

Treatment: Addressing the Specific Needs of

Women. These two volumes look at how gender-specific treatment strategies can improve 

outcomes for men and women, respectively.

The physical, psychological, social, and spiritual effects of substance use and abuse on 

men can be quite different from the effects on

women, and those differences have implications for treatment in behavioral health settings. Men are also affected by social and

cultural forces in different ways than women,

and physical differences between the genders 

influence substance use and recovery as well.

This TIP, Addressing the Specific Behavioral

Health Needs of Men, addresses these distinctions. It provides practical information based

on available evidence and clinical experience

that can help counselors more effectively treat

men with substance use disorders. 

Historically, standard behavioral health services for substance abuse have been designed

with male clients in mind. As the number of 

women presenting for substance abuse services 

increased, clinicians began to understand that

women had different treatment needs than 

men, related to differences in their patterns of

substance use and their perceptions of both

the problem of substance abuse and its treatment. Researchers began to investigate how 

standard substance abuse treatment in a variety of behavioral health settings can be altered

to improve outcomes for women. In the process, they have gained insight into how men’s 

and women’s responses to substance abuse and

substance abuse treatment differ. These insights can also improve treatment for men.

New research in the areas of gender studies 

and men’s studies can help providers understand why men abuse substances and how to

address masculine values in treatment. 

Why Are Men at Greater 

Risk for Substance Abuse? 

Men in America today may have advantages 

that women lack. However, in spite of these 

advantages, men die at a younger age on average than women; men are also more likely 

than women to have a substance use disorder,

to be incarcerated, to be homeless as adults, to

die of suicide, and to be victims of violent

crime. Conversely, men are less likely than

women to seek medical help or behavioral 

health counseling for any of the problems they 

face. These significant problems, combined

with men’s tendency to avoid addressing them,

call for a response from behavioral health

treatment providers. It is the consensus panel’s 

hope that this TIP will begin to focus providers’ and researchers’ attention on the diverse 

xiii 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

problems that men with substance use disorders face and to serve as both an introduction 

to the topic and a summary of what is known

regarding the subject to date. 

How Is the Term 

“Substance Abuse” Used? 

In this TIP, the term “substance abuse” refers 

to either substance abuse or substance dependence or both (as defined by the Diagnostic

and Statistical Manual of Mental Disorders, 4th 

Edition, Text Revision [DSM-IV-TR]; 

American Psychiatric Association 2000) and

encompasses the use of both alcohol and other 

psychoactive substances.Though unfortunately ambiguous, this term was chosen partly because the lay public, policymakers, and many 

substance abuse treatment professionals commonly use “substance abuse” to describe any 

excessive or pathological use of any addictive 

substance. Readers should attend to the context in which the term occurs to determine the 

range of possible meanings; in most cases,

however, the term refers to all substance use 

disorders described by the DSM-IV-TR. 

Who Can Use This TIP? 

This TIP is addressed to the variety of behavioral health service providers in a variety of

treatment settings who may be involved with

helping men recognize their need for treatment, mobilize to access appropriate care, participate in substance abuse treatment

interventions, involve their families and significant others in recovery, and continue services 

in extended recovery. Although traditional 

substance abuse treatment has been provided

in settings that are specific to substance use 

disorders, this TIP recognizes that treatment 

for substance abuse today can occur in a variety of behavioral health settings and that there

is no wrong door for men to enter and participate in treatment and recovery. 

What Is This TIP’s Scope? 

This TIP covers many topics relating to adult

men (defined here as individuals ages 18 and

over) and their use of, abuse of, and/or dependence on substances. What this TIP does 

not cover are the substance use patterns and

treatment of boys and adolescents, as they 

form a distinct population with particular

treatment needs. TIPs 31, Screening and Assessing Adolescents for Substance Use Disorders

(Center for Substance Abuse Treatment

[CSAT] 1999c), and 32, Treatment of Adolescents With Substance Use Disorders (CSAT 

1999d), address substance abuse assessment

and treatment, respectively, for both male and

female adolescents. Please note, however, that

some of the research used in this TIP does include men younger than 18, and in these cases 

the text indicates the age group referenced. 

The TIP represents the view of the consensus 

panel that a clear link exists between the social 

and cultural environment within which many 

boys are raised and the difficulty that many 

men have in seeking help from others. Pressures on men and boys can stem from expectations to conform to society’s view of the ideal 

man—successful, accomplished, independent,

and self-sufficient—which sometimes conflicts 

with a man’s need to seek help. Additionally,

when men do need help, such as in substance 

abuse treatment or other behavioral health 

services, negative consequences may arise,

such as stress, anxiety, shame, rejection, low 

self-esteem, depression, and other mental 

problems that have been sedated or disguised

by the substance use. These secondary effects 

can complicate the efforts of many men to

seek help for their behavioral health needs. 

In recent years, there has been increased

awareness of the extent of women’s substance 

abuse, but men in the United States are two to

five times more likely to develop a substance 

xiv 
 

Executive Summary 

use disorder than women (depending on the 

study). Research shows men are less likely to

seek help for medical or behavioral health

problems; even so, the majority of clients entering substance abuse treatment are male. 

Chapter 1: Creating the Context 

Much of this TIP is premised on the understanding that stereotypes of masculine behavior shape men’s attitudes, beliefs, and behaviors 

(including those related to substance use and

abuse). These socially defined concepts of

masculinity push men in our culture to restrict

their emotional responsiveness, be more competitive, be more aggressive, and be self-reliant.

Masculine roles may also hinder some men

from seeking needed treatment for a variety of

health, and particularly behavioral health, concerns, including those related to mental illness 

and substance abuse. 

Concepts of masculinity affect different men

to different degrees, but no man is unaffected

by them or by the ways in which proper masculine behavior is defined at a societal level. 

Not all effects of masculine ideologies are negative, however, and traditional masculine values can be helpful or beneficial. Also, although

there are certain masculine values that are 

dominant in contemporary American culture 

and fairly common across cultures, some cultures may define masculinity differently. Masculine values may also differ according to the 

role a man is filling (e.g., father, brother,

friend). 

In addition to explaining some of the research

on masculinity, the first chapter defines other

key concepts, such as gender, sex, and substance use disorders. It also presents some 

basic information on men’s substance use and 

abuse in relation to that of women. Finally, it

discusses the current state of the behavioral 

health field in regards to male-specific substance abuse treatment, what the future may 

hold for male-informed treatment, and how 

various audiences can use this TIP. 

Chapter 2: Screening and 

Assessment 

The screening and assessment of substance use 

disorders is an important and ongoing facet of

treatment that should be adapted to the needs

of the individual client. Part of this process of

tailoring screening and assessment to client

needs is being aware of how a man’s beliefs 

and concerns about his identity as a man affect 

how he responds to screening and assessment

questions and procedures—by doing so, clinicians will be better able to engage men in this 

process. 

This chapter reviews three parts of a comprehensive screening and assessment process, 

which are: 

1.	 The screening. 

2.	 An assessment of the presenting problem 

(e.g., substance abuse) and its social, spiritual, psychological, and medical consequences. 

3.	 A personal assessment that investigates 

other behaviors, values, attitudes, and experiences that may influence treatment in

behavioral health settings. 

Throughout this process, clinicians should be 

aware of the ways in which male gender roles 

influence men’s psychosocial adaptation, substance use/abuse, and help-seeking behaviors. 

Men are often ambivalent about seeking help

for health problems (whether related to behavioral or physical health), and clinicians should

acknowledge and possibly discuss this ambivalence with the client before assessment commences. Furthermore, many men are typically 

embarrassed or reluctant to talk about feelings.

Providers can acknowledge this difficulty and

work with clients to make the process less 

threatening. Because men are often actionoriented and focused on the concrete, it is 

xv 
 

 

Addressing the Specific Behavioral Health Needs of Men 

helpful to present specific goals in the assessment process and sometimes to use visual representations of their problems and past

experiences. 

Although screening for and assessment of substance use disorders are among the primary 

goals of behavioral health service providers,

there are a number of other factors that can 

affect treatment that need to be investigated as 

part of a comprehensive personal assessment.

Some of these areas will be investigated in almost every case, others will be pursued if particular information surfaces during the 

screening, and still other areas will only be investigated if the client expresses interest or

concern. The chapter briefly considers the following areas of assessment:

•	 Work/employment history 

•	 Housing status and needs 

•	 Criminal justice involvement and legal 

issues 

•	 Physical health 

•	 Functional limitations 

•	 Co-occurring mental disorders 

•	 Trauma histories 

•	 Motivation to change 

•	 Relapse risk and recovery support 

•	 Spiritual and religious beliefs 

In addition, the chapter provides a more indepth consideration of the assessment of family history (including both childhood abuse 

and current domestic violence), male sexuality,

and shame. 

Chapter 3: Treatment Issues 

Chapter 3 explores issues that may affect substance abuse treatment for most, if not all,

men. It begins with a discussion of some general considerations about how masculine roles 

may affect men in treatment, men’s treatmentseeking behavior, and methods of engaging

men in substance abuse treatment. 

The chapter then discusses at length the issue 

of gender dynamics, transference, and countertransference for male and female behavioral 

health counselors working with male clients.

Case examples are given to highlight some 

potential problems that can arise. The chapter

also discusses the pros and cons of having either male or female counselors working with

male clients. Because the majority of substance 

abuse treatment clients are male but most 

counselors are female, the chapter also includes some ideas about recruiting male counselors. 

A variety of social and behavioral issues can

affect men’s patterns of substance use/abuse as 

well as their success in treatment. These issues 

include counseling men who have difficulties 

expressing emotion and men who feel excessive shame, both common problems for men

in substance abuse treatment. Male roles and 

training may result in difficulties accessing

some or all emotions, or in problems reacting

appropriately to some emotions, such as anger.

Men are affected by different kinds of shame 

and social stigma than women, and men are 

expected to engage in different rituals or rites 

of passage, many of which involve alcohol. 

Men’s behaviors relating to sexuality and violence are often important issues in treatment.

Men are much more likely to commit violent

acts than women, and those acts of violence 

are often associated with substance use/abuse.

Violence, criminal behavior, and anger are factors that often need to be addressed if a man is 

to remain substance free. Although providers 

may be aware of the possibility that men may 

commit violent acts, they are less likely to consider that men are often victims of violence as 

well. Clinicians often do not look for—and 

men are rarely forthcoming about—histories

of childhood physical or sexual abuse or current victimization by domestic partners, and 

xvi 
 

 

 

 

 

Executive Summary 

yet these are factors that can have a strong

negative effect on treatment. 

Men’s sexual behavior is also often affected by 

their substance use/abuse, and this chapter

helps behavioral health service providers understand the relationship between sexuality 

and substance use. It also discusses sexual dysfunction, the effects of substance abuse on the 

male reproductive system, sexual identity,

compulsive sexual behaviors, and other issues. 

Behavioral health service providers have become more aware in recent years of the importance of parenting and child custody for 

women entering treatment, and they have responded with the creation of programs that 

work with mothers and their children together. Children and other family members can

also play an important role in encouraging

men to enter treatment, and fears about losing

custody of children can inhibit treatment entry. Men’s substance abuse can have lasting

effects on their children as well as themselves,

and behavioral health services provide an opportunity to improve their parenting skills that 

many men will gladly take. This chapter provides some guidance to clinicians who want to

address parenting in treatment programs for

men. Reproductive responsibility, child support, and family court involvement are also

discussed. 

A holistic approach to treatment involves addressing men’s spiritual and/or religious beliefs. Despite conflicting views among

researchers and other professionals in the field

about the link between spirituality and health,

the consensus panel believes that spiritual beliefs and/or practices do influence some men’s 

desire to abstain from using substances. Alcoholics Anonymous and Narcotics Anonymous 

are 12-Step organizations that use participants’ reliance on a higher power to aid in the

recovery process. These and similar groups 

have helped many individuals, both men and 

women, make tremendous progress on their

road to recovery. This chapter discusses the 

spiritual element of 12-Step groups and the 

relationship between spirituality and health. 

Chapter 4: Working With Specific 

Populations of Men in Behavioral 

Health Settings 

Numerous social and cultural factors either 

contribute to or help moderate men’s substance use, including their degree of conformity to masculine roles; culture, race, ethnicity,

and related issues, such as racism and acculturation; family roles (e.g., son, partner, husband, father) and history; sexual orientation;

geographic location; education; and professional background. Other factors related to 

some men’s specific circumstances (e.g., behavioral and physical health problems, unemployment or type of employment, criminal 

justice system involvement, homelessness) may 

play a significant role in men’s treatment and 

recovery plans. 

Chapter 4 explores some basic differences in 

men’s patterns of substance use/abuse based on

various demographic factors. Men typically

begin using substances at a younger age than

women do, and this appears to be a major factor in greater rates of substance use disorders 

among adult men than among women. Boys 

and young men may also turn to substance 

use/abuse for different reasons than girls and

young women do. For example, early use of

substances by men may be attributable to the 

fact that they are not adept at addressing emotional pain constructively. A man’s family 

background, sexual orientation, and cultural/ethnic identities may also affect his choice 

of substances and the possibility that he will 

develop a substance use disorder. 

Men are less likely to have a serious mental 

illness than women are, but men make up the 

majority of adults with co-occurring substance 

xvii 
Addressing the Specific Behavioral Health Needs of Men 

use and other mental disorders in behavioral 

health settings. This chapter considers rates of

different co-occurring mental disorders among

men and discusses how the course and presentation of different disorders may differ between the sexes. The chapter also looks at the 

related problem of suicidality, as men are more 

likely than women to die of suicide despite 

being less likely to attempt suicide. Physical 

illness or disability may also affect men’s substance use/abuse; treatment may need to address those issues. 

Masculine roles vary by age, as does men’s substance abuse. This chapter covers special 

treatment needs of young men (ages 18 to 24) 

and older adult men (ages 65 and older). Research suggests that patterns of substance 

use/abuse for gay and bisexual men may differ

from those of heterosexual men; a discussion

of the treatment needs of gay and bisexual 

men is also included. 

Employment has been shown to be especially 

important for men’s success in recovery, and

substance abuse is considerably higher among

men who are unemployed. Rates of unemployment are very high for men entering substance abuse treatment. In some cases,

occupation may also affect substance abuse for

men who are employed. The chapter also discusses the role economic and cultural factors 

play in men’s substance use/abuse. 

The specific needs of male veterans are also

addressed. Advice to behavioral health counselors for helping veterans access U.S. Department of Veterans Affairs (VA) services is 

provided, and the impact of combat stress reactions is discussed. 

The special dynamics of men entering treatment through the criminal justice system or

men who may interact with the criminal justice system while in substance abuse treatment

are also addressed in this chapter. The criminal 

justice system is the largest single source of

referrals to substance abuse treatment for men,

and many other men receive treatment while 

incarcerated in jails or prisons. It is essential 

that behavioral health counselors understand 

the criminal justice system and how to interact

with it appropriately. 

Men typically enter substance abuse treatment

with multiple needs that result, at least in part,

from years of substance abuse. To address 

these needs, providers will often have to interact with other systems, such as the criminal 

justice system and the housing/homelessness 

services system. Homelessness has been associated with substance use disorders and cooccurring disorders among men. Men make up

about four-fifths of homeless individuals in 

substance abuse treatment, but many programs 

cannot meet their particular needs—this chapter discusses ways programs can improve 

treatment outcomes for this group of men. 

The chapter ends with coverage of broad cultural groups in the United States and the ways 

in which men’s culture can affect their substance use/abuse and concepts of appropriate 

masculine roles. 

Chapter 5: Treatment Modalities 

and Settings 

Chapter 5 describes some treatment methods 

that researchers and providers have found useful in helping men recover from substance use 

disorders. It covers men’s treatment needs in 

the context of different modalities (e.g., group

therapy, individual therapy, family therapy)

and settings (e.g., outpatient, inpatient) and

some of the specific types of services that may

be used by programs treating men (e.g., enhancing motivation, money management). 

Men tend to be more reticent in group settings than women and less willing to attend

such sessions, which can account for somewhat better treatment outcomes for female 

xviii 
 

 

 

 

 

 

 

 

 

 

Executive Summary 

clients. Providers should try to increase men’s 

participation in groups. There are both benefits and potential problems involved in malespecific groups, and the chapter discusses some 

of these considerations. 

Family and significant others often play an 

important role in motivating men to enter

treatment. Once in recovery, men appear to

stay with their partners more often than women who enter recovery. Couples and family 

therapy can therefore be important options for

men in treatment. Men who are best suited 

for couples therapy:

•	 Have a high school or better education. 

•	 Are employed or willing to be employed. 

•	 Live with their partners or have partners 

willing to reconcile if they enter therapy. 

•	 Are older. 

•	 Have long-term substance abuse problems. 

•	 Have recently had a crisis that may have 

threatened the relationship. 

•	 Have a partner and/or other member of

the household who does not abuse substances. 

•	 Do not have other serious mental or emotional illnesses. 

•	 Are not violent. 

Some of the goals that providers should have 

when conducting family or couples therapy 

with men who are in substance abuse treatment include (1) developing perceptual and 

conceptual skills, (2) promoting mutual responsibility, and (3) challenging stereotypical

behaviors and attitudes. Readers are cautioned 

that couples and family therapy is contraindicated for clients where there is a history or risk 

of domestic violence. 

Chapter 5 covers family interventions that help

men enter treatment.These range from simple 

methods (e.g., fielding calls to an agency from 

concerned significant others) to formalized intervention models (e.g., the Albany-Rochester

Sequence for Engagement and Community 

Reinforcement and Family Training). 

Chapter 5 presents information on some 

common treatment strategies (e.g., motivational enhancement, relapse prevention) and

how they may be adapted for use with a specifically male clientele. Men often relapse for

different reasons than women; relapse prevention techniques may need to take those differences into account. Men’s participation in

mutual-help groups is also considered. 

xix 

Chapter 1–Creating the Context 

 

 

 

 

IN THIS CHAPTER 

• Introduction 

• Defining Sex and Gender 

• Defining Substance 

Abuse and Substance 

Dependence 

• Conceptual Frameworks 

of Masculinity and Male 

Roles 

• Gender Role Conflict and 

Masculine Role Stress 

• Men’s Substance Abuse 

• State of the Field 

• Audience for This TIP 

Creating the Context 1 

Introduction 

This Treatment Improvement Protocol (TIP) examines the history 

and theories of male socialization, changes in perceptions of masculinity and male roles, fatherhood, and other factors related to 

men’s substance use, abuse, and treatment. It emphasizes the fact

that there is no single concept of masculinity or male identity appropriate for all men. Many factors besides gender status influence 

men’s identities—age and cultural background, for example, affect

how men view what it means to be male. While recognizing that

there is tremendous variation among men, this TIP also discusses 

how American cultural norms shape the way many men evaluate 

themselves and how this relates to patterns of substance use or

abuse and to treatment provided by behavioral health counselors. 

Historically, substance abuse treatment services were developed

with male clients in mind because most admissions to substance 

abuse treatment programs were—and are—men. More recently,

though there are still more specialized programs and interventions 

for women than for men (Substance Abuse and Mental Health

Services Administration [SAMHSA], Office of Applied Studies 

[OAS] 2007d), the gender studies and men’s studies fields have begun to identify possible improvements in treatment services for men. 

Men and women abuse substances for many reasons—some gender-related, some not. Reasons overlap in many areas but markedly 

diverge in others, necessitating different treatment options. This 

TIP and TIP 51, Substance Abuse Treatment: Addressing the Specific 

Needs of Women (Center for Substance Abuse Treatment 2009c), 

explore gender-specific treatment needs and services that can address those needs. Note: TIPs referred to in this and subsequent

chapters are available at the Knowledge Application Program Web

site (http://kap.samhsa.gov). 

1 
 

 

Addressing the Specific Behavioral Health Needs of Men 

This chapter explains key issues, such as gender, sex, gender role conflict/stress, and conceptual frameworks relevant to behavioral 

health services for men with substance use 

disorders. It also describes concepts of masculinity and associated beliefs. It concludes with

discussions of specific patterns of male substance use and abuse and how certain substances affect men differently than women; the 

current state of male-specific substance abuse 

treatment; and how this TIP is useful for various audiences of behavioral health service providers. 

Although this TIP focuses on men with substance use disorders who are receiving treatment in substance abuse treatment settings,

much content is directly applicable to clients 

with other behavioral health problems and

disorders or who have a substance use disorder 

and a co-occurring mental disorder. The content of the TIP is directly applicable in various

settings beyond substance abuse treatment

programs, including mental illness treatment

programs; criminal justice, vocational, and social rehabilitation programs; settings that primarily address physical health or family issues;

and housing programs. 

Defining Sex and Gender 

One’s sex is generally assigned according to

biological markers. Individuals are typically 

classified as male or female based on their reproductive organs, but assigning sex based on

observable physical or biochemical traits leaves 

some individuals unassigned due to genital,

chromosomal, or hormonal ambiguities. 

Gender, on the other hand, is a sociocultural 

construct that defines expected characteristics 

of men and women. Femininity refers to characteristics ascribed to women, whereas masculinity refers to characteristics ascribed to men. 

Gender is not absolute; masculine behavior in

one culture can be the opposite in another. 

Moreover, notions of gender-appropriate behavior change over time and according to context. For example, in the 19th and early 20th 

centuries, it was considered appropriate for

young boys to wear dresses. Notions of gender-appropriate occupations have also

changed. For example, when the typewriter

was first invented, male clerks were thought to

have innate typing abilities far surpassing

those of women. However, those stereotypes 

changed and in a few decades, working as a 

typist was considered a female occupation.

Nursing, long considered a feminine job, has

attracted more men in recent years. 

In this TIP, masculinity is defined broadly to

include commonly accepted expectations for

men in the United States. A number of variables can alter accepted ideas about masculinity: economic status, occupation, geographic

location, religious affiliation, education, race,

ethnicity, and sexuality, among others. Some 

men are at odds with dominant notions of 

masculinity; others embrace such notions. Regardless of individual definitions of masculinity, ideas about gender roles and expectations 

can affect substance abuse treatment for men. 

A person’s gender identity must also be considered in discussions of masculinity. Gender

identity is usually defined as a subjective, continuous, and persistent sense of oneself as male 

or female, but the importance of gender identity varies from one individual to another. 

Defining Substance Abuse 

and Dependence 

Unless otherwise noted, in this TIP, substance 

abuse and substance dependence refer to all varieties of substance use disorders described in the 

Diagnostic and Statistical Manual of Mental 

Disorders, 4th edition, Text Revision (DSMIV-TR; American Psychiatric Association

[APA] 2000). The DSM-IV-TR states that 

2 
 

 

 

 

 

 

Chapter 1–Creating the Context 

“the term substance can refer to a drug of

abuse, a medication, or a toxin”—alcohol is 

included as a substance as well (p. 191). The 

text also notes that “many prescribed over-thecounter medications can also cause a substance-related disorder” and that “a wide range

of other chemical substances can also lead to 

the development of substance-related disorders” (p. 191). 

Substance dependence is “a cluster of cognitive,

behavioral, and physiological symptoms indicating that the individual continues use of the

substance despite significant substance-related

problems...[in which] there is a pattern of repeated self-administration that can result in

tolerance, withdrawal, and compulsive drugtaking behavior” (APA 2000, p. 192). Though

not a criterion, “craving (a strong subjective 

drive to use the substance) is likely to be experienced by most (if not all) individuals with

substance dependence” (p. 192). 

According to the DSM-IV-TR (APA 2000),

the essential feature of substance abuse is a 

“maladaptive pattern of substance use manifested by recurrent and significant adverse

consequences related to the repeated use of

substances” (p. 198). The text notes that, “unlike the criteria for substance dependence, the 

criteria for substance abuse do not include tolerance, withdrawal, or a pattern of compulsive 

use and instead include only the harmful consequences of repeated use” (p. 198). It specifies 

that “the term abuse should be applied only to

a pattern of substance use that meets the criteria for this disorder; the term should not be 

used as a synonym for ‘use,’ ‘misuse,’ or ‘hazardous use’” (p. 198). 

Although there is general agreement that intensive substance abuse treatment is best provided in specialized substance abuse treatment

programs, many men with substance use disorders enter and may continue care in a variety

of other behavioral health settings. As a result, 

in both specialized substance abuse treatment

programs and other settings, clients may be 

seen by behavioral health service providers

from a number of disciplines, including substance abuse counselors, mental health counselors, psychologists, social workers, professional 

counselors, ministers and chaplains, physicians,

and persons working in criminal justice settings. The general principles discussed in this 

TIP will be informative for the broader range

of behavioral health specialists who work with

men who have substance use disorders. 

Conceptual Frameworks 

of Masculinity and Male 

Roles 

Although no one set of behaviors or traits defines masculinity, certain characteristics or expectations are associated with masculinity in a

broad range of cultural contexts and across different age groups. Brannon (2005) reviews research on the cross-cultural applicability of

gender stereotypes and notes that although

diverse cultures label certain characteristics 

differently as masculine or feminine, there are 

generally more similarities than differences in

gender stereotypes across cultures. 

The stereotypical roles that define men within

a culture are referred to as masculinity ideologies 

(Good et al. 1994). Ideologies are systems of

values, beliefs, or ideas shared by a social group

and often presumed to be natural or innately 

true. Masculinity ideologies, then, are a body

of socially constructed ideas and beliefs about

what it means to be a man and against which 

men are measured by their societies (Addis 

and Mahalik 2003; Good and Sherrod 2001). 

Masculinity ideologies also affect how men

think and feel about themselves, and they influence male roles in a society (Pleck 1981,

1995). Men internalize these concepts from an

early age. Through a process of “masculine role 

3 
 

 

Addressing the Specific Behavioral Health Needs of Men 

socialization,” boys learn how they are expected to act, feel, and think, and they often

face negative consequences if they fail to meet

those expectations (Addis and Mahalik 2003;

Eisler 1995; Good and Sherrod 2001). 

Scholars have built upon Brannon’s blueprint

for masculinity (1976) to classify common,

socially accepted male roles (e.g., Levant et al.

1992; Mahalik et al. 2003b; Mahalik et al. 

2005; Pollack 1998b; Smiler 2004). Individual

men may identify with several roles or none

and may place more emphasis on some roles 

than others. The next sections examine specific masculinity concepts and their potential relation to substance abuse; these concepts exist

on a continuum and may change over time. 

Rituals, Rites of Passage, and 

Alcohol Abuse 

Rituals are socially supported events individuals and families use to mark transitions in their 

lives. The use of rituals is common to all cultures, although specific rituals vary. As ImberBlack (2002) notes, “human beings are ritual 

makers. Differing from mere routines in daily 

life, rituals enable individuals, families, and

cultures to create and derive meaning through

their symbols and symbolic actions” (p. 445). 

The potentially beneficial aspects of rituals are 

considerable. Rituals can reduce anxiety and

foster change (Schwartzman 1982), facilitate

development of individual identity and attachment to important values and beliefs of 

one’s culture, and contribute to “a shared and

necessary sense of belonging” (Wolin and

Bennett 1984, p. 402). However, rituals can

also be harmful—and certain rituals may harm

men differently than women. 

For centuries, men have been indoctrinated

into manhood through highly ritualized rites

of passage. Most cultures (Gilmore 1990) expect men to prove their worth through dangerous, painful tests of bravery. In the United 

States, men are often called on to prove their

masculinity through sports competitions, high

speed driving, or sexual conquests. Many such

conventional manhood rituals are intertwined 

with excessive alcohol consumption, with alcohol acting as a lubricant for the behaviors or

an end in itself. Indeed, some researchers who

examined binge drinking among college students found drinking to be a form of ritualized

behavior (Treise et al. 1999). 

Critical transitions in men’s lives—adulthood,

marriage, fatherhood, retirement, deaths—

often go hand in hand with excessive alcohol 

use, especially in the absence of clear guidance 

or preparation for the change. Although life

transitions are ideal times for men to give 

comfort and support to each other (those who

have made the journey already are especially 

equipped to do so), this rarely happens 

(Brooks 1995). Far too frequently, alcohol is 

substituted for open communication and caring. For example, on reaching legal adulthood

at age 21, many men celebrate by getting

drunk. Job promotions and sports victories are 

likewise frequently accompanied by drinking,

often to excess. The traditional celebration of 

the transition from bachelorhood to marriage

also often involves alcohol and drug use,

which many times drowns out a real need for

connection and communication among men. 

To reduce alcohol consumption among men,

the development of new celebrations and rituals that do not include alcohol consumption is 

necessary. Such changes will take time and

effort, but people in recovery already make use 

of rituals to help them get and remain abstinent. For example, 12-Step groups typically 

involve quite a few rituals (e.g., opening and

closing meetings, celebrating anniversaries,

welcoming new members, passing the hat for

contributions, giving out small objects such as 

key chains or coins to symbolize milestones),

and these rituals are important in creating a 

4 
 

 

 

Chapter 1–Creating the Context 

distinct cultural community that supports its 

members’ abstinence (Wilcox 1998). 

Emotional Restraint 

Starting in boyhood, many men learn that 

they should avoid stereotypical feminine characteristics or behaviors and strive to be tough.

Some do this by attempting to suppress emotions, thoughts, and behaviors potentially associated with vulnerability. Because of the 

stigma attached to expressing his emotions, a

man who experiences grief and sadness after

the loss of a loved one, for example, might resort to substance use as a way of coping (Good

et al. 2000; Pollack 1998b). Men are more 

likely than women to respond to emotional 

stress by drinking (Geisner et al. 2004) and

more likely to have a visceral response to alcohol-related cues when experiencing negative 

emotions (Nesic and Duka 2006). Even men

classified as mild to moderate social drinkers 

report significantly more alcohol craving as 

the result of negative emotional states than

women (Chaplin et al. 2008). 

Many men have problems both identifying

and expressing feelings, each of which has 

negative consequences. Difficulty identifying

emotions can increase trait anxiety among

men (Wong et al. 2006). Unlike women, men

often do not develop an adequate vocabulary 

for expressing feelings; instead, they express 

them nonverbally (e.g., through violent actions

or withdrawal) or suppress them (e.g., through

substance use). Certain emotional states (e.g.,

anger or sadness) may be predictive of violence 

toward partners, even after controlling for

gender role stress ( Jakupcak 2003). These 

problems appear to be pronounced among

men with substance use disorders, who often

have difficulty recognizing and expressing certain feelings—such as hurt or vulnerability—

that might be repressed and out of the individual’s awareness. Alexithymia (the inability 

to experience and/or communicate feelings) is 

not unusual in substance abuse treatment 

populations. In one sample of men entering

treatment for alcohol dependency, 30 percent

met criteria for this disorder (Evren et al. 2008). 

Competition and Success 

Competition can be a fun and important aspect of recreational activities and a positive

attribute in various professional and business 

settings, but it is also a significant source of

stress associated with increased substance use 

(Blazina and Watkins 1996). Only so many

persons can be recognized as the best in any 

given domain. Boys and men who perceive 

themselves as falling short in an important

area may attempt to suppress feelings of insecurity by using or abusing substances. Conversely, the effort and pressure often involved

with being the best leads some men to unwind

or celebrate their accomplishments with substance use. For example, higher success, power,

and competition orientations are linked with 

increased alcohol problems among male college students (Magovcevic and Addis 2005),

and male college athletes drink more than

nonathletes (Martens et al. 2006). In this same 

vein, men are significantly more likely than

women to respond to social stress by drinking

(Lemke et al. 2008), and work-related stress is 

strongly associated with heavy drinking in

men (Siegrist and Rodel 2006). The possible 

tension of living up to various concepts of masculinity likely contributes to, but does not solely 

cause, a man’s use or abuse of substances. 

Aggressiveness, Fearlessness, and 

Invulnerability 

Men are often socialized to be aggressive and

to appear fearless and invulnerable. To prove 

their masculinity, some men engage in reckless 

behaviors, including consuming large quantities of alcohol or drugs. The desire to take

risks and the need to avoid showing weakness 

can affect men’s health-related beliefs and 

5 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

behaviors (Courtenay 2000, 2003; Lejuez et al.

2004). Alcohol is also associated with increased aggression among men, and this effect

may be stronger for men than for women. For

example, Giancola (2002a) found that alcohol,

when combined with higher levels of irritability, led to more aggressive behavior in men but

not women. Illicit drug use may have a similar

effect, given that some drugs (notably stimulants) are known to increase aggression and

risk-taking behaviors. 

As a group, men do not seek health care during illness or following injury nearly as often

as women do (Addis and Mahalik 2003;

Courtenay 2003; Sandman et al. 2000). Men

are also more likely than women to engage in

risky sexual behavior but less likely to take 

preventive measures (e.g., performing selfexaminations for cancer, using sunscreen,

wearing seatbelts or helmets, not using addictive substances). These behaviors contribute to

the higher death rate among men for all leading causes of death, as well as their shorter life 

spans compared with women (Case and

Paxson 2005; Courtenay 1998; Eisler 1995;

Waldron 2005). Additionally, some frameworks of masculinity can exacerbate medical 

conditions by increasing stress. This could partially explain why Hunt and colleagues (2007)

found decreased death rates from coronary 

heart disease among men who scored higher

on measures of feminine traits, despite there 

being no similar findings for women. 

Sexual Accomplishment 

The gender socialization process can cause 

men many problems related to sexuality. Many 

American men learn from an early age that

identifying with girls, women, or anything

feminine is not socially appropriate, and emotional intimacy may be characterized as feminine. At the same time, sexual conquest is 

often presented as an expression of real masculinity. Fear of femininity drives some men to 

become counterdependent and emotionally 

vulnerable to no one; in some cases, they emotionally disconnect from others and start to

view sex as an achievement or a goal. 

Men who hold this outlook on sexuality can

have problems with what Good and Sherrod

(1997) call “nonrelational sex,” or “the tendency 

to experience sex primarily as lust without any 

requirements for relational intimacy or emotional attachment” (p. 181). Having multiple

partners with whom little communication is 

shared can result in unwanted pregnancies,

higher risk of exposure to sexually transmitted

diseases, and the spreading of diseases to multiple partners. Such behaviors add to growing 

public health problems. Men who engage in

nonrelational sex can find intimacy difficult and

relationship-building with members of either

sex challenging. 

Men’s use of alcohol and drugs may be linked

to their desire to fulfill male gender role expectations of power, dominance, and control

over women. Research bears this out. Men 

who believe they have consumed alcohol are 

more likely to be aroused by violent sexual images or fantasies (Roehrich and Kinder 1991),

and as they consume greater amounts of alcohol, their sexual fantasies are more likely to

involve control over others (McClelland et al.

1972). Greater alcohol consumption is also

associated with a greater likelihood of sexual 

aggression among men (Peterson et al. 2009),

as well as increased violence toward intimate 

partners (Foran and O’Leary 2008), both of 

which are discussed in detail in Chapter 4. 

A related aspect of this definition of masculinity is heterosexism—the assumption that heterosexual behavior is natural and therefore 

homosexual men are less masculine. Despite 

sexual orientation being a separate issue from 

gender identity, traditional concepts of masculinity equate the two. Heterosexual men may 

feel that their masculinity is threatened by 

6 
Chapter 1–Creating the Context 

 

 

homosexual behavior, resulting in homophobia

(i.e., fear of homosexuality and homosexual 

persons)—which further contributes to prejudice against gay men and pressures them to at

least appear to conform to heterosexual norms. 

Independence and Self-Sufficiency 

Men are expected to be independent and able 

to take care of themselves with little or no 

help from others. Help-seeking for many men

implies dependence, vulnerability, or even

submission to someone with more knowledge,

such as a healthcare professional. The negative 

mental and physical health effects of internalizing this masculine role, which is perpetuated

by cultural messages about masculinity and

health, can be seen in men’s underutilization 

of healthcare resources—including behavioral

health services (Addis and Mahalik 2003;

Berger et al. 2005; Biddle et al. 2004). Men

have significantly greater self-stigma related to

help-seeking (i.e., believing that seeking help

will decrease their self-confidence, cause them 

to doubt their abilities, and decrease their feelings of worth) than do women (Vogel et al.

2006). In addition, conformity with male gender norms of self-reliance is associated with 

increased psychological distress and less willingness to seek help for psychological problems (Mahalik et al. 2003b). 

These attitudes toward help-seeking also affect men’s interactions with primary care providers. Despite having a shorter life expectancy 

than women, men see their physicians less often (Cherry and Woodwell 2002) and ask fewer

questions than female patients (Courtenay 

2000). Compounding this problem, physicians 

make less effort to warn male patients about

health risks (Foote et al. 1996). 

Men consume considerably more alcohol and

drugs than women and are thus more likely to

have substance use disorders (Grant et al.

2005; SAMHSA 2009; von Sydow et al. 2001; 

von Sydow et al. 2002). However, men—

particularly heterosexual men—are less likely 

than women to seek help for substance abuse 

(Addis and Mahalik 2003; Grella et al. 2009a). 

What might explain this discrepancy? Physical 

differences between the sexes could partially 

account for the variance in substance use and 

abuse, as could the socialization process for

men and its resulting framework of masculinity. These may also contribute to differences in

help-seeking behavior (Isenhart 2001; Williams and Ricciardelli 1999): men with substance use disorders are more likely than

women to state that they can handle the problem on their own as a reason for not seeking

treatment, whereas women’s reasons tend toward concerns about what others might think

or lack of time (U.S. Department of Health and

Human Services, SAMHSA, OAS 2009a). 

Acknowledging their illness (such as substance 

dependence) can cause men to feel helpless—a 

feeling that directly contradicts societal messages about masculinity (Good et al. 2000;

Pollack 1995, 1998b). As Isenhart (2001) 

notes, “given this relationship between alcohol 

and masculinity, when a man is asked (or told)

to give up alcohol, he may feel like he is giving

up part of his masculine identity” (p. 250).

Some men see health-sustaining practices (e.g.,

having annual physicals, getting health screenings, performing health self-assessments) as

unnecessary or humiliating. 

The Value of Gender Roles 

Gender roles are neither all good nor all bad,

and they vary according to social role (e.g., a 

man’s role as a father differs from his role as a 

son), age, and cultural background. Some 

components are useful, especially in specific

situations. For example, men aligned with

more traditional masculine roles may have 

strengths in such areas as logical thinking,

problem-solving, risk-taking, anger expression,

and assertive behavior. These traits can be 

7 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

particularly useful in times of crisis (Betcher

and Pollack 1993; Levant 1995), enabling him

to remain calm and problem-focused or to

surrender his personal safety for the greater

duty of protecting and providing for his family,

community, or country (Good and Sherrod 

2001). Conformity to male gender norms also

fosters “acceptance from social groups, and

[provides] social and financial rewards as a result” (Mahalik et al. 2005, p. 662). For men of 

color, adherence to gender roles can be a

source of pride closely related to their cultural 

identity, helping protect them against racial 

and ethnic oppression and stigma (Levant et

al. 1998; Ojeda et al. 2008; Saez et al. 2009). 

Gender Role Conflict and 

Masculine Role Stress 

Several models attempt to explain how men

become socialized. Among these are the theories of gender role conflict (O’Neil et al. 1995) 

and masculine role stress (Eisler and Skidmore 

1987; Eisler et al. 1988), which focus on the

negative consequences experienced by men

who endorse particular beliefs regarding masculinity (Addis and Mahalik 2003; Good and

Sherrod 2001; Pederson and Vogel 2007). 

Gender role conflict occurs “when rigid, sexist,

or restrictive gender roles result in personal 

restrictions, devaluation, or violation of others

or self ” (O’Neil et al. 1995, pp. 166–167). This

conflict can be experienced at a cognitive,

emotional, or behavioral level, and may be 

conscious or unconscious.The Gender role 

Conflict Scale developed by O’Neil and colleagues (1986) gauges gender role conflict in

four areas: success, power, and competition issues; restrictive emotionality; restrictive sexual 

and affectionate behavior between men; and

conflict between work and family relations. 

As with gender role conflict, the theory of masculine role stress views the socialization of men 

from a cultural lens. Eisler (1995) notes that: 

Masculine gender role stress may arise from excessive commitment to and reliance on certain 

culturally approved masculine schema that limit

the range of coping strategies employable in any

particular situation.... Masculine gender role 

stress may also arise from the belief that one is

not living up to culturally sanctioned gender

role behavior. Men may experience stress if they

feel that they have acted in an unmanly or feminine fashion. Many men are doubly stressed by

experiencing fear or by feeling that they did not

appear successful or tough enough in situations

requiring masculine appearances of strength and

invincibility (p. 213). 

Masculine role stress has been refined to include links to shame (discussed in Chapter 3),

depression, and anxiety (Liu and Iwamoto

2006; Liu et al. 2005; Wong et al. 2006). 

Men’s Substance Abuse 

Regardless of age or race, men use alcohol and

drugs more frequently and in greater quantities than women. Similarly, young adults are 

more likely to use substances than are their

older counterparts. The highest rate of illicit

drug use is among young adult men, and the 

most common illicit drug used is marijuana.

According to SAMHSA’s 2008 National Survey of Drug Use and Health (NSDUH),

young adult men 18 to 25 years of age are also

more likely to drink alcohol (64.3 percent)

than their female counterparts (58.0 percent)

(SAMHSA 2009). Binge drinking (a pattern

of alcohol use that is more likely to result in

alcohol-related problems) is likewise more 

prevalent among men. An earlier NSDUH

study (SAMHSA 2005) indicated that even

though 32.9 percent of men ages 21 and older 

reported prior-month binge alcohol use, only 

14.7 percent of women in the same age group

reported binge drinking in the prior month.

People who binge drink have a higher incidence of alcohol-related problems (than those 

who do not binge drink), and men are more 

8 
Chapter 1–Creating the Context 

 

 

 

 

 

 

 

 

 

 

likely to binge drink than women, so counselors 

need to be aware, particularly when working

with younger male clients, that binge drinking

may be part of the individual’s drinking pattern. 

Perhaps reflecting these differences in use,

American men are two to five times more 

likely to develop a substance use disorder than

women (Brady and Randall 1999; Johnson 

and Glassman 1998; SAMHSA 2008;

SAMHSA, OAS 2004a). In fact, in developed 

nations around the world, men experience 

greater mortality and morbidity from alcohol 

and tobacco use than women, due in part to

greater rates of use (Lopez 2004). Worldwide,

the health burden for substance use disorders 

is more than three times greater for men than

women (World Health Organization 2004).

The economic cost of men’s substance abuse is 

greater as well; men who abuse substances 

have more criminal justice system involvement

than women who abuse substances, and because men are more likely to have jobs, they 

more often require disability payments (Harwood et al. 1998; Oggins et al. 2001; Timko et

al. 2009). When men receive substance abuse 

treatment, taxpayers benefit: For every dollar 

spent on treatment, an estimated $9.00 is 

saved in criminal justice, healthcare, welfare,

and disability costs (Harwood et al. 1998). 

Given the chance, men and women are equally 

as likely to use substances. However, men may 

be more likely than women to use and abuse 

them largely because they have more opportunities to do so (van Etten et al. 1999). This

could, in part, account for higher rates of

abuse and dependence among men. Men also

generally begin using alcohol and drugs at an

earlier age than women (SAMHSA 2005). 

Understanding how socially constructed gender role expectations affect some men’s choice 

of substances and attitudes toward treatment 

can help behavioral health service providers

choose more effective strategies. Alcohol consumption, in particular, can be tied to ideas

about masculinity and appropriately masculine 

activities. For young men, a first drink or first

episode of drunkenness is often a rite of passage (Blazina and Watkins 1996; Hunt et al.

2005), and drinking is commonly seen as a 

form of male bonding (West 2001). Such traditional ideas linking masculinity to drinking

are prevalent across cultures (Heath 2000) and

are associated with greater alcohol consumption among college men (Blazina and Watkins

1996; West 2001) and military personnel/veterans (Burda et al. 1992; West 2001). 

Men also respond differently than women to

certain substances, and some substances have 

effects in men that they do not have in women

(see Chapter 3). For example, when men and

women think about cocaine cravings, their

neural responses differ (Kilts et al. 2004); men

who use cocaine are also more likely than

women to state that cocaine increases their sex 

drive and that they have more sex when using

cocaine (Washton 2009). Findings such as

these suggest the possible usefulness of gender-specific treatment approaches for cocaine

dependence and other substances of abuse. As

with cocaine, there are differences between the 

sexes in both methamphetamine and opioid

dependence. Men show greater loss of mental 

faculties relating to executive function and

memory than women, and these effects persist

even after abstinence (Ersche et al. 2006). 

Men may use or start to abuse substances for

different reasons than women, and male institutions (e.g., fraternities, amateur sports 

teams) often encourage alcohol use (Brooks 

2001). Men who cannot talk about their feelings or manage them constructively sometimes

use substances to deal with difficult emotions. 

Shame, especially, can limit help-seeking behaviors for substance use and mental disorders 

(Brooks 2001; Pollack 1998b). 

9 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Exhibit 1-1: Lifetime Substance Use in 

the General Population Ages 12 and 

Older (2008) 

Substance % Men % Women 

Alcohol 85.5 79.3 

Cocaine (any form) 18.0 11.8 

Smoked cocaine 

(i.e., crack) 4.4 2.3 

Heroin 2.1 1.0 

Inhalants 11.6 6.4 

Hallucinogens 17.8 11.6 

Marijuana 45.6 36.9 

Methamphetamine 5.2 3.1 

Pain relievers (nonmedical use) 16 12.3 

Sedatives 4.2 3.1 

Tranquilizers 9.3 8.2 

Source: HHS, SAMHSA, OAS 2009b. 

Exhibit 1-2: Treatment Admissions by 

Primary Substance of Abuse 

Substance % Men % Women 

Alcohol 74.6 25.4 

Alcohol with another 

substance 73.7 26.3 

Smoked cocaine 

(i.e., crack) 58.4 41.6 

Other cocaine 65.0 35.0 

Heroin 68.3 31.7 

Other opioids 53.8 46.2 

Methamphetamine 54.2 45.8 

Inhalants 67.0 33.0 

Hallucinogens 72.7 27.3 

Marijuana 73.8 26.2 

Sedatives 42.7 57.3 

Tranquilizers 46.4 53.6 

Source: SAMHSA, OAS 2008b. 

SAMHSA’s 2008 NSDUH established rates of 

lifetime use of substances for men and women 

(Exhibit 1-1); it found that 12 percent of men

ages 18 and older met criteria for a substance 

use disorder in the past year compared with 6.3

percent of women (SAMHSA 2009). 

SAMHSA’s 2006 Treatment Episode Data

Set (SAMHSA, OAS 2008b) revealed differences in substance abuse patterns and preferred substances of abuse between men and 

women who entered substance abuse treatment programs funded through State agencies 

(Exhibit 1-2). For all drugs listed save sedatives and tranquilizers, most treatment-seekers 

were male. However, data reported in the exhibit are for the primary substance of abuse,

which was not necessarily the only substance a

person abused. 

State of the Field 

Substance abuse treatment was designed for a

largely male client population, and greater

numbers of men than women continue to be 

treated in a variety of behavioral health settings.

Additionally, much of the research on substance 

abuse treatment has been conducted with male 

participants; nevertheless, it has not examined

the specific, unique issues of men (e.g., their

health, psychological, cultural, and social needs)

as related to substance abuse and its treatment. 

There is a difference between designing a substance abuse treatment intervention for a population—the majority of whom are men—and

designing one specifically to address factors 

that distinguish male from female clients.The 

study of men’s issues is a growing field, and as 

researchers focus on issues specific to men, our

knowledge base—and thus our ability to design

treatment interventions for men—will increase. 

In 2006, 68.2 percent of admissions to substance abuse treatment programs receiving

State agency funds were men (SAMHSA,

OAS 2008b). However, data from 2005 show 

10 
Chapter 1–Creating the Context 

 

 

 

 

 

that only 25 percent of programs offered any 

type of specialized services for adult men (OAS

2007a). These data exclude treatment programs 

for incarcerated clients, an even greater percentage of whom are male. 

In 2003, the Addiction Technology Transfer

Centers (ATTCs) began offering two trainings

related to men’s issues in treatment: “Men in 

Therapy” and “Anger Management”

(http://www.attcnetwork.org/learn/education/

dasp.asp). Trainings in substance abuse treatment specific to men are also available from

other sources, such as the “Counseling Alcohol 

and Drug Dependent Men” training from the

Distance Learning Center for Addiction Studies (http://www.dlcas.com). Men in general,

regardless of age or cultural background, are 

less likely than women to seek treatment and

more likely to leave treatment early, so motivational interviewing and treatment engagement

skills should be a primary focus when training

staff members who treat men. 

Audience for This TIP 

Because men who have substance abuse problems are a large and diverse group of people,

this TIP will be useful to a broad audience of 

behavioral health service providers, including:

•	 Substance abuse treatment providers.

This TIP will help providers reevaluate 

treatment programs for men and the assumptions on which treatment is based.

Providers who understand current social 

expectations, how clients view themselves 

vis-à-vis these expectations, and the role 

that substances of abuse currently play in 

men’s lives can improve men’s engagement

in and outcomes for treatment. 

•	 Substance abuse prevention programs.

Substance abuse prevention efforts that focus on men’s and boys’ issues can use this 

TIP to help clients learn to interact with 

one another without using substances and 

to encourage help-seeking for substance 

abuse problems. 

•	 Primary care physicians and primary care

providers. Hospital workers will find resources and suggestions for improving the 

screening of men for substance abuse,

mental health, violence, and related problems. 

•	 Psychiatrists, psychologists, counselors,

social workers, and other behavioral

health workers. This TIP is a useful tool 

for modifying screening, assessment, engagement, referral, and treatment approaches when working with men who

have substance abuse problems. 

•	 Educators. This TIP can help students 

modify and/or challenge how men are 

viewed, to dispel misconceptions about

men who abuse substances, and to encourage critical thinking and discourse about

men who have substance abuse problems. 

•	 Criminal justice professionals. Professionals associated with courts, prisons, probation and parole systems, and other criminal

justice settings can use this TIP as a resource when urging programs to address 

the multiple needs of men as related to substance abuse, physical and mental health,

violence, and other concerns, including vocational and parenting programs. 

•	 Faith-based organizations. Content from 

this TIP can be incorporated into the

work of faith-based programs to help men

address issues related to substance abuse. 

•	 Researchers. This TIP summarizes some 

of the central issues relating to men’s 

treatment currently being studied and suggests directions for future research. 

•	 Administrators. Administrators of agencies, provider organizations, treatment and

prevention programs, medical facilities,

and businesses can use this TIP to better 

inform community members not currently 

involved with the problems of substance 

use and abuse. 

11 

Chapter 2–Screening and Assessment 

 IN THIS CHAPTER 

• Introduction 

• Screening and 

Assessment of Men 

• Comprehensive Screening 

and Assessment 

Screening and 2 Assessment 

Introduction 

This chapter discusses how to engage men in the treatment process and addresses factors that can influence men’s behaviors and 

attitudes toward behavioral health services. It reviews screening

and assessment instruments and discusses these processes, including assessment of risk-taking, shame, male sexuality, and anger. 

Screening and Assessment of Men 

Screening and assessment are used to identify a client’s strengths

and problems. Normally, screening and assessment occur at intake,

and both processes should continue throughout the course of

treatment. Routine screening and assessment can identify problems 

that may arise or manifest after initial intake and can help pinpoint

a client’s strengths—such as strong marriage or family ties, strong

motivation to change, or the absence of pressing crises. Routine 

administration of these processes is imperative, as the counselor’s 

understanding of a client’s strengths and problems significantly influences the type and duration of interventions applied as clients 

enter treatment in various behavioral health settings. 

Screening and assessment are often grouped together, but they are

distinct processes. Screening is a formal interviewing and/or testing

process that identifies areas of a client’s life that might need further

examination. It evaluates for the possible presence of a problem,

but does not diagnose or determine the severity of a disorder. For

instance, screening a man for substance abuse might entail asking

him a few interview questions about drug use and related problems 

and using a brief screening scale for substance abuse and/or substance dependence. When positive indicators are found, schedule 

the individual for an assessment. 

13 
 

Addressing the Specific Behavioral Health Needs of Men 

Assessment is a more indepth evaluation that

confirms the presence of a problem, determines its severity, and specifies treatment options for addressing the problem. It also

surveys client strengths and resources for addressing life problems. Assessment typically 

examines not only possible diagnoses, but also

the context in which a disorder manifests. A 

substance abuse assessment, for example, assesses the severity and nature of the substance 

use disorder and may also explore the possibility of co-occurring disorders; the client’s family, marital, interpersonal, physical, and spiritual 

life; financial and legal situations; and any other issues that might affect treatment and recovery. Assessment generally involves indepth

interviews and the use of various assessment 

instruments, such as psychological tests. 

Although there has been little research into

the differences between men’s and women’s 

responses to screening and assessment, some 

literature (e.g., Cochran 2005) suggests that

men present unique difficulties. Masculine 

gender role socialization can lead some men to

minimize difficulties or underreport problems—and some problems, such as depression,

can manifest differently in men, thus disguising the disorder and leading to underdiagnosis 

or misdiagnosis (see Chapter 4 for discussion

of this and other co-occurring mental disorders). In addition, different screening or assessment settings (e.g., prisons, outpatient

programs, primary care offices) influence 

whether and how men present their struggles.

Culture also plays a role; men from some 

nonmainstream cultures may be reluctant to

share information about difficulties or illnesses. Counselors must be sensitive to these nuances and create an environment in which 

men feel open to sharing their vulnerabilities 

or perceived shortcomings. 

This chapter focuses on screening and assessment processes and instruments specifically 

applicable to male clients. Certain wellestablished physical, mental, and social assessments that are useful regardless of gender

are also briefly introduced. When possible, the 

reader is referred to other Treatment Improvement Protocols (TIPs) that cover screening and assessment activities relevant for both

male and female clients. 

Comprehensive Screening 

and Assessment 

The Institute of Medicine’s (1990) three-step

assessment process for problematic alcohol use 

offers a useful framework for organizing the 

assessment of men who abuse substances; see 

also TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (Center for

Substance Abuse Treatment [CSAT] 1997a). 

Comprehensive substance abuse assessment

documents detail the nature of the substance 

use problem and thoroughly describe the person with the problem so that appropriate decisions about intervention can be made. 

The three steps in a comprehensive substance 

abuse assessment are screening, problem assessment, and personal assessment. The process begins with a screening to identify men in

need of a problem assessment. Screening can

be provided by any behavioral health counselor

who has been trained in the screening process.

Problem assessment documents patterns of

use; signs and symptoms of substance abuse or

dependence; and the social, spiritual, psychological, and medical consequences of use.

Problem assessment typically occurs in the 

substance abuse treatment or behavioral health 

system. Assessment skills for behavioral health

service providers include additional training,

experience and clinical supervision in understanding the interrelationships between drug

use and other facets of the individual’s life, exploring an individual’s motivation for and any

resistance to treatment, and understanding the 

14 
Chapter 2–Screening and Assessment 

 

 

 

scope of treatment services that might be 

available in the community behavioral health

system. When problem assessment indicates 

the presence of substance abuse or dependence, a comprehensive, gender-aware personal 

assessment can add psychosocial data important for treatment. 

Comprehensive assessment of men with substance use disorders should be carried out by a

behavioral health specialist with a clear understanding of how male gender role socialization

broadly influences the psychosocial adaptation,

substance use, and help-seeking behavior of

men. Behavioral health clinicians performing

assessments should understand how chronic 

substance use affects the biopsychosocial adaptation of men and should be aware of the 

other social, psychological, and medical problems common among this population. 

The screening and assessment instruments 

presented in this chapter serve to inform readers of current work in different clinical and 

research settings. The decision to pursue a

specialized assessment (e.g., of a client’s comfort level with gender roles or history of childhood abuse or neglect) must be made on a

case-by-case basis that considers the appropriateness of the assessment, the skill and resources of behavioral health service providers 

in pursuing such an assessment, and the wishes and interests of the client. Treatment programs need to determine how best to use 

available resources when assessing clients.

When a program is unable to conduct an assessment that providers believe is necessary—a 

mental health evaluation, for example—it 

should be able to refer the client to another 

provider for that assessment. 

Assessors should show sensitivity to the values,

attitudes, and behavioral dispositions that men

share, as well as differences related to age, ethnicity, socioeconomic status, geographic location, disability status, and sexual orientation. 

That is, while considering ways in which men

are alike because of their gender, clinicians 

must also account for other characteristics that 

make them different from one another. See 

the planned TIP, Improving Cultural Competence (Substance Abuse and Mental Health

Services Administration [SAMHSA] planned 

c) for more information on assessing cultural 

identity and acculturation. 

Screening Men for Substance 

Abuse 

The primary goal of screening is to identify 

men who need a comprehensive problem assessment. In a screening intake, the behavioral 

health clinician gathers facts by asking simple

questions that evaluate whether a person requires further assessment. For screening, clients often fill out self-reports prior to a

clinical interview. In such cases, the screener

should be sensitive to possible language or literacy barriers by asking clients if they want

assistance with forms or if they prefer to fill 

them out by themselves. 

A client with a drug- or alcohol-related driving offense will likely have been screened in

the criminal justice system and sent for further

assessment and treatment. The clinician can 

thus move on to problem assessment using the 

justice system report but should go over it

with the client, seeking input with questions,

such as “Do you think this report is substantially accurate?” or “What other information

would you add?”TIP 44, Substance Abuse 

Treatment for Adults in the Criminal Justice 

System (CSAT 2005b), discusses treating clients in the criminal justice system, and TIP

30, Continuity of Offender Treatment for

Substance Use Disorders From Institution to 

Community (CSAT 1998b), addresses treatment for clients transitioning from the criminal justice system to community-based

treatment. 

15 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

For listings of substance use disorder screening

instruments, see TIP 16, Alcohol and Other 

Drug Screening of Hospitalized Trauma Patients 

(CSAT 1995a), and TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring Disorders (CSAT 2005c). TIP 24 (CSAT 1997a)

addresses conceptual, procedural, and legal issues associated with screening for alcohol and

drug abuse. TIP 24 and Alcohol Alert No. 56,

Screening for Alcohol Problems: An Update (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 2002), also contain lists of

proven screening instruments.The Center for

Social Work Research at The University of

Texas–Austin (http://www.utexas.edu/research/

cswr/nida/instrumentListing.html) and the

University of Washington Alcohol and Drug

Abuse Institute (http://lib.adai.washington.

edu/instruments/) offer comprehensive lists of

screening and assessment instruments online. 

Clients can be screened by behavioral health 

service providers in a variety of settings for

current or recent substance use using a variety 

of testing methods (e.g., urine, oral fluid, or

hair for drug tests; breath analysis for alcohol).

For more on these testing methods, the reliability of testing, specimen collection, and responding to test results, see Chapter 9 of TIP

43, Medication-Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs

(CSAT 2005a), and Appendix B of TIP 47,

Substance Abuse: Clinical Issues in Intensive 

Outpatient Treatment (CSAT 2006c). Providers interested in laboratory tests for alcohol 

used in ambulatory medical settings can refer

to Alcohol Alert No. 56 (NIAAA 2002). 

Screening in other settings 

Because substance abuse, especially involving

alcohol, is the most frequent behavioral health

issue among men in the general population

(Kessler et al. 1994), healthcare, legal, educational, occupational, and social service organizations should always carefully screen men for 

substance use when they present (see TIP 16

[CSAT 1995a]). Chronic substance abuse often contributes to legal, family, employment,

housing, mental health, and medical problems;

men with substance use disorders (particularly 

those reluctant to seek help for their substance 

abuse problem) may first seek help for related

problems outside the behavioral health treatment system. When performed using proven

methods, screening need not be expensive or

burdensome. In fact, as noted in TIP 16

(CSAT 1995a), effective screening of men 

who abuse substances can prevent unnecessary 

expenditure of resources and promote more 

effective referral of men to the service delivery 

systems that can best meet their needs. 

Often, the presenting problem indicates a

need for problem assessment. For example,

men warrant referral for further assessment 

when they present in the legal system after

driving under the influence, in the emergency 

room after being injured while under the influence, or in a primary care practice with

medical problems directly related to substance 

abuse. Service systems can integrate simple,

structured screenings with clear markers of

need for further assessment into their admission procedures (see TIP 11, Simple Screening

Instruments for Outreach for Alcohol and Other 

Drug Abuse and Infectious Diseases [CSAT 

1994b]). 

Substance Abuse Assessment 

Procedures for Men 

When screening suggests the presence of a

substance use disorder, problem assessment

will help better define the nature of the client’s 

problems. In many ways, assessment procedures for men and women do not differ significantly. Nevertheless, at each stage of the

assessment process, providers should consider

how gender may have affected a male client’s 

past behaviors and how it may affect current 

16 
Chapter 2–Screening and Assessment 

 

 

treatment. Assessment for substance abuse or 

dependence should focus on:

•	 Historical and situational factors contributing to the onset of the substance use. 

•	 Patterns of use. 

•	 Common signs and symptoms of a substance use problem. 

•	 Consequences of use. 

Comprehensive assessment also investigates 

other factors related to the client’s substance 

abuse; these factors are discussed in this chapter under the heading “Gender-Aware Personal Assessment.” 

A variety of standardized approaches can be

used in problem assessment. Retrospective 

methods using timeline follow-back procedures (Fals-Stewart et al. 2000b) define the 

nature and consequences of substance use during a circumscribed period of time. Because 

some men are more comfortable analyzing

visual information, visually representing substance use and consequences of substance use 

along a timeline or on a calendar may be a 

better method of collecting and displaying information for male clients. Laboratory studies 

may also be used to document recent use, obtain markers of chronic use, and document

medical consequences of chronic use. 

Most standardized assessment instruments 

were developed largely with male client populations, and most are normed for men. Readers 

are referred to resource guides developed by 

NIAAA (Allen and Columbus 2003) and the 

National Institute on Drug Abuse (1994),

which contain listings of clinical and research

tools that can be used during problem assessment. The Center for Social Work Research at 

The University of Texas at Austin has also assembled a valuable list of screening and assessment instruments (http://www.utexas.edu/

research/cswr/nida/instrumentListing.html). 

Gender-Aware Personal 

Assessment 

Once the nature of the substance abuse problem has been clearly established, the assessment process moves to the personal 

assessment phase. A comprehensive personal 

assessment routinely includes a complete 

physical examination, an exploration of significant events in the client’s life that could affect 

treatment and recovery, the client’s history of

mental health or developmental problems, and

an evaluation of his close relationships. In each

of these areas, client strengths should also be 

assessed. Personal assessment aims to distinguish values, attitudes, and behavioral dispositions that the individual may share with other

men or that make him different from other 

men. The first step should be a broad-based,

gender-aware screening to identify substantive

areas in need of more detailed assessment, such

as those described in the following paragraphs. 

Employment status and work history: Employment before and during treatment has 

been associated with better retention and improved treatment outcomes (Platt 1995; Sterling et al. 2001), especially for men (Arndt et

al. 2004). Chapter 3 of TIP 38, Integrating

Substance Abuse Treatment and Vocational Services (CSAT 2000a), discusses the assessment

of vocational goals and training needs. Providers should also talk with clients about current 

and past employment and education to get a

better understanding of what roles these factors may have played in the clients’ substance 

abuse as well as how they might be used in

promoting recovery. 

Housing status and needs: A significant number of clients entering substance abuse treatment lack adequate housing or are at risk of

losing housing. TIP 55, Behavioral Health 

Services for People Who Are Homeless 

(SAMHSA 2013), discusses issues relevant to

the assessment of men who are homeless. 

17 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Criminal justice involvement and legal issues:

Providers should understand what outstanding

legal problems clients face, any past history of

involvement with the criminal justice system,

and the roles these issues have played in their

clients’ lives. Counselors should also ask if a 

client is currently on probation or being monitored in the criminal justice system, how often

the client is required to report to probation or

parole officers, and the conditions under

which the counselor might be required to report the client’s progress to the criminal justice system. During assessment, inform the 

client of what information you are required to

provide to representatives of the criminal justice system (e.g., probation officers), such as the 

results of positive urine drug screens or threats 

to self or others. Chapter 4 discusses how to

address these issues in treatment. 

Health status/physical health: Because chronic substance abuse is associated with poor

physical health, comprehensive substance 

abuse assessment must include a complete 

physical examination (and is required for admission to most healthcare facilities). Ideally,

the examination will include laboratory studies 

to screen for health problems associated with

the use of specific substances (e.g., hepatitis C

and HIV/AIDS for men who use injection

drugs, cirrhosis and pancreatitis for men who

abuse alcohol) and those health problems most

common among men. If the male client is being seen in a hospital or residential setting, a

physical examination with laboratory studies 

will undoubtedly be part of the routine admission process. In ambulatory settings, the initial 

interview should include questions about

health history, general nutrition, sleep patterns,

weight changes, last physical examination, and

last dental examination. Men who have access 

to primary health care should be referred to

their primary care physician upon admission

to an ambulatory setting. Otherwise, programs 

should work with clients to help them access 

needed care through other channels, such as

public health clinics. One health-related area

that can pose particular problems for clients in

substance abuse treatment is chronic pain, the 

assessment of which is discussed in TIP 54,

Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

(SAMHSA 2011b). 

Functional limitations: Assessment should 

determine if the client has any functional limitations due to co-occurring physical and/or 

cognitive disabilities (Schrimsher et al. 2007).

The behavioral health service provider must 

be able to accommodate a client with special 

needs. For example, a provider can accommodate a client who has lower back pain (which

may not necessarily be described as a disability 

by the client) that is exacerbated by sitting for

extended periods by giving the client permission to stretch or stand during long group

therapy sessions. Similarly, a person with limited skills in reading or writing English may

require modified versions of written client material. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive

Disabilities (CSAT 1998e), offers more information on screening individuals for functional 

limitations. 

Co-occurring mental disorders: Rates of cooccurring mental disorders among substance 

abuse treatment clients (both male and female) are high, and these clients often require 

special behavioral health services for effective 

treatment (see TIP 42 [CSAT 2005c]). Details 

on the assessment of mental disorders and cooccurring disorders are available in Chapter 4

of TIP 42. Additionally, TIP 50, Addressing

Suicidal Thoughts and Behaviors With Clients in

Substance Abuse Treatment (CSAT 2009a),

presents information on screening potentially 

suicidal clients, and TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (CSAT 2008b), discusses 

18 
Chapter 2–Screening and Assessment 

screening specifically for depressive symptoms.

Chapter 4 of TIP 48 also discusses rates of

specific co-occurring disorders among men

and provides some insight into assessing and

treating specific disorders in this population. 

Trauma histories: Men with substance use 

disorders often have experienced multiple 

traumatic events during their lives. Men are 

more likely than women to be exposed to

trauma, and substance abuse may increase the 

risk of trauma exposure (Breslau 2002). Even

if past traumas have not resulted in a mental 

disorder, such as posttraumatic stress disorder,

traumatic events can have lasting effects. Behavioral health service providers should be 

aware of a client’s trauma history to better understand his substance abuse and better aid 

him in recovery. The planned TIP, TraumaInformed Care in Behavioral Health Services,

includes a chapter on assessing trauma histories (SAMHSA planned g). The assessment of

childhood trauma, specifically, is discussed later in this TIP as well as in TIP 36, Substance 

Abuse Treatment for Persons With Child Abuse 

and Neglect Issues (CSAT 2000b). 

Motivation to change: A client’s motivation to 

seek and comply with treatment is a key factor

in predicting a successful outcome. TIP 35,

Enhancing Motivation for Change in Substance 

Abuse Treatment (CSAT 1999b), includes valuable information on a variety of assessment instruments that evaluate a client’s level of 

motivation and readiness for treatment. 

Relapse risk and recovery support: Although it 

may be left to later stages of treatment, an assessment that evaluates a client’s risk factors 

for relapse and supports for recovery can reduce relapse risk and promote long-term recovery. The planned TIP, Recovery in 

Behavioral Health Services (SAMHSA planned 

e), focuses on this important topic. 

Spirituality: At minimum, spiritual assessment

should determine the client’s denomination,

beliefs, and spiritual practices, if any, and

should identify how these might affect his 

treatment or pose barriers to participation in

mutual-help groups or other treatment practices (e.g., meditation). Specific questioning

about how spirituality has helped a client

through difficult times can elicit spiritual 

strengths that might positively influence substance abuse treatment. Clinicians can ask clients such questions as, “Who or what provides

you with strength and hope? How do you access your sense of ‘higher power’? Is a belief in 

a higher power important in your life? Has it

ever been?” ( Joint Commission on Accreditation of Healthcare Organizations 2004). Gorsuch and Miller (1999) provide valuable 

insights into assessing spirituality in a mental

health or substance abuse treatment setting.

The Spirituality Competency Resource Center outlines a spiritual assessment that behavioral health counselors may find useful in

discussing spirituality with clients 

(http://www.spiritualcompetency.com/recovery/

lesson7.html). 

Other assessment areas include beliefs about 

masculinity, family history, sexuality, and

shame. These call for male-specific assessment

and are thus discussed separately in this TIP. 

All assessment should be ongoing with periodic reassessment throughout treatment, but

the initial personal assessment can occur over

a longer period of time than an initial problem

assessment for substance abuse and dependence. Circumstances could require a personal 

assessment to be deferred. For example, if

problem assessment shows alcohol dependence with the need for detoxification, then

medically supervised detoxification in a hospital or residential setting should be pursued

immediately—personal assessment should be 

deferred until the individual returns to an 

19 
Addressing the Specific Behavioral Health Needs of Men 

ambulatory setting. Similarly, if a problem assessment done in a medical, behavioral health,

legal, occupational, or social service setting

shows a need for substance abuse treatment,

personal assessment should be deferred to the 

substance abuse treatment setting. A client’s 

sensitivity to some of the topics discussed in

the following sections might also lead to deferral of indepth exploration until the therapeutic alliance is sufficient to allow the client

to be comfortable talking about such issues. In

exploring gender and sexuality, clinicians 

should be sensitive to the degree of discomfort

clients might experience. However, if a client

shows that these issues are meaningful for

him, further exploration enables the clinician

to solidify the relationship with the client

while also letting him discuss issues of likely 

importance for his recovery. 

Some programs evaluate readiness for treatment in all men but reserve resources for detailed assessment of childhood trauma,

cognitive impairment, personality disturbance,

and other domains of psychosocial functioning

for men who demonstrate a clear and convincing need for such assessments. However, a detailed assessment of personal definitions of

masculinity and the relationship among these 

definitions, their substance use, and their attitudes toward help-seeking will aid treatment

planning. 

Assessing Personal Definitions of 

Masculinity 

Behavioral health clinicians can examine a client’s personal definitions of masculinity during a clinical interview to better address his 

unique problems and challenges. Using the 

traditional concepts, roles, and norms of masculinity described in Chapter 1 as a guide, clinicians can determine which roles a client 

identifies with (if any) and to what extent. For

example, if the client pursues success at all 

costs at his office, does that behavior also carry 

over into other aspects of his life— into his

relationships with friends and family? Does he 

expect others to act similarly? 

Once the clinician understands the client’s 

personal definitions of masculinity, he or she 

can then explore the positive function these 

roles serve for the client. Is the client unusually aggressive so others do not bully him? Is he 

especially strong and independent so that he 

feels he does not have to rely on others? The 

clinician should also examine with the client 

the possible costs of such behaviors. Are the 

behaviors hurting the client’s life and relationships with others, and, if so, how? Keeping

these basic precepts in mind during the clinical interview will help both clinician and client better understand what changes need to be 

made. They will also help motivate the client

to make those changes, thus enabling the clinician and client to develop a more effective 

treatment plan (Mahalik et al. 2003a; Pollack 

2001). 

A number of rating scales can quantify personal endorsement of traditional concepts of

masculinity. In general, these instruments document individual differences in attitudes, beliefs, behavioral dispositions, and internal 

conflicts commonly associated with traditional

concepts of masculinity.Thompson and Pleck 

(1995) compiled a list of these instruments 

with comments on the content and potential

utility of each. The Male Role Norms Scale 

(Thompson and Pleck 1986), Gender Role 

Conflict Scale (O’Neil et al. 1995), and Masculine Gender Role Stress Scale (Eisler 1995)

are among the briefer and more widely used

measures. The Brannon Masculinity Scale 

(Brannon and Juni 1984) and the Male Role

Norms Inventory (Levant et al. 1992) are

longer measures that also quantify personal

endorsement of traditional concepts of masculinity. Mahalik and colleagues (2003b) describe the Conformity to Masculine Norms 

20 
Chapter 2–Screening and Assessment 

 

Inventory, a comprehensive measure that documents personal endorsement of the emotional, attitudinal, and behavioral dimensions of

traditional concepts of masculinity, which may 

also prove useful. 

Unfortunately, no reliable normative data exist

for any of these instruments, and most have 

been used primarily in research (sometimes 

with populations that may not reflect the clients with whom many treatment providers 

work). However, if a client expresses an interest in improving his understanding of issues 

concerning masculine roles/norms, the clinician may use one of the instruments discussed

here to help him explore the topic. In some 

cases, the client can use these scales and score 

himself without sharing the information with

the clinician—if that will make him more 

comfortable. The decision to use any of these 

instruments or to perform an indepth assessment of masculinity at all must be based on

the ongoing sensitivity of the counselor to the 

client’s situation, needs, and current status. 

Assessing Family History 

Repeated substance abuse by men tends to be 

consistent across generations within the same 

family (Kirisci et al. 2001). Consequently, any 

comprehensive behavioral health assessment

of men with substance use disorders should 

include careful documentation of family history. A family tree can help document the nature 

and extent of substance use disorders and related problems in both the immediate and extended family (Gerson 2008). Marlin (1989) 

had men construct family trees to identify destructive, repetitive family processes occurring

across generations. For more on family trees 

and assessing family history, see TIP 39, Substance Abuse Treatment and Family Therapy 

(CSAT 2004b). 

Any assessment of family history should explore current relationships with family as well 

as the client’s concerns and wishes about how 

those relationships might change with continued abstinence from substances. For example,

a man may hope that abstinence will improve 

his relationship with his children or worry 

about its effect on a relationship with a partner who continues to use. Men may have 

strong feelings about improving their relationships with children, spouses, or significant

others, but might be reluctant to discuss those 

feelings and concerns; the assessment of family history is an opportunity for counselors to

introduce these issues. 

It is equally important to assess a man’s family

strengths. A sense of bondedness with significant others, the ability to rely on family for

support, expressed concern from family members and their willingness to offer help, the 

physical proximity of family members, and a

family history of resolving crises among family 

members are all indices of family strengths 

that can support clients in crisis. 

Assessing a history of childhood 

abuse and neglect 

Boys are more likely than girls to experience 

emotional neglect and to sustain a serious injury as a result of physical abuse (Sedlak and

Broadhurst 1996). Although sexual abuse of

boys is less common, its effects are lasting.

Zielinski (2009) found that a significant proportion of men who have been sexually abused

in childhood are negatively affected into

adulthood. Men are likely to experience childhood sexual abuse differently than women,

and a number of adverse effects from this 

abuse are uniquely experienced by men. Chapter 3 discusses the impact of childhood abuse 

and neglect (and other trauma) on men and

suggests how to address it in treatment. 

TIP 36 (CSAT 2000b) includes recommendations for formal assessment of child abuse and 

parental neglect. The short form of the 

21 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Childhood Trauma Interview (Bernstein et al.

2003) is a structured research interview that 

evaluates exposure to childhood abuse and parental neglect in adults who abuse substances.

The instrument screens for childhood exposure to physical, sexual, and emotional abuse 

and physical and emotional neglect. TIP 36

includes a listing of standardized instruments 

for evaluating the psychological consequences 

of experiencing abuse and parental neglect as a

child (CSAT 2000b). 

Assessing current physical or sexual 

violence in the client’s family 

Several validated, structured protocols can

screen, assess, and treat individuals who may be 

involved in ongoing domestic violence. Men

with histories of physical or sexual violence 

typically present with angry defensiveness.The 

State-Trait Anger Expression Inventory-2, for

example, helps identify men who are excessively 

angry (Spielberger 1999) by measuring experience and expression of anger. (For information

on treating anger problems, see Chapter 3 of

this TIP.) 

Screening substance abuse treatment clients 

for the experience of domestic violence is important (Chermack et al. 2000; TIP 25, Substance Abuse Treatment and Domestic Violence 

[CSAT 1997b]; Easton et al. 2000). Screening

measures, such as the Revised Conflict Tactics 

Scale (Straus et al. 1996), and guidelines, such

as those developed by EMERGE (1995), can 

help determine the extent of abuse (see TIP

25, CSAT 1997b, p. 43). Additionally, understanding and applying Prochaska and

DiClemente’s stages of change model (1984) 

can help counselors perform a basic evaluation

of the client’s readiness to address intimate 

partner violence (Alexander and Morris 2008).

The “Safe at Home” instrument for assessing

readiness to change intimate partner violence 

is a 35-item self-report measure that can be 

administered when domestic violence is suspected or reported (Begun et al. 2008). Counselors can be trained to do basic screening for

domestic violence, but assessment services are 

more complex and require indepth knowledge 

and skill (see TIP 25 [CSAT 1997b]). 

A variety of instruments can help clinicians 

assess domestic violence risk. These include 

the Sexual Violence Risk-20 instrument (Boer

et al. 1997), the Risk for Sexual Violence Protocol (Hart et al. 2003), the Spousal Assault

Risk Assessment Guide (Kropp et al. 1995),

and the Historical-Clinical-Risk Management

instrument (Webster et al. 1997). Given the 

sensitivity of these issues and the differing

stages of development these testing instruments are in, counselors should seek guidance 

in their selection and administration from behavioral health professionals who are trained 

in testing instruments and are knowledgeable 

about intimate partner violence. 

Substance abuse and especially alcohol abuse 

are associated with increased domestic violence; substance abuse also is associated with

increased victimization by domestic partners.

Men may be the victims of domestic violence 

(perpetrated by either male or female partners)

as well as the perpetrators. Although the extent of female-on-male domestic violence is 

debated, data suggest that it occurs more often

than most people think (see Chapter 3 for

more information and citations). Due to gender role expectations and norms, most men are 

reluctant to discuss victimization by their

partners or even refuse to see violent behavior

directed toward them as domestic violence. 

For more information on screening and assessing anger and violence, see TIP 25 (CSAT

1997b). TIP 25 includes the Revised Conflict

Tactics Scale for couples, among other resources. The Family Violence Prevention Fund

offers a Practitioner Reference Card 

(http://fvpfstore.stores.yahoo.net/prreca.html)

that suggests model questions to ask about 

22 
Chapter 2–Screening and Assessment 

 

abuse, how to make referrals, and how to document findings. 

Assessing Male Sexuality 

Sexual assessment involves talking with clients 

about sensitive topics, including sexual trauma,

sexual behavior, and the client’s history of sexual development. For many clients, this area is 

fraught with anxiety and shame; sensitivity to

the client’s level of comfort in discussing these 

issues is needed, especially during the assessment stage when counselor and client are just

beginning to develop a therapeutic alliance 

(Pridal 2001). Clients should be reassured of

the confidentiality of any information they

provide. To approach the matter with clients

in an open and nonjudgmental way, counselors 

must explore their own concerns related to

sexuality and should always have access to supervision to help them address this issue. 

Assessment of a client’s sexuality should address multiple aspects of sexual behavior as 

well as the client’s understanding of that behavior. In terms of sexual orientation, for example, counselors should understand how the 

client self-identifies (e.g., gay, straight, bisexual) and what types of sexual behavior he engages in and with whom. Determine whether

clients understand the importance of taking

measures to prevent the sexual transmission of

disease and how to use birth control when 

necessary. Explore the client’s feelings about

the relationship of emotional intimacy to sexual activity and the importance of sexual activity in defining his masculinity. 

Chapter 4 of TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 

2000c), includes a section on HIV/AIDS risk 

assessment that is useful in assessing client

risk for various sexually transmitted diseases.

It provides a section on sexual risk reduction, 

which should play a part in any assessment of 

men’s sexual behavior. Some clients engage in

risky sexual behavior because they do not understand the risks involved (and need to be 

educated), but others may gain pleasure from 

pursuing risk; the text box on the next page

explains the motivations of this particular

group of clients. 

The Sexual Sensation Seeking Scale 

(Kalichman et al. 1994; Kalichman and

Rompa 1995) and the Sexual Compulsivity 

Scale (Kalichman and Rompa 1995) help clients examine sexual risk-taking behaviors. The

Sexual Sensation Seeking Scale is an 11-item

self-report measure of sensation seeking related to sexual interests, and the Sexual Compulsivity Scale is a 10-item self-report measure of

excessive preoccupation with sexual encounters. The reliability and validity of these brief

scales when used in research on diverse samples of men has been documented (Kalichman

et al. 1994; Kalichman and Rompa 1995). The

Sexual Risk Scale is a 9-item self-report scale 

that measures risk for exposure to sexually 

transmitted disease based on engagement in

specific sexual behaviors in the previous 6

months (Li et al. 2011). 

Assessing for Shame 

Clinicians and researchers have repeatedly 

highlighted the role that shame plays in the

socialization of men (Pollack 1998b). Because 

men tend to be sensitive to experiences that

provoke feelings of shame, clinicians need to

be aware of how this sensitivity can affect

treatment beginning in the screening phase.

Although shame is not a male-only problem,

the specific reasons men feel shame may be 

different from the reasons women do—and 

men may manifest their shame differently 

than women. 

23 
Understanding Risk-Taking 

Human beings seek stimulation beyond that which satisfies their biological needs. This behavior is 

often referred to as sensation seeking. On the underlying motivation for high risk behaviors, Zuckerman 

(1979, 1984, 1994) hypothesized that certain individuals, called sensation seekers, were physiologically predisposed to seek out and engage in a variety of different, highly stimulating, novel behaviors. These included recreational activities (such as parachuting or mountain climbing), occupational 

activities (such as police work or car racing), increased experimentation with various substances (such 

as alcohol or marijuana), and increased exploration with numerous sexual partners and sexual practices. Early definitions of sensation-seeking emphasized the performance of actions that entailed 

physical risks. However, later research showed that other kinds of risk were also involved in this trait, 

including legal, social, and financial risks. 

Burns and Wilde (1995) define risk-taking as any behavior for which there is significant uncertainty 

regarding potential losses associated with the outcome (e.g., speeding). Losses are undesirable consequences, whether foreseen or not (e.g., a speeding ticket or a car crash). The benefits of taking 

risks serve as positive reinforcers (e.g., making it to work on time or feeling that one has accomplished something others are afraid to do). When the subjective or perceived benefits of this behavior exceed the losses, the person is motivated to take the risk. However, sensation-seeking need not 

involve real threats or risks. For example, bungee jumping may seem terrifying and very risky, yet is 

not especially dangerous given appropriate safety precautions. The risk is deceptive. It is possible to 

experience the heightened arousal associated with this seemingly risky activity without great risk. 

Thus, being a sensation seeker does not always signify the taking of actual risks. 

Male and female sensation seekers often take risks, but such activity is more pronounced in men. For 

many men, masculinity involves taking risks. As Thom (2003) notes, “most...leading causes of death 

among men are the result of gendered behaviours” related to risk-taking (p. 4). 

Addressing the Specific Behavioral Health Needs of Men 

Shame associated with a socially stigmatized

behavioral health problem can cause some 

men to avoid screening and comprehensive 

assessment or to resist, in a hostile manner,

screening and assessment (Fortenberry et al.

2002). Once the screening and assessment

process begins, sensitivity to shame may cause 

men to withhold information about specific

thoughts, feelings, and behaviors (MacDonald

1998). Because shame involves an interpersonal dimension, fear of shame will frequently be 

of concern to men as they begin to develop a

helping relationship with a clinician

(Retzinger 1998). Moreover, shame can influence compliance with specific aspects of a

comprehensive assessment, particularly medical assessment and screening for sexually 

transmitted diseases (Fortenberry et al. 2002). 

To evaluate shame accurately, clinicians must

understand the conceptual differences between 

shame and other negative emotions, particularly guilt. To evaluate men for sensitivity to

shame, observe for it during the initial interview (Tangney and Dearing 2002)—clinicians

usually can distinguish accurately between

shame and other emotions. According to

Retzinger (1998), shame generally is not expressed verbally, but verbal clues can show that

a client may be feeling shame. Shame can be 

overt, with associated feelings projected onto 

an external source (such as another client);

shame can also cause someone to focus on 

himself and his inferiority, which is known as 

bypassed shame. Signs of bypassed shame can

include rapid speech, thought, or behavior, or

comparing self to others. Another common

sign of shame in men is anger, often used to

hide from the pain of rejection (Retzinger

1998). 

24 
 

 

 

 

Advice to Behavioral Health Clinicians: Identifying and Evaluating Shame 

• The best way to evaluate men for shame is to observe for it during the initial interview. 

• Signs of bypassed shame include rapid speech, thought, or behavior, or comparisons between 

self and others. Another common sign of shame among men is anger. 

• The Differential Emotions Scale, Experiential Shame Scale, and State Shame and Guilt Scale are 

brief measures designed specifically to measure current feelings of shame. 

• When evaluating shame associated with victimization, questions like “Do you feel ashamed about 

_____? Can you describe how you feel? Do you feel like that often?” can help quantify frequency 

and intensity of shame reactions. 

• The Internalized Shame Scale documents the extent to which shame as a negative emotion is 

magnified and internalized as feelings of inferiority, worthlessness, inadequacy, and alienation. 

• The timing of the exploration of shame is important; such an assessment may need to wait until a 

working alliance has been formed between client and counselor. 

• Shame can be evaluated through structured interviews and self-report instruments. The Test of 

Self-Conscious Affect-3 is a measure of how likely someone is to feel shame. 

Chapter 2–Screening and Assessment 

If shame is evident, behavioral health clinicians can use a simple procedure (Andrews et

al. 2002) to evaluate shame responses. When

evaluating shame associated with victimization, Andrews and fellow researchers simply 

asked their subjects, “Do you feel ashamed

about _____? Can you describe how you feel?

Do you feel like that often?” Responses to this 

short series of questions are then used to

quantify frequency and intensity of shame reactions. The timing of this exploration is key 

and may need to wait until a working alliance 

exists between client and counselor. 

Structured interviews and self-report instruments provide additional means for evaluating

shame. Tangney and Dearing (2002) outline 

conceptual issues relevant to the measurement

of shame and review many of the instruments 

commonly used to measure shame as an emotional state, as well as the tendency to feel 

shame as a psychological disposition. The Test

of Self-Conscious Affect-3 (Tangney and

Dearing 2002) is a measure of how likely 

someone is to feel shame.The Differential 

Emotions Scale, Experiential Shame Scale,

and State Shame and Guilt Scale are brief 

measures designed specifically to measure current feelings of shame (for reviews, see 

Tangney and Dearing 2002). Although clinicians are unlikely to rely solely on such instruments to gauge the extent and nature of

client shame, it is useful to understand the 

methods researchers use to evaluate shame. 

Cook (2000) developed the Internalized

Shame Scale to document the extent to which 

shame as a negative emotion is magnified and

internalized as feelings of inferiority, worthlessness, inadequacy, and alienation. The most

recent version of the scale includes norms developed from a sample of more than 1,100

men and women drawn from the general population. The reliability and validity of the scale 

has been documented when used with men 

who have substance use disorders (Cook 2000;

Rybak and Brown 1996). Thompkins and

Rando (2003) used it to associate internalized

shame with male gender role conflict. For men

with substance use disorders, however, 

Tangney and Dearing (2002) argue that the

instrument may blur distinctions among shame 

as an emotion, the psychological predisposition

to experience that emotion, and self-esteem as a

stable personality trait representing general appraisal of self across situations. 

These instruments have, for the most part,

been used in research; norms against which to

evaluate the emotional world of men with 

substance use disorders must be secured from 

25 
 

 

Addressing the Specific Behavioral Health Needs of Men 

research reports but should be used cautiously.

Each instrument also can be influenced by 

culture, including cultural and/or gender differences between the counselor and the client. 

For example, in some cultures, sustained or

direct eye contact may be perceived as a sign of

disrespect. For some men from certain cultures,

it is more difficult to share shame with a woman, whereas others will find it more difficult to 

admit shameful feelings to other men. Chapter

3 provides information on how to address 

shame and stigma in treatment. For more information on issues relating to cultural competence, refer to the planned TIP, Improving 

Cultural Competence (SAMHSA planned c); 

Georgetown University’s National Center for 

Cultural Competence also offers numerous 

resources (http://nccc.georgetown.edu/). 

26 
Chapter 3–Treatment Issues for Men 

 

 

 IN THIS CHAPTER 

• Introduction 

• Treating Men for 

Substance Abuse: 

General Considerations 

• Counselors’ Gender: 

Some Considerations 

• Counseling Men Who 

Have Difficulty Accessing 

or Expressing Emotions 

• Counseling Men Who 

Feel Excessive Shame 

• Counseling Men With 

Histories of Violence 

• Counseling Men About 

Sexual Issues 

• Family Issues 

• Spirituality and Religion 

Treatment Issues for 3 Men 

Introduction 

This chapter describes specific issues facing men that can affect all 

elements of the treatment process, including the decision to seek 

treatment in the first place. Behavioral health counselors can anticipate barriers and better engage men in treatment by being aware 

of factors that influence why men abuse substances, which substances they choose, and the behavioral, social, and situational issues they may confront.The chapter begins by addressing cooccurring disorders—a major issue in the treatment of men—and

goes on to examine social, behavioral, family, spiritual, and situational issues. 

Treating Men for Substance Abuse: 

General Considerations 

Many treatment approaches useful for men are the same that have 

been found useful for all clients. As noted in Chapter 1, most clients in substance abuse treatment are male, and most research into

treatment methods has used populations that reflect the composition of treatment programs. Small adaptations can be made to improve treatment for men, such as ensuring that waiting rooms have 

decorations and reading material that appeal to men, and asking

about client preferences regarding types of treatment (many men

prefer more instrumental approaches, such as cognitive–behavioral

therapy) and behavioral health service provider gender (see the discussion on therapist gender later in this chapter). Providers should

also recognize the motivations that typically bring men to treatment (such as criminal justice system involvement, referrals from 

other behavioral health resources, and family or work-related pressures, discussed in Chapter 5) and the possible resentment of 

27 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

treatment staff that can result. In treatment 

planning, consider approaches that have been

found effective with men or with men who 

have particular characteristics (such as a high

degree of anger)—these, too, are discussed in

Chapter 5. 

The other considerations of which behavioral 

health service providers need to be mindful 

follow from an understanding of the factors 

that define masculinity and male roles in our

society, which are discussed in Chapter 1. Men

are expected to be independent, self-sufficient,

stoic, and invulnerable. Consequently, they 

may have trouble identifying or expressing

weaknesses or problems within treatment,

which may be perceived as a lack of trust or an

unwillingness to be open with counselors or

fellow clients. Men often have concerns about 

privacy and need reassurance that treatment

will pose no threat to their image or standing.

They may also have trouble analyzing their

own problems, particularly feelings related to

those problems. This too is, in part, a reflection of men’s stoicism. Their need to be selfsufficient may result in a false sense of accomplishment or security in their recovery, which

may manifest as unwillingness to follow 

through with continuing care or attend

mutual-help meetings. 

Men are also expected to be competitive and,

at times, aggressive. As a result, male clients 

may develop combative or competitive relationships with male treatment group members 

and staff or may appear resistant to others’ 

suggestions. They may resent being told what

to do, and so suggestions may need to be reframed as conclusions that are reached collaboratively between client and counselor. Their

need to prove themselves may extend into a

number of different areas, including sexual 

accomplishment, physical domination (which

can lead to violence), or competitive interactions with other clients (e.g., through the telling of war stories about their substance abuse). 

Treatment-Seeking Behaviors in 

Men 

When screening and assessing male clients for

substance use disorders, behavioral health clinicians can take a number of steps to alleviate

the discomfort men may experience when

seeking professional assistance. Of course, establishing rapport and trust with the client 

from the start is essential. Although time restrictions are a reality, clinicians can make the 

most of the time they do have, even if only a

few minutes. From their first contact with a 

male client, clinicians can be sensitive to the 

ways traditional male gender norms may be 

influencing the screening and assessment process. Certain male clients feel threatened by or

uncomfortable with the help-seeking process,

so clinicians in behavioral health settings can

spend time initially developing rapport and

establishing a connection before beginning

screening and assessment. In some areas, this 

can be done by developing kinship: for instance, knowing a bit about where the client

grew up, having a common understanding of

the client’s work, or sharing an interest in a

recreational pursuit. When establishing kinship, though, counselors should take care not

to transcend confidentiality boundaries or appear too intrusive in questioning. 

Although male clients may have some common attitudes and behaviors based on gender

role socialization, their personal definitions of

masculinity and attitudes toward behavioral

health services and interventions (e.g., therapy 

and assessment) will vary. As much as possible,

clinicians need to determine the values, attitudes, and ways of behaving that define masculinity for specific clients and be sensitive to

the fact that men who more strongly adhere to

traditional male gender role norms might be 

more anxious than others about the process of 

28 
Chapter 3–Treatment Issues for Men 

 

 

Advice to Behavioral Health Clinicians: Helping Men Get Comfortable With 

Seeking Professional Assistance 

• Establish rapport and trust with the client from the start. 

• Male clients may feel threatened by or uncomfortable with the help-seeking process, so consider 

spending some time initially talking with the client about neutral topics (e.g., his work or hobbies) 

before beginning screening and assessment. 

• Understand, as much as possible, what set of circumstances prompted the help-seeking behavior. “Why are you here now?” and “For help with what problem?” are useful questions to ask 

when beginning the screening and assessment process. 

• Creatively engage a male client in discussions of his life and situation. 

• Consider acknowledging common fears related to relationships, health, abandonment, career, 

and financial issues. 

• Conceptualize the engagement process as a series of steps in which the client moves from 

screening to assessment to treatment planning to active treatment to follow-up care. 

• Men are typically socialized to be goal-directed and action-oriented: Try ending each screening 

or assessment session with a clear plan for what will happen next. 

• Something concrete (e.g., a letter documenting attendance, a telephone call to arrange a session 

with a significant other) may facilitate compliance with the next step. 

• It can be helpful to give men something to do to prepare for the next step, which can support 

their sense of confidence, control, and usefulness. 

seeking help (Good et al. 2005; Philpot 2001;

Pollack and Levant 1998). Because men are 

generally ambivalent about seeking help for

behavioral health problems, it is useful for clinicians to understand the circumstances that 

prompted a given man’s help-seeking behavior.

“Why are you here now?” and “For help with 

what problem?” are useful questions the clinician can ask when beginning the screening

and assessment process.Treatment Improvement Protocol (TIP) 35, Enhancing Motivation for Change in Substance Abuse Treatment

(Center for Substance Abuse Treatment

[CSAT] 1999b) offers useful techniques for

working with clients who are ambivalent

about entering treatment. 

Many clients are resistant to entering treatment; although traditional concepts of substance abuse treatment emphasize personal 

responsibility for change, it can be useful for

clinicians to accept some responsibility for engaging male clients in the helping process and

motivating them for change (Marini 2001;

Miller and Rollnick 2002). Clinicians can creatively engage male clients by asking what a 

client hopes to change via treatment or what 

he hopes to gain by beginning treatment. 

Men are often embarrassed or reluctant to 

self-disclose emotions, such as sadness or anxiety, so clinicians should consider acknowledging (e.g., through counselor self-disclosure)

fears many men share about relationships,

health, abandonment, career, and financial issues. Sometimes, self-disclosure is not warranted; therapists should not reveal personal 

information if they feel uncomfortable doing

so or lack the training to do so properly (Forrest 2010). Clients’ reactions to clinician selfdisclosure will depend on their expectations.

Counselors should try to gauge those expectations, as research suggests that clients who expect self-disclosure will respond by giving more

information when their expectations are met

(Dixon et al. 2001). Self-disclosure, when done 

in the best interests of the client, can help move 

sensitive topics into the open, thus giving clients permission to begin talking about them. 

The engagement process can be conceptualized as a series of consecutive steps through 

29 
Advice to Behavioral Health Clinicians: Treatment Engagement Considerations 

With Men 

• Emphasizing options and the importance of free choice, even when choices are limited, generally 

supports men’s need for a sense of independence and autonomy. 

• Confrontation about behavior and right/wrong issues almost always increases resistance. Avoid 

arguments and use a more subtle, less confrontational manner. 

• Reframe coming to treatment as a success and a sign of strength and courage. 

• Some men are uncomfortable expressing some or all emotions or have difficulty recognizing and 

labeling their emotions early in treatment. When discussing emotions, monitor intensity, and 

don’t push clients to experience emotions that may overwhelm them. In some settings, talking 

while walking can decrease the intensity of direct eye contact and allow clients to dissipate excess energy. 

• Some men find it easier to explore and discuss their problems using visual references, such as 

timelines, node-link maps, and genograms. 

Addressing the Specific Behavioral Health Needs of Men 

which the client moves: screening, assessment,

treatment planning, active treatment, and lastly, follow-up care (Good and Mintz 1990).

Brooks (1998) suggests that, for men, clinicians assertively promote the need for substance abuse treatment and initiate the process 

one step at a time. The primary goal of each

contact is to ensure that the client returns for 

his next appointment. Even if treatment is 

clearly indicated, it may be useful to first get

the potential client to agree to an initial

screening to determine whether further assessment is warranted. If it is, the next step is 

to get the potential client to agree to an initial

assessment; next, to the completion of a comprehensive assessment; and finally, to a course 

of treatment. 

Men are typically socialized to be goaldirected and action-oriented (Pollack 1998a, b,

2001), so emphasizing the immediate goal of

each step in the screening and assessment process can be helpful, as can ending each screening or assessment session with a clear plan for

what comes next. Offering something tangible 

at the end of an initial contact can also help.

Depending on the circumstances that led to

the initial screening or assessment session,

something concrete (e.g., a letter of attendance, a telephone call to arrange a session with 

a significant other) can facilitate compliance 

with the next step. Giving men something to

do to prepare for the next step supports their

sense of confidence, control, and usefulness. 

Engagement Techniques for Men 

Motivational techniques can help behavioral

health clinicians engage men in the process of

screening and assessment (Miller and Rollnick 

2002). Emphasizing the importance of free

choice, even when there appears to be none,

generally supports men’s need for autonomy.

For example, even when men have legal mandates to seek treatment or are threatened with 

the loss of employment or a relationship, the 

decision to enter treatment can still be presented as voluntary. As much as a man might

complain about his lack of choice, he often can

still choose separation, legal sanction, or a job

search over treatment. Men also can be offered 

choices about where and how screening and

comprehensive assessment proceed; as much

as possible, they should be offered choices and

allowed to decide how the process will unfold. 

This process can be as simple as asking the 

man whether he would like to return next 

Tuesday or Wednesday or in the morning or

afternoon. Emphasizing choices usually facilitates engagement. Similarly, although some

treatment models emphasize assertive confrontation of denial, it may be useful, as Miller 

30 
Chapter 3–Treatment Issues for Men 

 

 

 

and Rollnick suggest, to avoid argument and

circumvent resistance in a more subtle, less 

confrontational manner. For more on how to 

use Miller and Rollnick’s approach to motivate

clients with substance use disorders, see TIP

35 (CSAT 1999b). TIP 34, Brief Interventions 

and Brief Therapies for Substance Abuse (CSAT 

1999a), discusses the use of brief strategic and

solution-based therapies in substance abuse 

treatment, which also may be useful in motivating clients to address specific problems. 

Directly acknowledging that men often have 

difficulty seeking assistance can be useful. Reframe comments about failure or weakness by 

defining help-seeking behavior as a sign of 

strength and courage. Early in the process, the 

clinician can highlight ways that adherence to

traditional norms about help-seeking behavior

may conflict with or undermine other gender

norms about being gainfully employed, a good

husband, and a good father. 

Because men may be particularly uncomfortable with emotional expression or have difficulty identifying and understanding their own 

emotions early in treatment, the clinician

should carefully monitor the emotional intensity of initial interactions, offering men time 

to compose themselves if needed. It may be 

useful to defer exploration of feelings until 

there is less anxiety about the helping process 

and a better working alliance. Avoiding competitive exchanges, comments, or questions 

that might provoke shame can likewise be 

helpful. In some settings, talking while walking can decrease the intensity of direct eye 

contact and allow clients to dissipate excess 

energy, which may help make some men more 

comfortable during initial sessions. 

Some men find it easier to look at their problems through a concrete visual representation

(Halpern 1997). A variety of visual mapping

techniques are available for clinicians to use.

Timelines (Suddaby and Landau 1998), nodelink maps (Czuchry and Dansereau 2003;

National Institute on Drug Abuse 1996), and

genograms (DeMaria et al. 1999; McGoldrick 

et al. 2008), among others, can be useful in

treatment (Dees and Dansereau 2000). Ecomaps, similar to genograms, are graphic portrayals of personal and family social

relationships (Rempel et al. 2007). Node-link 

maps help clients see, in concrete terms, the 

consequences of life choices. Exhibit 3-1 provides an example of a node-link map to help a

client address a cocaine addiction. For more 

on genograms, see TIP 39, Substance Abuse 

Treatment and Family Therapy (CSAT 2004b). 

Counselors’ Gender: Some 

Considerations 

Like ethnicity, race, religion, and culture,

counselor and client gender can play a role in

both the counselor’s and client’s experience of

the therapeutic relationship. Gender colors the 

attitudes, feelings, beliefs, and interactions of

both behavioral health counselors and clients. 

Therefore, it is important for treatment programs working with male clients to consider

counselor gender. Both male and female counselors have their advantages, and programs

need to consider the specific client as well as a

range of other counselor- and program-related

factors in assigning the best counselor for any 

given client. Counselors, too, need to be aware 

of gender dynamics and how they affect their

practice. 

Gender bias and stereotyping are among the 

most important issues that arise in substance 

treatment contexts with regard to the client’s 

and counselor’s gender. Other considerations 

that must be examined in the context of counseling men with substance abuse issues include 

the interplay between sexual orientation and

gender, client preferences, the availability of

male counselors, the appropriateness of raising 

31 
explore their own biases and assumptions 

about men. Clinicians should ask themselves,

“What is my first thought and immediate reaction to a male client who cries in a session? 

Do I directly or indirectly praise or encourage

male clients who work long hours at the expense of their families? Do I assume that men

respond to cognitive–behavioral therapy better

than emotionally supportive therapy because 

men are rational?” Questions like these can

help the clinician challenge deeply embedded

assumptions and biases about men. 

In general, questioning oneself helps overcome 

stereotypes and gender biases. When a male 

client walks into a clinician’s office, the clinician should be able to adopt a stance of curiosity about his or her own understanding and

the client’s understanding of what it means for 

Exhibit 3-1: Node-Link Map 

Addressing the Specific Behavioral Health Needs of Men 

the issue of gender with clients, and transference and countertransference issues. 

Overcoming Gender Bias and 

Stereotyping 

Like ethnic or racial bias, gender stereotyping

is often ingrained in the subconscious by socialization, and even the most well-meaning

clinician may be affected by it. Everyone has 

expectations about how men should behave,

and some of these expectations are stereotypes 

that tend to limit behavioral health clinicians’ 

opportunities to provide the best possible 

treatment for their male clients. 

How can clinicians overcome gender bias so

that it does not negatively affect their work

with men in substance abuse treatment? It is 

crucial that both male and female counselors 

32 
Chapter 3–Treatment Issues for Men 

 

 

 

 

 

Advice to Behavioral Health Clinicians: Addressing Gender Bias and 

Stereotyping While Working With Male Clients 

Female counselors 

• Explore your own gender biases and refrain from stereotyping men. 

• Be curious and transparent. Make no assumptions about a client’s lived experience based on 

gender. 

• Don’t be afraid to challenge male clients’ psychological defenses and behavior in a nonjudgmental, nonshaming way. 

• Take the client’s preference for the gender of his counselor into consideration and match client 

and counselor when possible. 

• Raise the issue of gender in the assessment phase and as a therapeutic issue. 

• Explore your own countertransference issues in clinical supervision. 

Male counselors 

• Explore your own gender biases and refrain from stereotyping men. 

• Be curious and transparent. Make no assumptions about a client’s lived experience based on 

gender. 

• Don’t be afraid to be supportive and help male clients touch upon emotional content. 

• Take the client’s preference for the gender of the counselor into consideration and match client 

and counselor when possible. 

• Raise the issue of gender in the assessment phase and as a therapeutic issue. 

• Explore your own countertransference issues in clinical supervision. 

the client to be a man and how this identity is 

expressed in relation to his family, colleagues,

friends, and the clinician. For example, many 

American men are raised to be independent

and autonomous. Seeking or being mandated

to treatment may feel like a weakness and affront to their sense of masculinity; however,

such responses may not apply to a particular

male client. Clinicians can inquire about such

matters by saying, “I imagine that it may be

difficult to ask for help because men are socialized to be strong and independent in our

culture, but I am curious what it is like for you,

specifically, to be here today.”The advice box

below summarizes how both male and female 

counselors can address gender bias and stereotyping when working with male clients. 

Raising the issue of gender with 

clients 

Whether or not clients can choose to work 

with a male or a female counselor, asking

about their preference during initial assessment is a way of raising the issue of gender. 

Clients can be asked not just about dates of

previous treatment if applicable, but also about

the gender of their primary counselors in

those episodes. Counselors can then use this 

information to inquire about clients’ past experiences with male and female counselors, 

what their preferences might be, and why. Exploring past counseling experiences and current preferences with regard to counselor

gender is a nonjudgmental, empathetic way to

let male clients know that their lived experience and preferences matter, even if it is not

possible to match clients with their preferences. Johnson (2001) suggests including

questions that address gender socialization and

counselor gender preferences on the intake

form and/or in the initial conversation with a 

male client. 

Client Transference Related to 

Counselor Gender 

Transference is an unconscious process in 

which individuals assign attributes from important persons in their past to persons in 

33 
 

Addressing the Specific Behavioral Health Needs of Men 

their present lives. In behavioral health counseling, transference generally refers to attributes clients assign to their counselors. 

Countertransference reactions are the attributes counselors assign (from their histories) to

their clients. Transference and countertransference are not inherently good or bad, but

both can potentially disrupt the therapeutic

process if not recognized and monitored. 

One of the most difficult issues to address in 

any counseling context is the sexualized transference that is likely when a female counselor

works with a heterosexual male client or a 

male counselor works with a gay male client.

In therapy, the counselor invites the male client to be open to his feelings, be vulnerable,

and engage in a kind of intimacy that may or

may not be present in other relationships in

that client’s life. It is common and normal for 

the male client to feel emotional and/or sexual 

attraction for the counselor. Although this is a

common occurrence, substance abuse treatment counselors may have received very little 

training in how to address client transference

feelings, particularly sexual feelings. The following clinical scenario offers some options 

for addressing sexualized transference. 

Case example: Hank and Jennifer 

Hank is a married 32-year-old African American man with two young children. His drugs 

of choice were alcohol and marijuana; he entered treatment after his wife threatened to 

divorce him if he did not stop using. Hank 

describes his marital relationship as still shaky.

He recently completed an intensive outpatient

treatment program and was referred to individual counseling as part of his continuing

care plan. He was given several counseling options and chose to make an appointment with

Jennifer, a 28-year-old White American woman who has worked at the outpatient substance 

abuse clinic for 2 years. She is a lesbian who

has lived with her domestic partner for 5 years. 

She is a licensed substance abuse counselor. 

Jennifer has been seeing Hank on a weekly 

basis for 3 months when Hank discloses, during a session, that he feels a strong attraction

to Jennifer. The following is a brief excerpt of

the conversation that ensues. 

Jennifer: Hank, I really appreciate the fact that

you are risking being so open with me about

your feelings toward me. I want you to know 

that your feelings are normal and a common

experience for people who come to counseling.

I know this is your first time in individual 

therapy, so I am wondering how it is for you to

hear me say that what you are feeling is normal. 

Hank: Well, it’s kinda a relief. I thought I was 

going crazy or that I’m really weird. Especially 

since, well . . . you know . . . because you’re gay. 

And you know I’m trying to make things right 

with my wife and I was worried that this 

meant that I don’t love her anymore. 

Jennifer: I understand your worry, but I want

to reassure you again that it is very common

for people to have all kinds of feelings, including sexual attraction, for their counselors. A

good thing about these feelings coming up for

you with me is that, because we have a professional relationship, there are boundaries that

make it safe to talk about those feelings without acting on them. 

Hank: Really? 

Jennifer: Yes, really. In fact, think about how 

you have learned that you can talk about your

desire to drink and how that helps you not act

on your impulse to drink. You can talk about

all sorts of feelings with me. I can help you 

learn how to experience and express those 

feelings in ways that support your goal to stay 

abstinent and that make things better with 

your wife and kids, instead of acting on your

impulses in ways that aren’t consistent with 

34 
Chapter 3–Treatment Issues for Men 

 

your values and what’s important to you in 

your life. 

Hank: I never thought about it that way. 

That’s a relief. 

Jennifer acknowledges Hank’s attraction in a 

nonjudgmental way, establishes professional 

boundaries without shaming Hank, and uses 

his disclosure to reinforce the idea that feelings and impulses do not have to be acted out

in negative ways, but can be expressed in ways 

that support his hopes and values. The key for

the counselor is to understand that sexualized 

transference, which is not necessarily dependent on the gender or sexual identity of the 

counselor, is a common part of the counseling

relationship and to view it as a potentially useful therapeutic opportunity to help the male 

client lessen the impact of shame in his life 

while modeling healthful ways of expressing

and managing intense feelings. 

Countertransference dynamics for 

men working with men 

Scher (2005) states that “countertransference 

issues are more significant with men working

with men than women working with men” (p. 

317). He suggests that countertransference 

issues for male behavioral health clinicians 

may be more subtle when working with men

than when working with women. He states 

that “when power elements surface, the male 

therapist goes into competitive mode and does 

not easily give the competitiveness up; once he 

does, he begins to feel closer and therefore 

more vulnerable to the client, which raises

homophobic issues and necessitates a pulling

back” (p. 317). So the male counselor faces a

dilemma when working with male clients.

How can he be supportive, model vulnerability, and develop the intimacy required to establish a strong therapeutic alliance without 

pulling away from the male client due to internalized homophobia? How can he do so 

without becoming competitive and dictating

treatment goals and plans from the position of

the expert who has the objective, rational,

right answer? 

Certainly, one of the most important things

male counselors can do is address countertransference reactions in clinical supervision

and consider them in their own practice. As

discussed in Chapter 1, strong feelings of

shame and inadequacy may arise whenever the 

male client consciously or subconsciously perceives that he is not living up to socially defined norms of male behavior, such as not

asking for help and not being emotionally vulnerable. Male counselors also experience this 

dilemma when they open up to a clinical supervisor, and their experience of this vulnerability may be used to better understand clients’ 

feelings. Any strong emotional attraction the 

male counselor might experience for a male 

client should also be monitored and addressed 

in clinical supervision. Due to prescribed masculine gender norms, male counselors might

be reluctant to bring up feelings of warmth,

love, and emotional attraction for male clients.

Clinical supervisors should be nonjudgmental 

and create a safe relational space for male 

counselors to bring up any strong reactions 

they might have to their male clients. 

If the male counselor is able to explore, with

understanding and self-compassion, his own

internalized beliefs about what it means to be 

a man, he will be in a much better position to 

help male clients challenge a story of masculinity that might not be their preferred way of

being in the world. He will also be able to

model a different kind of male behavior simply by being more open emotionally, less competitive and powerful, and working more 

collaboratively with clients. 

35 
Addressing the Specific Behavioral Health Needs of Men 

Countertransference dynamics for 

women working with men 

Female behavioral health clinicians may have,

at one time or another, been ignored or belittled by men in authority; sexually harassed;

and/or subjected to domestic violence, child 

abuse, or childhood sexual abuse. As a result,

two of the most potent countertransference 

issues female counselors may experience in

working with men are fear and unresolved anger. A female counselor may subconsciously 

fear that her male clients will ignore, judge, or 

belittle her, dominate or take over the therapy,

or reject her efforts to help. One of the most 

difficult experiences women face in our society 

due to gender role socialization and culturally 

defined gender norms is a sense of being invisible. If a male client ignores the female counselor’s recommendations or belittles the 

efficacy of the treatment, shame and inadequacy may be activated. A female counselor’s 

subconscious anger may surface in the therapeutic relationship as cynicism, rejection of the 

client’s ideas about what works best for him,

or being judgmental. Female counselors may 

also be sexually attracted to male clients. Such

feelings should be normalized and addressed

in clinical supervision, where supervisors can

address gender differences between themselves 

and their supervisees to help them understand

countertransference toward male clients. 

Due to gender socialization, some female 

counselors tend to defer to the male client’s 

authority and his perception of his situation.

Carlson (1981) suggests that “deference to

male thinking, again reinforcing the traditional sex role for both, rarely assists the client in

considering alternatives to his perception. Instead, it may only help to avoid the real problems and the potential for his growth” (p. 230).

This can be a particularly challenging situation for female counselors in predominantly 

male substance abuse treatment programs. The 

female counselor must walk the line between 

being supportive and accepting and being

willing to gently challenge the male client’s 

psychological defenses, such as denial and

minimization of the reality that substance 

abuse is interfering with his life and relationships. 

Case example: Clinical team 

discusses male counselor/male client 

interaction 

This behavioral health team consists of six clinicians ( Jim, Larry, Lillian, Jason, Mary, and

Kristen) and the clinical supervisor, Ken. The 

team is part of an intensive outpatient substance abuse treatment program at a major

metropolitan hospital, which provides group

therapy 5 days a week and individual counseling sessions twice a week. It is a mixed-gender 

program, but there is one women’s and one 

men’s group each week. 

Jim brings up a clinical situation in group supervision. He has been assigned as the primary 

counselor for Kurt, a 45-year old bank executive who was referred to treatment through his 

company’s employee assistance program. Kurt

had been involved in derivative trading and a 

series of high risk mortgages. He had been a

heavy drinker most of his adult life; because of

the stress of the economic downturn and his 

bank teetering on the brink of bankruptcy,

Kurt has been getting drunk three to four

times a week and recently started taking tranquilizers to deal with his anxiety. Jim states 

that this is Kurt’s first experience in counseling or treatment and that he is very resistant

to Jim’s recommendation to attend Alcoholics 

Anonymous (AA) meetings as part of his continuing care plan. The following discussion 

ensues. 

Jim: This guy really irritates me. I’ve been 

clean and sober for 20 years and he thinks he 

is such a hot shot executive. Every time I try 

to suggest something that might help him stay 

36 
Chapter 3–Treatment Issues for Men 

 

 

 

away from the booze and the pills, he comes at

me with some story about how I don’t have a 

clue about what kind of stress he is under and 

that he knows what works for him . . . after all,

he made it all the way up the corporate ladder

to where he is today. I want to talk about

whether or not we should consider shifting

Kurt to another counselor. Maybe Mary or

Kristen or Lillian could make more headway 

with him. 

Ken: What makes you think that it might be

better for Kurt to work with a woman? 

Jim: Well, he seems to be more relaxed in the 

“Feelings Group” when Kristen is co-leading.

And I think he really pushes my buttons. He 

reminds me of my older brother who was a

varsity football player and won all kinds of

awards. I hated football and was more interested in playing guitar in a local rock band.

My father kept harping on me about how being in a rock band was for sissies. Now that I

am talking this through, it seems to me that 

Kurt probably feels the same kind of shame 

about not being a real man because he was 

forced to come to treatment. Asking for help

was not something that was real big in my 

own family. 

Ken: Jim, I really appreciate your selfawareness here. It sounds like you are even

beginning to feel less irritated and more compassionate toward Kurt. 

Jim: Yeah, I guess so . . . but I don’t know how 

to not react so strongly when Kurt gets so defensive. 

Ken: Well, I am wondering if you would be 

interested in briefly role-playing with Kristen.

We could get the woman’s perspective on how 

to challenge Kurt’s defenses in a nonthreatening, noncompetitive way. What do you think? 

Jim: Well, I feel a little embarrassed about being in the spotlight. 

Ken: I can imagine. I am wondering if that’s 

some of your own fear about being vulnerable 

and thinking that because you’re a guy, you

always have to have all the answers. 

Jim: You know me too well. Yeah, let’s do it. 

Ken sets up a roleplay in which Kristen plays 

counselor and Jim plays Kurt. Kristen is instructed to challenge Kurt’s competitive behavior in a nonjudgmental, nonshaming way

by pointing out the behavior and then asking,

“What were the different expectations for

boys and girls in your family?” 

This question begins a conversation about

gender roles and expectations for Jim as the 

client. Inviting Kristen to take on the role of

counselor allows all participants to indirectly

challenge their own gender stereotypes and

biases. By the end of the roleplay, Jim decides 

that he can continue to work with Kurt, feels a

deeper appreciation for Kurt’s strategy of

competitiveness as a way to hide his shame,

and experiences renewed confidence for challenging Kurt’s behavior in a nonjudgmental 

way. He leaves the team meeting feeling reassured that he can ask his female colleagues for

help with countertransference. 

Advantages of Female Behavioral 

Health Counselors in All-Male 

Settings 

The reality in most behavioral health clinical 

settings is that female counselors outnumber

male counselors, and this disparity is even

more striking when considering that male clients in substance abuse treatment significantly 

outnumber female clients (Lyme et al. 2008).

Even in criminal justice settings, where the 

client population is typically all male, there are 

more female counselors than men (Ewing

2001). 

Both male and female medical patients talk 

more and provide more relevant information 

37 
Addressing the Specific Behavioral Health Needs of Men 

to female physicians (Bertakis 2009; Bertakis 

et al. 2003; Hall and Roter 2002). However, 

two studies (Farber 2003; Farber and Hall

2002) found that gender did not predict disclosure among therapy patients. A small study 

(107 patients, 75 percent male) of a Dutch

population ( Jonker et al. 2000) found that 

men in substance abuse treatment preferred

female counselors (64.5 percent) and that

most (58 percent) thought counselor gender 

played an important role in their treatment.

However, when patients were asked to describe ideal characteristics for male and female 

therapists, those they listed were identical. 

Men may be more comfortable with female 

counselors for any number of reasons: they

may feel more comfortable showing their

weakness to female therapists, who they believe are less likely to judge them for their failures, real or imagined; they may believe that

women are more sensitive and better able to 

address emotional problems; or they may have 

had negative experiences with male counselors 

in the past ( Johnson 2001). Some of these 

perceptions are based on real differences between common male and female counseling

styles. Compared with male clinicians, female 

clinicians typically are more open to discussing

relational issues and focusing on underlying

process issues during treatment (Miller 1984).

This approach may be helpful for some men,

who generally tend to have difficulty dealing

with their emotions in therapy (Levant 1995; 

Pollack 1994). Among physicians, women

provide more counseling but men are more 

likely to address substance abuse (Bertakis et

al. 2003). 

Another benefit to having female behavioral

health service providers in facilities serving allmale populations is that they can model 

healthy male–female relationships for clients. 

Teamwork, cofacilitation of counseling, and

collaborative working relationships between

male and female staff members are of benefit 

to both the clinical team and clients because 

they provide positive role models for gender

cooperation and communication. If clients see 

men and women interacting in healthy relationships with clear, nonsexist communication,

they are likely to learn how men and women

should act together. 

Potential Challenges for Female 

Counselors in All-Male Settings 

Female clinicians who work with men do face 

certain challenges. Each client, whether male 

or female, brings a set of individual experiences 

as well as a unique cultural background into the

client–counselor relationship that will influence how that client responds to a counselor.

For example, some male clients may see the 

male counselors as the real therapists having

the real power in the organization, and may

not allow their female counselors the same 

authority, power, or credibility. Some men have 

difficulty hearing their female counselors,

which likely has to do with differences in how 

men and women communicate. Also, some

men are not used to communicating openly 

with women. 

Behavioral health programs need to be sensitive to the reality that some men who may be 

antagonistic toward or biased against women

in positions of authority may not be able to

form a healthy therapeutic alliance with female counselors. Rather than looking for a

scapegoat or blaming the client for this, the

institution should work with the client to devise a solution that will most benefit him in 

his recovery from substance abuse. In such

cases, it may be best to pair the client with a

male counselor. 

38 
Chapter 3–Treatment Issues for Men 

 

Advantages of Male Behavioral 

Health Counselors in All-Male 

Settings 

Men tend to address concrete tasks more readily with male behavioral health counselors,

which may work more effectively in a treatment setting that uses task-oriented brief

therapy, solution-focused techniques, and motivational interviewing (Lyme et al. 2008); see 

the “Enhancing Motivation” section in Chapter 5 of this TIP for more information. Some 

literature supports the theory that men, particularly those from certain cultural backgrounds, disclose more thoroughly to other

men. For instance, one study showed that Hispanic/Latino men were more willing to report

risk-taking behavior to men than to women,

and to older men than to younger men (Wilson

et al. 2002). 

There are many potential benefits to having

all-male group sessions, and a program typically needs male counselors to run these. Some 

well-known treatment centers, such as the 

Betty Ford Center and the Hazelden Clinic,

will allow only male counselors to work with

all-male treatment groups (Powell 2003). 

Potential Challenges for Male 

Behavioral Health Counselors in 

All-Male Settings 

Problems can arise when men alone work as 

behavioral health clinicians in all-male settings. Male clinicians’ biases and sexism can 

reinforce negative male communication patterns. Many patients seeking treatment prefer

female counselors, so an all-male staff can

greatly limit the choices and potential treatment of clients who have such a preference.

Male counselors are themselves subject to

gender role strain and may have difficulty seeing clients in terms of individual or family pathology or as struggling with cultural issues,

such as how to be a husband and father 

(Silverstein et al. 2002). Male clinicians and

supervisors working with men who are gay 

need to be aware of their own biases, countertransference, and level of awareness of gay development and gay culture (Frost 1998). 

Recruiting Male Behavioral Health 

Counselors 

The first step for administrators in behavioral

health settings assembling a trained, gendersensitive male treatment staff is to understand 

their current staff makeup and the pool of

providers from which they can expect to draw.

The Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s) 

National Treatment Improvement Evaluation

Study (Ewing 2001) examined staff members 

in treatment facilities that received SAMHSA 

funding. More than 800 counselors responded

to the questionnaire. A majority of the counselors in each treatment setting (i.e., methadone, 

outpatient, short-term residential, long-term 

residential, and corrections) were women. In a

larger study, Mulvey and colleagues (2003)

used data from the retrospective study of

treatment professionals to gain a profile analysis of the workforce within the substance 

abuse treatment field. Demographic information from 3,267 participants demonstrated

that most treatment professionals were White 

(84.5 percent) and middle-aged (between 40 

and 55 years of age), and slightly more were 

female (50.5 percent) than male (49.5 percent). Further, it was noted that most professionals remain in the field for a considerable 

period of time and that approximately 80 percent had earned a bachelor’s or higher education degree. Most professionals were licensed

or certified and provided treatment services to

clients with racial and ethnic backgrounds different from their own. 

It generally has been assumed that most clinical—and especially medical—education addressed men’s issues to the detriment of 

39 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

women’s issues. However, the 2003 SAMHSA

Strategic Planning Initiative indicated that

coverage of issues specific to men and substance abuse was lacking in most medical education programs (Haack and Adger 2002). As

part of the 2003 SAMHSA initiative, training

in substance abuse treatment, including men’s 

issues, became a mandatory part of all medical

education. This project is a three-way collaboration involving SAMHSA, the Health

Resources and Services Administration 

(HRSA), and the Association for Medical

Education and Research in Substance Abuse 

(AMERSA). SAMHSA and HRSA fund the

project, which is administered by AMERSA.

The project is known as “Project Mainstream.” 

All clients, regardless of gender, age, or culture,

should have treatment tailored to their needs. 

Although a specialized credential for clinicians 

whose patients are mostly or all male may not

be necessary, the consensus panel recommends 

that ongoing training be provided to all clinicians in the substance abuse field concerning

the unique issues of both men and women. 

The number of female counselors is disproportional to the predominantly male client

population seeking substance abuse treatment

(Ewing 2001; Mulvey et al. 2003). Clinical

centers staffed with both men and women of 

varying ages are better equipped to treat all 

clients. Agencies not committed to staff development, training, fair practices, and reasonable reimbursement can have problems in

recruiting efforts, regardless of gender issues. 

Centers that need more male staff members 

may have to develop them from the ground

up. A variety of distance learning and local 

certification resources are available, and cultivating talented counselors from among the 

many individuals in recovery who join the

field may be an appropriate avenue for many 

agencies. For instance, SAMHSA has established 14 regional Addiction Technology 

Transfer Centers (ATTCs) along with a national center dedicated to identifying and advancing opportunities for substance abuse 

treatment, upgrading the skills of practitioners 

and health professionals, and disseminating

the latest science to the treatment community.

The ATTC Network Web site offers more 

information on ATTCs (http://www.nattc.org). 

Counseling Men Who 

Have Difficulty Accessing 

or Expressing Emotions 

A significant number of men participating in

substance abuse treatment and other behavioral health services have difficulty accessing or

expressing emotions (Evren et al. 2008). These 

deficits can range from a profound absence of

any emotion (sometimes referred to as alexithymia or being emotionally frozen) to a more 

common difficulty in recognizing and expressing specific emotions, such as anger, sadness,

or shame. Sometimes, difficulty in handling

emotions is a symptom of a mental illness, 

such as Asperger’s disorder, social anxiety disorder, or obsessive–compulsive disorder. Other

times, it may result from transient or chronic

stress, profound loss, or other environmental 

factors. For others still, difficulty with emotions 

may be a personality trait that has been with

the individual since early childhood. All of

these problems are likely to be exacerbated by

substance use as a strategy for coping with unpleasant emotional states; finding new, positive

strategies for understanding and expressing

emotions is often necessary for a man’s recovery 

from substance abuse (Holahan et al. 2001). 

Some of the features of deficits in emotional 

expression include:

•	 Difficulty coping with situations in which

emotions that the client has disavowed are 

pervasive (e.g., sadness at a funeral; 

40 
Chapter 3–Treatment Issues for Men 

 

 

Advice to Behavioral Health Clinicians: Addressing Male Clients Who Have 

Deficits in Emotional Expression 

• Clients who emphasize rationality over emotionality often respond to psychoeducational efforts, 

which can reduce problems related to feeling and expressing emotions for men (Levant et al. 2009). 

Learning about feelings is a first step for patients like Jack in addressing emotionally loaded issues. 

• Work with these men during group and in individual sessions to apply feeling words to their internal/physical experience. 

• Help the client identify emotions that are more comfortable for him (e.g., being scared) and support his efforts to manage the emotions that are more readily available first. 

• Intervene and support him if other clients in the group shame or strongly confront his inability to 

express certain emotions. 

• Help the client set goals for his group participation, particularly in terms of learning about emotions and how to express them to others. 

• Work with him to develop self-grounding techniques for use when he becomes anxious in the 

presence of others who are expressing powerful emotions. 

• Provide homework assignments to help him express his emotions within a highly structured context (e.g., through expressive writing assignments, which have been found to decrease emotional 

distress for men with restrictive emotionality [Wong et al. 2006]). 

tenderness at seeing a grandchild for the

first time). 

•	 Being dismissive of certain emotions (“anger is worthless”) or people who express 

emotions (“scared people are chumps”). 

•	 Channeling a difficult emotion into another emotion (e.g., expressing fear as anger). 

•	 Fearing that emotional expression will result in losing control (“if I start crying, I 

won’t be able to stop”) or being overwhelmed (“if I feel my shame, I’ll sink into 

nothingness; I won’t exist anymore”). 

•	 Projecting emotions onto others (e.g., assigning an emotion that is disavowed in

oneself to others). 

•	 Being very uncomfortable when someone

expresses an emotion that is difficult to

experience (e.g., being uncomfortable in the 

presence of someone expressing anger). 

Case Example: Jack 

Jack is a 51-year old electrical engineer and

computer software designer who recently 

completed the intensive phase of outpatient

substance abuse treatment and has been referred to an ongoing therapy group for clients 

in recovery. His primary therapist in the intensive outpatient program felt the group would

help Jack get in touch with his feelings. Jack 

readily acknowledges that he is a logical guy 

who sees emotions as having little utility, is 

uncomfortable around others who easily express emotions, and recognizes that his lack of

emotionality has been a barrier in relationships. In his initial interview with the group

leader, Jack comments that a primary reason

for his heavy alcohol consumption (which began in high school) was that he felt more 

comfortable relating to others after drinking.

He also recognizes that he was drawn to his 

occupation because it allows him to spend

large amounts of time working alone and that

he becomes uncomfortable in social and work 

situations when he cannot drink. In treatment,

he found emotional expression in an all-male 

group difficult, and he is very apprehensive 

about being in a mixed-gender group now. He 

offered his primary counselor numerous reasons for not attending the outpatient group,

but the counselor insisted that the experience 

would be good for him. He finally agreed to

come for 12 visits (3 months). The following

advice box gives some tips for Jack’s counselor. 

41 
Addressing the Specific Behavioral Health Needs of Men 

Anger Management 

Anger is a common problem for men with substance use disorders and can be exacerbated by 

the stress of early recovery. Because of men’s 

socialization, anger is one of the only emotions 

that many men feel comfortable expressing—

thus, they often use it to cover up emotions 

(e.g., fear, grief, sadness) that they feel inhibited

about expressing (Lyme et al. 2008). 

A high level of anger, particularly trait anger, 

in men has been associated with substance use 

disorders and physical aggression (Awalt et al.

1999; Giancola 2002b; Tafrate et al. 2002;

Tivis et al. 1998). Trait anger refers to an individual’s disposition to experience anger in different situations, whereas state anger is the

magnitude of the anger felt at a given time.

According to a review of the literature, high 

trait anger is associated with a tendency to experience anger more frequently, more intensely, and for a longer period of time (Parrott and 

Zeichner 2002). The effects of alcohol on male 

aggression are most prominent in those who

have moderate—as opposed to low— levels of

trait anger (Parrott and Zeichner 2002). 

Men with anger problems are more prone to

relapse to substance use (Kirby et al. 1995;

McKay et al. 1995). A few cognitive–

behavioral interventions have been shown to 

be effective in reducing anger in men who

abuse substances (Awalt et al. 1997; Reilly and

Shopshire 2000). Strategies used in one study 

to help subjects control their anger included

the use of timeout, cognitive restructuring,

conflict resolution, and relaxation training

(Reilly and Shopshire 2000). Fernandez and 

Scott (2009) evaluated a 4-week-long cognitive–behavioral intervention for people in substance abuse treatment that was delivered in 

gender-specific groups; although the intervention had a high level of attrition (32 of 58 left

before completion), it did reduce anger, especially trait anger. 

Motivational enhancement therapy or motivational interviewing may be even more effective 

than cognitive–behavioral approaches in reducing substance use for men with a high level 

of anger. Researchers analyzing data from the

Matching Alcoholism Treatments to Client

Heterogeneity Project found that, in general,

clients who had high levels of anger did significantly better (in terms of days sober and drinks

per drinking day) if they received motivational

enhancement therapy rather than 12-Step facilitation or cognitive–behavioral therapy, but 

that the opposite held true for clients with low

levels of anger (Stout et al. 2003). Karno and

Longabaugh (2004), looking at the same data,

however, concluded that what was more important than the type of treatment received was 

the level of counselor directiveness; they determined that clients who had high levels of anger

did significantly better with counselors who

were less directive (as the motivational enhancement counselors were). 

SAMHSA has produced an anger management curriculum with an accompanying client

workbook that provides a manualized 12-week 

group treatment for use in substance abuse 

treatment settings (Reilly and Shopshire

2002). Exhibit 3-2 outlines some techniques 

used in this anger management intervention. 

42 
Chapter 3–Treatment Issues for Men 

couraged to engage in service activities related

to those groups, and others can seek service 

opportunities in their communities or religious 

institutions, or with national or international

groups. Service activities can be matched to 

men’s interests and skills. For example, men in

building trades can work with Habitat for 

Humanity; men who like to cook can help prepare soup kitchen meals. Counselors should be 

sensitive to the kinds of service that would be 

most rewarding and therapeutic for the client

and should not assume that all clients will benefit therapeutically from service work. 

Learning To Cope With Rejection 

and Loss 

Some male clients may need to learn how to

accept being told “no.” Consider this scenario:

A man is at a social hour after work and asks a 

woman at the party out on a date. She is not 

interested and politely says “no” to him. He

feels disappointed and either becomes more 

aggressive with her or returns to the bar for a

pick-me-up to restore his ego. It is important

for him to hear “no” not as a rejection of who 

Learning To Nurture and To Avoid 

Violence 

Many men with substance use disorders need

to learn nurturing skills in their roles as husbands and fathers. Behavioral health counselors can teach and model affirming, caring,

nurturing, forgiving, and having patience.

Emotional vulnerability is critical if men are to

be nurturing, loving, and caring husbands and

fathers; it is important in many men’s recovery.

For example, the 12 Steps of AA address vulnerability and openness to others. Counselors 

can suggest that men express vulnerability by 

engaging in nonstereotypical activities (e.g.,

creating art, poetry, or music; performing

community service) instead of stereotypically 

competitive male activities like sports and

work. Clinicians can also help men identify 

sports that they enjoy that promote cooperation, bonding, and commitment rather than

extreme competition and violence. 

For many men, service is another essential part

of recovery from substance abuse. Men who

participate in mutual-help groups can be enExhibit 3-2: Anger Management Counseling Techniques 

The main goals of anger management are to stop violence or the threat of violence and to teach clients ways to recognize and control their level of anger. There is no one correct way to conduct anger 

management counseling, but most interventions involve: 

• Breathing and relaxation techniques for managing the physiological components of anger. 

• Cognitive restructuring to make clients aware of their self-talk while helping them actively stop 

and revise their counterproductive thought processes. 

• Taking time out by leaving an intense situation for several minutes to cool off. 

• Introducing clients to the basics of assertiveness training and conflict resolution. 

• Helping clients examine how anger and other emotions were displayed in their families and how 

the messages they received in the past affect them today. 

Given the nature of the topic, anger management counseling should only be conducted by trained 

clinicians. At the start of the first session, the clinician should explain to the group any policies on 

safety, confidentiality, homework assignments, absences and cancellations, time outs, and relapses. 

SAMHSA curricula on anger management are available in two volumes—a therapy manual and a participant workbook—and can be ordered from the SAMHSA Store (http://store.samhsa.gov) or downloaded from SAMHSA’s Knowledge Application Program Web site 

(http://kap.samhsa.gov/products/manuals/index.htm). 

Source: Reilly and Shopshire 2002. Adapted from material in the public domain. 

43 
 

Addressing the Specific Behavioral Health Needs of Men 

he is but as the result of other factors (e.g., the 

woman’s interest in someone else). This insight could avert a relapse trigger for the client. The counselor may need to talk about and

model for the client how to treat women with 

respect: taking “no” as an acceptable answer,

giving women the power to accept or decline 

his invitation without intimidation, and experiencing her decision without it leading to

substance use. 

A man who is new to recovery may hear family members telling him “No, I won’t lend you 

my car” as an expression of doubt concerning

his recovery. He needs to consider that there 

may be other reasons for not lending him the 

vehicle and, in any case, it does not reflect who

he is today; it may take time for others to see 

that he has changed. There are many such situations, and men in recovery need to understand that being denied something is not a

reflection of their own self-worth. 

Providers can introduce men to rituals that 

will help them deal with negative feelings, 

such as grief and fear, in a positive manner.

Some examples include rituals for expressing

grief, being vulnerable in the presence of other

men, managing disagreements, and celebrating

successes. Men can also observe the value of 

rituals in 12-Step programs, such as AA and

Narcotics Anonymous. 

Counseling Men Who Feel 

Excessive Shame 

Stigma and shame are strong obstacles to 

men’s seeking help, and research shows that

men in substance abuse treatment often rate 

their level of shame as high (Simons and

Giorgio 2008). Many men with substance use 

disorders and their families “ignore prevention 

messages, avoid treatment, [and] endure suffering and risk death daily for the simplest of reasons: They’re ashamed” (McMillin 1995, p. 3). 

Social stigma tied to substance abuse, cooccurring disorders, other behavioral health

problems, failure to meet society’s expectations, and other problems can cause intense 

feelings of shame among men. Shame, in turn,

can cause men to avoid needed treatment and 

can cause their families and friends to deny a 

man’s substance use problem or try to control 

or cure him (Krugman 1995; McMillin 1995;

Pollack and Levant 1998). Shame can also be

a major impediment to growth in recovery. It

can inhibit a man from looking inward, selfassessing, or experiencing personal deficits,

resulting in white-knuckle abstinence and

high risk of relapse. 

Different men will react differently to shame,

and not all men in treatment will experience it

(although it is very common). When clinicians 

are uncertain about a client’s degree or sources 

of shame, they can use an assessment instrument (see Chapter 2), and if the client is resistant to the notion that shame is affecting

him, the clinician can share assessment results 

with him. For some men, shame can be an impetus for behavior change, whereas for others,

it may impede change by fueling a desire to

escape from the feeling rather than deal with

its cause. Others respond to shame with secrecy, anger, denial, and/or hopelessness. Both

Lewis (1971) and Scheff (1987) observe that

some men externalize—holding others responsible for their actions—to shield themselves from experiencing shame. 

A client’s cultural orientation may also affect

how he responds to shame. Anthropologists 

have proposed that certain cultures are shame 

based whereas others are guilt based; for example, for men from many Asian cultures,

shame may be an even more significant feeling

than for men from European cultures. There 

are also cultural differences in how individuals 

are expected to respond to shame. In some 

cultures, a man may be expected to publicly 

44 
Chapter 3–Treatment Issues for Men 

 

demonstrate his shame; in other cultures, a

man may be expected to strike out in revenge 

at whomever caused him to feel shame. 

Stigma is different from shame; it results from 

social attitudes that label certain people, behaviors, or attitudes as disgraceful or socially 

unacceptable. Crocker and Major (1989) 

found that people experiencing stigma:

•	 Frequently experience prejudice and discrimination. 

•	 Feel that their social identity is devalued. 

•	 Are aware that they are being stereotyped

or worry that their behavior may be seen as 

stereotypical. 

•	 Feel unjustly criticized or feel uncertain

about the fairness of others’ criticism. 

Cultural stigma can produce shame in many 

men with substance use disorders. Men who 

break gender norms, for example, can be subjected to stigma and experience shame as a

result. Eisler (1995) describes gender role 

stress for men, which can result when a man

feels that he has transgressed traditional gender norms. This stress can lead to shame if he 

perceives that he has violated the norms of a

social group or failed to live up to the group’s 

expectations for appropriately masculine behavior. 

Substance abuse can lead to behaviors or situations that a man might find shameful or

stigmatizing, and many of these relate to a

failure to meet prescribed gender roles. Because of substance abuse, a client may have 

failed to support his family, lost an important

job, or experienced detriments to his sexual 

performance or alterations in his pattern of

sexual behavior. Medical conditions, such as 

HIV/AIDS and certain disabilities (especially 

physical), are also often stigmatized, as are

lack of employment and homelessness; Nonn

(2007) notes that men who are homeless or

have low socioeconomic status have been 

“stripped of everything that qualifies a man for 

full participation in society” and thus belong

to a shamed group (p. 282). Sources of stigma

are discussed in greater detail later in this 

chapter. 

Interventions for Shame 

In many ways, behavioral health clinicians are 

already addressing client shame (whether the 

client is male or female). Mutual-help group

and modern substance abuse treatment processes both begin with a fundamental antishame message. A major reason for educating

clients about the disease model of substance 

use disorders and their psychological, physiological, and natural histories is to help them

overcome the shame they may have experienced in believing their illness to be a personal 

or moral failing. Clients also benefit from psychoeducation about shame and stigma. In mutual-help groups, the camaraderie of working

with others to overcome the effects of substance abuse can be a powerful force for replacing shame with acceptance. Clinicians

who are in recovery can also help eliminate the 

shame of having a substance use disorder by 

serving as powerful role models for recovering

people learning to accept their disorder. 

Other interventions for shame are also already 

in use in most clinical situations. The most 

important way to help a client who is experiencing significant amounts of shame (see 

“Case example: Harry”) is to build a strong

therapeutic alliance and create an atmosphere 

of trust in which the client feels comfortable 

openly exploring the sources of his shame. After building an alliance and exploring sources 

of shame, clinicians can help clients develop a 

realistic (i.e., not false) sense of pride, as pride 

in oneself is a major counter to shame 

(Krugman 1998). Shame is likely to emerge in

many interventions with men; clinicians 

should thus tailor treatment to avoid further 

shaming a client (Krugman 1998; Pollack 

1998c). 

45 
 

 

Advice to Behavioral Health Clinicians: Addressing Male Clients Who Are 

Disruptive in Group Settings Due to Excessive Shame 

• Help the client positively bond with other group members and aid him in finding commonalities 

with them rather than seeing himself as different. 

• Additional individual counseling is less likely to provoke shame and may be efficacious. 

• In individual sessions, psychoeducation about shame and its effects can be helpful. 

• Involve the client in a 12-Step program where he’ll feel safer identifying with others. 

• Gently intervene when the client becomes sarcastic with other group members, taking care to 

confront him in a nonshaming way. 

Addressing the Specific Behavioral Health Needs of Men 

Case Example: Harry 

Harry is a 46-year-old man in an intensive

outpatient substance abuse treatment program 

who has had numerous struggles in group and

is seen by some counselors as uncooperative.

He has resisted attending AA, tends to monopolize the group with long-winded stories 

of his successes, is defensive when confronted

in group, and has not bonded well with other

clients. He is also often sarcastic to other clients, but when they return the sarcasm, he either gets angry or withdraws and won’t 

participate in the group process. His behavior

tends to alienate him from others, which increases his isolation in the program. In a recent group clinical supervision session, staff

members discussed his case and concluded 

that shame motivates much of Harry’s disruptive behavior in group settings and that directly confronting his behavior makes him more 

defensive. Tips for counseling a client like 

Harry are given in the following advice box. 

Counseling Men With 

Histories of Violence 

Violence and the use/abuse of certain substances (particularly alcohol and stimulants)

are associated in numerous studies in many 

different contexts (Friedman 1998). Although

violent behavior is not the sole prerogative of

men, research has consistently found that men

are more physically aggressive than women

(Giancola and Zeichner 1995) and are much 

more likely to commit violent acts. For some 

men, acting in a violent manner may be a way 

to define their masculinity. Whether this response is simply the result of cultural factors 

or is due in part to biological differences is a

question beyond the scope of this TIP. What 

is relevant, however, is that behavioral health

service providers who work with men must be 

able to address violent behaviors in a client’s 

past and be prepared for violence in the present (both in and outside the treatment setting).This section addresses men’s involvement 

in violent behaviors; for more information on

treating the short- and long-term consequences 

of exposure to violence, see the trauma section

in Chapter 4. 

Violence and Criminal Behavior 

Some men may engage in criminal behavior as

a way of showing adherence to a particular

concept of masculine identity (Copes and

Hochstetler 2003); others take risks that can

make them the victims of violent crime for the 

same reasons (Thom 2003). Men are more 

likely than women to be the perpetrators as 

well as the victims of violent crime. In 2006,

men were more likely to be the victims of every type of violent crime except rape, sexual assault, and purse snatching. In that same year,

26.7 per 1,000 men ages 12 and older were 

victims of violent crimes, whereas 22.7 women

per 1,000 were victims of violent crimes (U.S.

Department of Justice [DOJ] 2008). More 

than 60 percent of people treated in emergency rooms in 1994 for injuries resulting from 

46 
Chapter 3–Treatment Issues for Men 

 

 

 

 

violence were male (Rand 1997). In the case of

murder, 77 percent of all victims and 90 percent of all perpetrators were male (Catalano

2004). According to 2006 data, men were

more than 3 times as likely to be violent offenders as women. When violent crimes were 

committed by a single offender, 78.3 percent

of offenders were male (DOJ 2008). Throughout North America and Europe, women

commit fewer than 1 in 10 assaults (United

Nations Economic Commission for Europe

2004). However, men who commit assaults 

while intoxicated are also more likely than

women who do so to become involved in the 

criminal justice system as a result, although

whether or not this reflects an existing bias 

remains to be determined (Timko et al. 2009). 

Violent crime is also strongly linked with alcohol and drug use, with alcohol being the 

most commonly reported substance in cases of

violent crime. In 2006, approximately 27.1 

percent of victims of violent crimes reported

that the offender was using illicit drugs (either

alone or in combination with alcohol) at the

time of the offense (DOJ 2008). Reports by 

violent offenders are similar, with 41 percent

of those in jails, 38 percent of those in State 

prisons, and 20 percent of those in Federal 

prisons reporting that they were under the influence of alcohol at the time of offense 

(Greenfeld et al. 1998). People who abuse alcohol (whether determined by self-report or

official data) are also more likely to commit

property crimes (Andersson et al. 1999). In a

Federal Government survey of State prisoners 

who were expecting a 1999 release, 83.9 percent tested positive for alcohol or drugs when

they committed their offense, with 45.3 percent having used drugs at the time of the 

crime (Hughes et al. 2001). 

Certain substances are more likely to be associated with violent behaviors than others, but 

there is little research on how many substances 

affect violent behavior. However, enough data 

exist to support a link between alcohol use or 

abuse and being a perpetrator or victim of violence, especially among men (Stuart 2005).

For men who are career criminals, substance 

use can be as important as criminal activity in

defining masculinity (Copes and Hochstetler

2003). 

Although different theories have been proposed for why men commit violent crimes, it

does seem clear that gender roles hinder criminal behavior in women and enable it in men. 

Substances of abuse, especially alcohol, also

seem to aid in removing inhibitions against

violent and criminal behavior (Streifel 1997).

Researchers postulate that men may expect

alcohol to make them more prone to violence 

while women do not—a theory supported by 

Kantor and Asdigian (1997), who found that

men were more likely than women to believe 

that alcohol increased irritability and feelings 

of power over others. 

Lisak (2001a) suggests that many men who

perpetrate violence are themselves victims of

violence, and that it “is therefore imperative to

treat this underlying trauma” (p. 286). He

notes that this process begins by demonstrating empathy for their pain, which helps these 

men feel their own past pain; being able to do

so and to believe that they are worthy of sympathy is a first step toward empathizing with

the pain of others. 

To reduce violent behavior in men, many behavioral health service providers have used

cognitive–behavioral therapies to help men

understand how criminal thinking patterns 

and irrational beliefs contribute to violent behavior. These approaches, often modeled on

the Oakland Men’s Project, typically teach

communication skills to help men address 

problems in a more constructive manner. They 

are described in more depth in TIP 44, 

47 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Substance Abuse Treatment for Adults in the 

Criminal Justice System (CSAT 2005b). 

Anger management is another useful adjunct

for men trying to address violent behavior.

Several studies show that many men with substance use disorders have high levels of anger

(Awalt et al. 1999; Giancola 2002b; Parrott 

and Zeichner 2002; Reilly and Shopshire 

2000; Tafrate et al. 2002). Anger can often

lead to aggression and violence and can serve 

as a precipitant for relapse. Teaching men cognitive–behavioral strategies that help them

manage their anger can reduce aggression and

violence and possibly improve treatment outcomes (Reilly and Shopshire 2000). 

SAMHSA has produced Anger Management

for Substance Abuse and Mental Health Clients: 

A Cognitive Behavioral Therapy Manual (Reilly

and Shopshire 2002) and the accompanying

Anger Management for Substance Abuse and

Mental Health Clients: Participant Workbook

(Reilly et al. 2002), which detail an anger

management intervention appropriate for substance abuse treatment settings. Interventions 

that address criminal thinking and improve

communication skills may also prove useful in

substance abuse treatment for men who have a 

history of violent criminal behavior. In particular, these approaches can help men understand how their substance use is related to 

criminal thinking patterns. 

Providers should note that the experience of

violence can have a dissociating quality, and

remembering past violence (whether one is 

victim or perpetrator, although typically perpetrators have also been victims of violence)

can be a painful and problematic experience.

Providers need to be sensitive to the difficulties clients may face in addressing violence in

their past. (See the following sections on violence and abuse.) 

Domestic Violence and Child 

Abuse 

The relationship between domestic violence 

and substance abuse is well documented 

(Caetano et al. 2001; Chase et al. 2003;

Chermack et al. 2000; Cohen et al. 2003;

Easton et al. 2000; Schumacher et al. 2003;

Stuart 2005). The use of certain substances 

(e.g., alcohol, cocaine, methamphetamine) is

associated with increased domestic violence,

whereas use of others (e.g., marijuana, opioids)

is not (Cohen et al. 2003). Some estimates 

suggest that up to 60 percent of men seeking

treatment for alcohol abuse have perpetrated

partner violence (Chermack et al. 2000;

O’Farrell et al. 2004; Schumacher et al. 2003).

A DOJ survey found that more than half of

both prison and jail inmates convicted of a

violent crime against a current or former partner had been drinking or using drugs at the 

time of the offense (Greenfeld et al. 1998). 

A survey conducted by the National Committee to Prevent Child Abuse found that up to

80 percent of child abuse cases are associated

with the use of alcohol and/or drugs by the 

perpetrator (McCurdy and Daro 1994). Many

individuals who abuse their children were 

themselves abused in childhood. The rate at 

which violence is transmitted across generations in the general population has been estimated at 30 to 40 percent (Egeland et al.

1988; Kaufman and Zigler 1993). These probabilities suggest that as many as 4 of every 10

children who observe or experience family violence are at increased risk for becoming involved in a violent relationship in adulthood,

either as perpetrator or as victim. 

Substance use is also associated with being the 

victim of domestic abuse for both men and 

women (Chase et al. 2003; Cohen et al. 2003;

Cunradi et al. 2002; Miller et al. 1989;

Weinsheimer et al. 2005). Other risk factors

for both genders include being young, having 

48 
Chapter 3–Treatment Issues for Men 

 

 

 

a high number of relationship problems, and

having high levels of emotional distress 

(Chase et al. 2003). 

Violence between intimate partners tends to

escalate in frequency and severity over time,

much like patterns of substance abuse. Thus,

identifying and intervening in domestic violence situations as early as possible is paramount. Staff members should understand 

relevant State and Federal laws regarding domestic violence and their duty to report. More 

information on the legal issues relating to domestic violence and duty to report can be 

found in TIP 25, Substance Abuse Treatment 

and Domestic Violence (CSAT 1997b), along

with other valuable information on this topic.

TIP 36, Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues (CSAT 

2000b), discusses child abuse and neglect issues for clients in treatment who have been 

abused as children and/or have abused their

own children. 

Relapse can be a particularly high risk time for

domestic violence, although it is unclear which

event (relapse or domestic violence) precipitates the other. Regardless of causality, both

issues need to be addressed. In the midst of a 

relapse crisis, it can be easy for the counselor

to decide to deal with the violence at a later 

date. Several complications arise, however, as a

result. Not addressing the violent behavior

may imply that it is not significant or important. It also invites the client to sweep the 

event under the rug and not address it at a later date. Not addressing the violence may also

signal to other family members that the violent behavior should not be brought into the

open and discussed. Additional material on

addressing domestic violence in counseling is 

offered later in this section. 

When issues like domestic violence or child 

abuse are discussed, all behavioral health clinicians should be aware of confidentiality laws 

and any exceptions to those laws that may apply in specific instances. Providers should also

be aware of applicable Federal regulations (notably, the Confidentiality of Alcohol and

Drug Abuse Patient Records laws contained

in 42 CFR Part 2) and specific State regulations or laws (e.g., “Megan’s Laws”). Appendix 

B in TIP 25 (CSAT 1997b) and Appendix B 

in TIP 36 (CSAT 2000b) provide detailed discussions of these topics. In addition, the 

SAMHSA (2004) publication, The Confidentiality of Alcohol and Drug Abuse Patient Records 

Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse Programs

discusses these regulations as well as Health

Insurance Portability and Accountability Act

regulations that affect confidentiality of patient records. 

Men as victims of domestic violence 

Although women are commonly perceived as 

the victims of domestic violence, the reality is 

that men can also be victimized by either male 

or female partners. In the National Violence 

Against Women Survey, 15.4 percent of men

who lived with male partners and 7.7 percent

of men who lived with female partners reported stalking, physical assault, and/or sexual assault by their partners (Tjaden and Thoennes 

2000). Other studies, which contextualized

domestic violence as family conflict rather

than criminal behavior, report higher rates of

female-on-male violence, although the types

of violence perpetrated and the likelihood of it

resulting in injury were inconsistent (George 

2003). In a meta-analysis of physical aggression between opposite-sex partners, Archer

(2002) found that men were more likely to

cause injury to partners but that men still sustained one third of injuries resulting from such

acts. 

Studies of clients in substance abuse treatment 

have found high levels of intimate partner violence perpetrated by women against men. 

49 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Cohen and colleagues (2003) interviewed

1,016 men and women in treatment for methamphetamine dependence: 26.3 percent of

men (compared with 63.2 percent of women)

reported that their partners had threatened

them, and 26.3 percent of men (compared

with 80 percent of women) reported that their

partners had been physically violent. In a study 

of 103 women with alcohol use disorder seeking couples-based outpatient treatment, women were more likely to report having

committed serious violence toward their partners (50 percent) than having been victims of 

such violence (22 percent), although this was 

not the case in a study of women seeking individually based treatment for alcohol abuse 

(Chase et al. 2003). It should also be noted

that unmarried intimate partners appear to be 

more likely to commit violent acts toward one

another than married partners (Straus 1999). 

Because stereotypes of masculinity (see Chapter 1) stress self-sufficiency and strength, men

who have been abused by their partners may 

be even less willing to seek help than women.

Additionally, there are fewer resources available for male victims of domestic violence than 

for female victims. The majority of domestic

violence programs are designed for women,

and many will not provide assistance to male 

victims; also, many men who are abused by

their partners do not feel that the justice system will support them even if they do report

the crime (McNeely et al. 2001). The problem 

is further complicated by traditional beliefs 

that men should be the head of the household 

and men’s fear of ridicule for not filling that 

role; the shame men may feel at disclosing

family violence is compounded by the shame 

of not being able to keep their partners under

control (Straus 1999). Often, providers presume that men in treatment should be 

screened as potential abusers but not as victims of domestic abuse, especially when the 

man’s partner is a woman (CSAT 1997b). 

Limited data are available on the rates of intimate partner abuse among gay male couples:

for example, the National Violence Against

Women Survey (Tjaden and Thoennes 2000)

found that men with male partners were twice 

as likely to experience domestic violence as 

men with female partners. Bartholomew and

colleagues (2000) compared factors associated 

with partner abuse in heterosexual and gay 

couples, concluding that they were largely the

same and that substance use played a significant role in both situations. In a review of 19 

studies that examined partner violence in gay 

and lesbian couples, Burke and Follingstad

(1999) only found 3 that gathered data from

gay male couples and 1 that extrapolated data

on rates of abuse for heterosexual men. Still,

these limited studies suggest that men in

same-sex relationships are at least as likely to

experience violence from their partners as men

in opposite-sex relationships. 

Treatment and referral for domestic 

violence 

For men who have a history of either perpetrating or being victimized by domestic violence, collaboration with and referrals to

domestic violence intervention programs can

facilitate their substance abuse treatment. At 

the same time, behavioral health service providers need to be aware that certain therapeutic interventions (particularly couples or family 

therapy) can increase the likelihood of further

domestic violence and should not be used with 

clients who have such a history. In some 

States, standards for domestic violence treatment programs warn against couples counseling as an initial intervention, and some 

standards regulate what individual treatment

improvements need to occur prior to any couples counseling. Interventions designed to reduce domestic violence without addressing

substance abuse have proven to be minimally 

effective (Stuart 2005). 

50 
Chapter 3–Treatment Issues for Men 

 

 

 

 

 

 

Counselors not specifically trained in treating

domestic violence issues should refer clients to 

counselors qualified to treat these problems,

either within their own behavioral health program or elsewhere in the community, and they 

should share pertinent information with domestic violence staff (as permitted by confidentiality rules) to ensure that both problems 

are addressed. Providers should not hesitate to 

leverage the criminal justice system to ensure 

that male batterers participate in domestic violence treatment. 

When a clinician suspects that a man may be 

being abused by an intimate partner, he or she 

should address the problem in an individual 

counseling session emphasizing nonshaming

support and education. Options for accessing

help and potentially removing himself from 

the relationship should be discussed. Very few 

domestic violence programs or shelters exist

for male clients, but in certain areas, there are 

programs to which clinicians can refer a man.

The Battered Men Web site posts information

on such programs 

(http://www.batteredmen.com). 

Because of the close relationship between substance use/abuse and domestic violence, substance abuse treatment in and of itself may 

help reduce domestic violence for some clients 

(Stuart 2005). Behavioral couples therapy (also

known as behavioral marital therapy) is a substance abuse treatment approach designed

specifically to improve relationships while also

increasing abstinence. O’Farrell and colleagues 

(2004) found that this therapy significantly

reduced domestic violence (as measured by the 

Conflict Tactics Scale) and was effective up to

2 years after treatment for men with alcohol 

use disorder. Again, however, if the potential

for a reoccurrence of domestic violence exists,

caution should be exercised in implementing

couples therapy. More information on this intervention can be found in Chapter 5, as well 

as in TIP 39 (CSAT 2004b). 

Sexual Violence 

Sexual violence has long been associated with

alcohol consumption. In one study, 75 percent

of men who admitted to behavior that met 

legal definitions of rape acknowledged being

under the influence of alcohol when they 

committed the act (Koss and Dinero 1988).

Peugh and Belenko (2001) report that two

thirds of incarcerated sex offenders either used 

substances at the time of their crime or had a 

history of substance abuse. Alcohol use is 

more common than illicit drug use among

these men. Illicit drug use, however, is more 

common among offenders who victimize 

adults than those who target children. The

consensus among researchers is that substance 

use does not cause sexual assault; rather, it

contributes to the crime in other ways. Sex

offenders also frequently have histories of victimization or co-occurring mental disorders or 

other behavioral health problems, which further complicate their treatment picture (Peugh 

and Belenko 2001). (See the sections later in

this chapter on male survivors of adult or

childhood sexual abuse.) 

The vast majority of sex offenders are male. In

2006, 95.4 percent were male, whereas just 2.9

percent were female and 1.8 percent were of

unknown gender (DOJ 2008). Among incarcerated sex offenders in 1994, 99.6 percent of

an estimated 33,800 convicted rapists were

male, as were 98.8 percent of the 54,300 people

convicted of sexual assault (Greenfeld 1997). 

Several studies have addressed the comorbidity of substance abuse and sexually abusive or

violent behavior. Raymond and colleagues 

(1999) found that 60 percent of a group of 45 

pedophiles had a lifetime prevalence of substance use disorders. In a similar sample size of

adult sex offenders, McElroy and colleagues 

51 
 

 

Addressing the Specific Behavioral Health Needs of Men 

(1999) reported that 83 percent met criteria

for a substance use disorder; these men also

had high lifetime rates of co-occurring mental 

issues (e.g., mood and anxiety disorders). 

Screening for and addressing patterns of sexual violence among clients in substance abuse 

treatment is imperative, but treatment of sexual violence requires specialized training, close 

clinical supervision by someone trained in sexual violence treatment, special programmatic

constraints, and often, mandates for treatment 

from legal and criminal justice resources. Substance abuse counselors should be skilled in 

screening for sexual violence and knowledgeable of community resources for care. When

possible, substance abuse programs should facilitate concurrent care for both substance use 

and sexual violence. 

Violent Behavior in Treatment 

A man’s violent behavior can interfere with his 

substance abuse treatment, and conversely, his 

substance abuse can interfere with interventions aimed at changing his violent behavior

(Bennett 1995; CSAT 1997b). Clients should

be informed upon entering a program what

behaviors are acceptable and what consequences result from unacceptable behaviors 

(e.g., treatment termination, loss of privileges).

The nature of a program’s response depends 

on its ability to impose sanctions and its requirements to retain or not retain clients. Anger management techniques (see Chapter 5),

which are used by many substance abuse 

treatment programs, can help reduce violent

behavior and can have a number of positive

secondary outcomes, such as helping clients 

reduce impulsive behavior and maintain selfcontrol. Conflict resolution, cognitive restructuring, relaxation exercises, and other such 

techniques can help clients with their anger

and aggressive impulses. Having a client take 

time out from individual or group therapy sessions if he feels increasing anger is also a useful intervention for deescalating violence. Substance abuse treatment programs are responsible for protecting the health and welfare of all 

clients and for monitoring potentially violent

clients to ensure the safety of other clients in

the program. Programs should have policies to

guide staff in addressing situations in which

one client’s violent behavior might affect the

welfare of others. 

Counseling Men About 

Sexual Issues 

Sexuality and sexual behavior are intimately 

connected with gender identity for most men

(regardless of their sexual orientation). Masculine norms that put a priority on success, selfreliance, and reliability all contribute to men’s 

fear that sexual performance problems reflect

negatively on their masculine identities. 

Some men are more comfortable discussing

sexual issues with a male counselor; others 

prefer doing so with a female counselor. Both

male and female counselors can help male clients feel more comfortable with questions 

concerning sexual behavior. Male counselors 

can use self-disclosure and empathy to reduce 

the client’s sense of isolation; female counselors can react positively to the client’s disclosure of sexual fears and concerns, thus offering

a positive and therapeutic experience. 

Substance Use and Sexuality 

According to Braun-Harvey’s (1997) review of 

the literature, compulsive sexual behavior is 

much more common among men than women. Limited research and clinical experience 

also show that sexual dependency (a term used

to refer to a broad range of behaviors involving

problems of sexual control and preoccupation

that result in psychological distress) is more 

common among men who abuse substances 

than those who do not. 

52 
Chapter 3–Treatment Issues for Men 

 

 

 

Using substances to lower one’s inhibitions 

before and during sex is a widespread practice 

among youth in the United States, which often carries over into adulthood. As adults,

some men might use alcohol to calm anxious 

feelings they may have about sexual performance (e.g., being able to achieve an erection

or please a partner) or as an excuse for certain

sexual behaviors that may otherwise be the

source of intense guilt or shame. Other men

use illicit drugs to control sexual response. For

example, some individuals who use methamphetamine believe that it can prolong an erection and provide stamina for longer sessions of

sexual activity. Stimulants (such as methamphetamine and cocaine) are also associated with

intensified sexual thoughts, feelings, and fantasies (although very large doses can have the opposite effect). Some people use these substances 

only in sexual situations, while others seek sexual encounters because of the drug’s effects. 

Research with 464 men and women entering

outpatient substance abuse treatment found

that 55.3 percent of men who used cocaine as

their primary substance of abuse and 85.3 percent of those who used methamphetamine reported that the drug increased their sex drive;

by comparison, 11.1 and 55.6 percent of women, respectively, reported the same (Rawson et

al. 2002). In the same study, 55.3 percent of

men who primarily used cocaine and 76.5 who 

primarily used methamphetamine reported that

the drugs made them obsessed with sex or

made their sex drive abnormally high. 

Crack cocaine has also been thought of as 

heightening sexual experiences, and cocaine 

has been viewed as affecting the sexual arousal 

areas of the brain (Angrist 1987). Men often 

report relapse as a result of wanting to experience sexual activity under the influence of the 

drug (Gottheil et al. 1998), and similar associations are found in those who use methamphetamine (Rawson et al. 2002; Washton 

2009). Among gay men, methamphetamine 

use is also associated with a greater likelihood

of engaging in impulsive sexual activity

(Halkitis et al. 2009a; Semple et al. 2006). In

treatment, counselor and client should engage

in a therapeutic dialog regarding the relationship of stimulant use to sexuality; particularly 

for these clients, management of sexual desire 

should be incorporated into a relapse prevention program. 

3,4-methylenedioxymethamphetamine 

(MDMA), also known as ecstasy, is another

drug used to enhance sexual desire and satisfaction. In a study of 35 healthy individuals 

who used MDMA for recreational purposes,

20 of whom were men ages 21 to 48, more

than 90 percent perceived that their sexual desire and satisfaction were moderately to profoundly increased by MDMA. However,

despite its alleged enhancement of sexual desire 

and satisfaction, MDMA may impair sexual

performance: orgasm was delayed but perceived

as more intense, while erection was impaired in

40 percent of the men (Zemishlany et al. 2001). 

Substance Abuse and the Male 

Reproductive System 

Substances of abuse can have a profound effect on men’s reproductive health as well as 

their sexual functioning. Data are not available

on the effects of many illicit drugs on men’s 

reproductive health, but the use of alcohol is 

prevalent enough to delineate certain facts.

Men who drink heavily increase their risk for

both impotence and low sperm count. According to the literature, some studies have shown

that even moderate alcohol consumption can

decrease the production of sperm and alter its 

physical structure (Burke 1999; Nudell et al.

2002). Impotence may be reversible with the 

return of abstinence, but it can be persistent

when chronic heavy drinking has contributed 

to neurological, endocrine, or vascular dysfunction (Burke 1999). Alcohol is known to 

53 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

affect the endocrine system, which regulates 

growth, reproduction, and other bodily functions. Alcohol use has also been linked to low 

testosterone, which can intensify levels of depression for men (Booth et al. 1999), and to

altered levels of other reproductive hormones 

(Emanuele and Emanuele 2001). 

Not only does chronic alcohol consumption

affect a man’s ability to impregnate his partner; it also influences his ability to produce 

healthy children (Emanuele and Emanuele 

2001). In Klonoff-Cohen and colleagues’ study 

(2003) of 221 couples with female infertility,

increased risk of spontaneous miscarriage and

failure to achieve a live birth were both linked 

with male alcohol use in the month before and 

during in vitro fertilization (a process in which 

a woman’s eggs are fertilized in an artificial

environment and then inserted into her uterus) or gamete intrafallopian transfer (a technique in which eggs and sperm are inserted 

directly into a woman’s fallopian tubes, where 

fertilization may occur). In another study, male 

rats, whose reproductive systems are similar to

those of human men, were treated with alcohol 

for 9 weeks prior to breeding.The alcohol significantly decreased the average weight of the 

resulting fetuses and increased the incidence of

undersized offspring (Bielawski et al. 2002). 

Other substances can also affect a man’s 

fertility. Some studies have associated cigarette 

smoking with decreases in male fertility (Curtis 

et al. 1997; Nudell et al. 2002). Marijuana appears to decrease sperm density, motility, and

morphology (Nudell et al. 2002); methadone 

decreases the amount of sperm ejaculated

(GlaxoSmithKline 2005). Many men are not

aware and should be informed that marijuana 

use has also been associated with increased 

rates of a number of male-specific cancers

(e.g., prostate, testicular, penile) as well as a

range of other health problems (see review by 

Pujazon-Zazik and Park 2009). Anabolic steroids, too, affect the male reproductive system 

in several ways, including producing testicular

atrophy. Other substances, such as opioids, cocaine, and amphetamines, may decrease libido

when taken in large doses (Nudell et al. 2002). 

Sexual Identity 

Men trying to come to terms with a gay or

bisexual identity often need to focus “on stigma and negative societal attitudes [and] coping mechanisms ranging from denial to

nondisclosure” (Taylor 1999, p. 524). In a

study on homosexual identification, Weinberg

and Williams (1974) found a relationship between gay men’s “worrying about exposure and

anticipating sanctions” (p. 178) and “being

publicly identified as a homosexual” (p. 9).

This inhibition is sometimes associated with 

multiple health and substance use problems 

for gay men. For example, Cole and colleagues 

(1996) found that gay men who tested negative for HIV/AIDS and who were closeted

had higher rates of cancer and moderately serious infectious diseases than those who were 

able to be open about their sexuality. 

Some men may identify as heterosexual despite engaging in sex with other men. Such

behavior may be a temporary or experimental 

stage, as might occur during adolescence or in

the absence of female partners (e.g., in prison).

Some men who identify as heterosexual may 

only have sex with men when under the influence of substances, either because they feel too

much shame to do so when abstinent or because the substances impair their judgment;

this causes them to feel shame afterward,

when no longer under the influence. This can

be a significant problem for some men in recovery who feel an added compulsion to use 

substances to escape feelings of intense shame 

associated with past sexual behavior or to feel 

able to express their sexuality. 

54 
Chapter 3–Treatment Issues for Men 

 

 

 

 

Becoming comfortable identifying oneself as 

gay or bisexual is an important part of seeing

oneself as part of a larger gay/bisexual community. Being a part of such a community can

provide greater access to sources of emotional 

support that could combat feelings of marginalization due to heterosexism, which can otherwise contribute to distress and mental 

disorders among gay men (Meyer 1995).

These feelings of distress, coupled with a lack

of social support or ineffective coping skills,

may lead to use of alcohol or drugs. If

gay/bisexual men are able to see themselves as 

part of a larger gay/bisexual community, it may 

improve their self-esteem and thereby lessen

their substance abuse. Some gay men feel considerably more comfortable in programs or

treatment groups that are specifically organized to assist gay men, although such options 

are not available in all areas. Clinicians working with self-identified gay men in other

treatment settings should speak with them to

determine whether they wish to identify 

themselves as gay (i.e., be out) in the program. 

Sexual orientation is sometimes misperceived

as reflecting a person’s masculinity, leading to

assumptions that all gay or bisexual men are

inherently feminine. This belief can result

from simple misinformation or can be the 

product of homophobia. However, what is labeled as effeminate behavior has no real relation to sexual orientation. Gay/bisexual men

may be very masculine; heterosexual men may 

act effeminate. Counselors should educate clients about sexual orientation and the fact that 

the degree of masculine or feminine behavior a 

person exhibits is not related to it. 

A Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and

Transgender Individuals (CSAT 2001) contains more information on substance abuse 

treatment for gay and bisexual men. 

Sexual Performance and Sexual 

Dysfunction 

Fracher and Kimmel (1987) identify the three 

most common sexual complaints of men seeking therapy—premature ejaculation, inhibited

sexual desire, and erectile dysfunction—as issues of sexual performance. Although men

often focus on physical symptoms when seeking assistance, Fracher and Kimmel note the

importance of the response to the symptom 

(e.g., anxiety, depression, low self-esteem) that 

prompts men to seek help and that those responses result from men’s failure to perform at

the standard dictated by traditional masculine

gender roles. To treat sexual dysfunction, they 

recommend addressing the client’s beliefs 

about masculinity through “exploring and

challenging the myths of male sexuality, modeling by the therapist of a different version of

masculinity, giving permission to the patient

to fail, and self-disclosure by the therapist of 

the doubts, fears of inadequacy, and other anxieties that all men experience” (p. 92). 

Medications for male sexual dysfunction are 

now widely used. However, a man in recovery 

may be resistant to such medication—

sometimes with good reason—as there have

been some reports of abuse of medications like 

sildenafil (Viagra), especially among gay and

bisexual men (Crosby and DiClemente 2004;

Smith and Romanelli 2005). Abuse of sildenafil also appears to be more common among

men who abuse other substances. Crosby and

DiClemente (2004) found that in a sample of

men who had sex with men, those who abused

cocaine, MDMA, or alkyl nitrate inhalants

were 2 to 3 times more likely (depending on

the substance) to use nonprescription sildenafil than men who did not use them. Clients 

considering medication to improve sexual performance should be cautioned about the potential for abuse and other health risks. 

55 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Sex and the Internet 

Thanks to the Internet, millions of people can

now easily access a wealth of information on

just about every topic of interest and effortlessly talk with others despite great physical 

distance. However, this technology also enables people to find an “impersonal, detached

sexual outlet” (Schwartz and Southern 2000,

p. 128). Those who seek sexual partners and

gratification over the Internet are engaged in

what is often referred to as cybersex. They may 

be involved with a variety of partners in different ways. Some participants compulsively 

search for partners for hours, seeking to create 

various fantasy scenarios; others spend large 

sums of money on interactive pornography.

Some men believe that cybersex allows them 

to engage in sexual activity with less anxiety. 

Men are significantly more likely than women

to engage in online sexual activities. In one

large study (n=7,037) men were twice as likely 

as women to report engaging in online sexual 

activity to deal with stress (rather than as a

distraction or for educational purposes); however, the same study found no significant difference in the number of men (10.5 percent) 

and women (4.9 percent) who reported a sexual addiction (Cooper et al. 2002). Schwartz

and Southern (2000) linked compulsive online 

sexual activity with male substance abuse in a

study of 40 people seeking treatment for problematic cybersex involvement: 73.7 percent of

men (but just 42.9 percent of women) reported a substance abuse problem. 

The investigation of compulsive online sexual 

activity is a relatively recent field of study, and

screening and treatment approaches are still in

development. Cooper and colleagues (2004)

found that Internet users who spend more 

than 11 hours per week engaged in online sexual activity are also likely to score high on

measures of sexual compulsivity, and the number of hours spent on such activity may be 

used as a simple screening question. Schwartz

and Southern (2000) suggest that cognitive–

behavioral approaches be used to change behaviors for men with a cybersex addiction.

They also suggest additional therapies to treat

other problems that may be at the root of such 

addiction (e.g., depression, trauma, conflicts in

relationships, sexual dysfunction, conflict over

sexual identity). Some substance abuse treatment programs now also offer treatment for

sexual compulsivity and addiction, either as an

integrated component of substance abuse 

treatment or as a separate therapeutic effort. 

Sex Trade Workers 

Participating in the sex trade is typically not so

much a sexual behavior as it is the product of

economic necessity and should generally be 

considered in that light. Poverty may lead adult

or adolescent men into prostitution or into exchanging sex for drugs, alcohol, or money. 

Involvement in the sex trade (which, for men,

typically involves sex with other men) appears 

to be more common among men who identify

as gay or bisexual, but even men who identify 

as heterosexual may engage in sex with men

for money. Prostitution also appears to be

much more common among younger men,

and a number of clients in treatment settings 

may have participated in the sex trade as juveniles. In a study of 358 men ages 19 to 35, all

of whom identified as gay or bisexual and were 

HIV negative, 9.8 percent stated that they had

engaged in juvenile prostitution (Ratner et al.

2003). Sex trade work also appears to be much

more common among gay and bisexual men

who inject drugs than among those who do

not (Rietmeijer et al. 1998). 

Some men choose prostitution primarily as a

way to experiment sexually while earning extra

money, not as an economic necessity. Cates 

and Markley (1992) compared a group of 15 

young men who stated they were prostitutes 

56 
Chapter 3–Treatment Issues for Men 

 

by choice rather than necessity with 15 men

from the same cohort who were not prostitutes; those prostituting by choice reported

significantly more substance use than those

uninvolved in prostitution. Men who had been

prostitutes also reported more familial substance abuse. 

Rape and Sexual Abuse Among 

Adult Men 

The sexual abuse of adult men is rare. According to DOJ estimates, only 0.2 out of every 

1,000 men were victims of sexual abuse in

2003 compared with 1.5 out of every 1,000 

women (Catalano 2004). A survey of 2,500 

British men found that 2.9 percent had experienced nonconsensual sex as adults, although

5.4 percent reported having had nonconsensual sex as children (Coxell et al. 1999). In samples of self-identified gay and bisexual men,

rates of adult and childhood sexual abuse are 

higher. Ratner and colleagues (2003) sampled

358 HIV-negative men who identified as gay 

or bisexual; of these, 14 percent reported

childhood sexual abuse and 14.2 percent reported nonconsensual sex as adults (defined as 

being over the age of 14). 

What little research exists into sexual assault 

among incarcerated men suggests that rates in

this population are comparable to those found

among women in the general population. 

There is wide variation in prevalence rates 

across studies because of differences in definitions of sexual assault, methods used to obtain

data, and sample sizes. However, all studies 

imply that sexual assault in prison is significant. The Prison Rape Elimination Act of

2003 (P.L. 108-79) called for a comprehensive 

study of prison rape to more accurately determine the extent of sexual assault among incarcerated men (Gaes and Goldberg 2004;

Thompson et al. 2008). The Just Detention

site (http://www.justdetention.org) offers a

resource guide for survivors of rape during incarceration as well as other information of use 

to survivors and their clinicians. 

Because of high rates of HIV/AIDS and other

sexually transmitted diseases in the prison

population, men who have been raped while 

incarcerated run a high risk of contracting a 

sexually transmitted disease (Robertson 2003).

Many prison institutions do not test for

HIV/AIDS unless an incident report has been

filed, but the majority of cases of sexual assault

behind bars may go unreported (Gaes and

Goldberg 2004; Robertson 2003). In addition

to counseling, men in substance abuse treatment who state that they have been sexually 

assaulted (while incarcerated or not) should

receive HIV/AIDS testing and counseling. 

Given data on childhood and adult sexual 

abuse, the number of adult men who have 

been sexually abused at some point during

their lifetimes may be significant, and especially so for men in substance abuse treatment.

For example, Ouimette and colleagues (2000)

assessed the physical and sexual abuse histories 

of 24,959 veterans (24,206 of whom were

male) who had substance use disorders; 8 percent of the men had experienced sexual abuse 

during their lifetimes. Lifetime rates of sexual 

abuse were much higher for women in their

study (49.4 percent), but both men and women with sexual abuse histories had similarly 

poor outcomes as measured 2 years later, even

taking into account baseline functioning, cooccurring mental illnesses, and relevant demographic variables (Rosen et al. 2002a). 

Childhood Sexual Abuse 

Rates of child abuse (of all types) are similar

between the sexes, but the types of abuses endured differ. According to 2002 data from

child protective service agencies across the 

United States, 48.1 percent of victims ages 17 

and under were boys and 51.9 percent were 

girls (Administration for Children and 

57 
Addressing the Specific Behavioral Health Needs of Men 

Families [ACF] 2004). A more recent report

shows that, among children reported to child

protective services throughout the United

States, 48.2 percent were boys and 51.5 percent were girls; in 0.3 percent of cases, the 

gender was unknown (U.S. Department of

Health and Human Services [HHS], ACF

2009). A large-scale review by Trocmé and

colleagues (2001) of child maltreatment investigations in Canada found that 51 percent involved male children and that, among children

over age 15, a greater number of investigations 

were substantiated involving boys (60 percent)

than girls (42 percent) (Trocmé et al. 2001). 

Girls under age 18 are about three times more 

likely than boys to experience sexual abuse, but

boys are more likely than girls to experience 

emotional neglect or serious physical injury 

due to abuse (Sedlak and Broadhurst 1996).

Self-reports from college students and general 

population surveys suggest that 10 to 20 percent of men were physically abused as children

(Lisak 2001b). Boys are also more likely to die 

from maltreatment than girls of comparable 

age (ACF 2004). 

Girls are more often sexually abused than

boys, but male individuals are more likely to be 

sexually abused as children than as adults; the 

age at which a man is most likely to be a victim of sexual assault is 4 years old (Snyder

2000). Estimates as to the prevalence of sexual 

abuse of boys vary widely (Holmes and Slap

1998), but studies have found that between 8

and 29 percent of adult men have endured

childhood sexual abuse (Gorey and Leslie 

1997; Putnam 2003; Snyder 2000). Based on

16 cross-sectional studies of sexual abuse of 

children in North America (adjusted for sample size), Gorey and Leslie (1997) estimate 

that approximately 8 percent of adult men

were childhood victims of sexual abuse. 

Despite one fifth to one quarter of juvenile 

victims (ages 18 and under) of sexual assault 

being male, few providers screen for histories 

of sexual abuse among male clients. In a study 

of 179 mental health professionals, 82 percent

reported that they rarely or never inquired

about the sexual abuse histories of men receiving services; many were unaware of the extent

of sexual abuse of male children, and most

(69.2 percent) felt that they had received insufficient training to inquire about it (Lab et

al. 2000). Male victims of childhood sexual 

abuse may be even less willing to report it than

female victims (Holmes and Slap 1998)—

especially if the perpetrator is an adult woman

and the victim a male adolescent, as both the 

victim and society have a harder time recognizing such acts as abuse (Mathews 1996). 

Sexual abuse in childhood is linked with increased rates of substance use and various other behavioral health problems, including

mental illness, suicide attempts and completions, gender role confusion, and involvement

in high risk sexual behaviors; it can also increase the likelihood that the individual will 

sexually abuse others (Dube et al. 2001;

Holmes and Slap 1998; Zielinski 2009). Unfortunately, only after becoming involved in

the criminal justice system do many adult men

receive any assistance with their childhood

sexual victimization (Mathews 1996). 

A history of childhood sexual abuse can profoundly affect a male client’s substance abuse 

treatment in adulthood. For instance, typical

efforts to help men bond with other male clients in treatment may provoke significant anxiety, and the abused client may withdraw, 

appear angry or threatening to others, or act 

fearful and hesitant. Sexually charged humor

may be misconstrued by such a client; even

demonstrations by counselors (or clients) of

being interested in or concerned about the client can be seen as similar to the interest 

shown by a sexual perpetrator. It is often difficult to identify a client with a history of sexual 

58 
Chapter 3–Treatment Issues for Men 

 

 

 

Advice to Behavioral Health Clinicians: Addressing Childhood Sexual Trauma in Men 

• Screen all male clients in substance abuse treatment for childhood sexual trauma. 

• If screening reveals the possibility of childhood sexual trauma, have the client assessed by a clinician competent to diagnose and recommend treatment approaches for trauma. 

• In treatment, focus on how the trauma affects the client today, not on the details of the trauma. 

• Most clients prefer to work on the effects of their childhood trauma in individual, not group, sessions. 

• Childhood sexual trauma may be part of a larger process of abuse and disrespect of the individual in 

childhood and into adulthood. Do not presume childhood sexual abuse to be an isolated incident. 

abuse, so routine physical exams that require a

client to disrobe or that involve touching a

client’s genitalia must be conducted with respect and sensitivity for the man’s privacy. 

Case example: George 

George is a 26-year old client in an inpatient

substance abuse treatment program for men

with co-occurring disorders. This is his first

admission for substance abuse treatment, but

he has, since early adolescence, been treated

for various mental disorders, including depression, attention deficit hyperactivity disorder,

panic disorder, and mixed personality disorder.

Prior to entering treatment, he never told anyone that when he was 12, he was repeatedly 

sexually assaulted by a counselor at a camp for

boys without fathers. In late adolescence, he 

questioned his sexual orientation and tried to

resolve this dilemma by refraining from sexual 

activity. He never dated and allowed no close 

male friendships. He later described his experience as “feeling like a damaged freak.” In his

early teens, he began to abuse marijuana and

alcohol. 

Twice in his first week in the program, George 

had panic attacks that he blamed on fears of

being trapped. He had nightmares almost every 

night and had rushes of feeling overwhelmed

and ashamed. He appeared frightened and unable to bond with other male clients in the 

group. He became visibly anxious when asked,

in individual appointments, about his sexual 

and interpersonal history. 

In clinical supervision, the counselor described

George’s symptoms and problems on the unit,

expressing concern that George might have a

trauma-related disorder. The counselor’s supervisor suggested screening George for trauma symptoms, and when the counselor did so,

George began to allude to a history of sexual 

abuse. Subsequent mental health consultation

confirmed a posttraumatic stress disorder

(PTSD) diagnosis, and integrated treatment of

PTSD and substance abuse was undertaken. 

Efforts were made to ensure that George’s 

treatment did not unintentionally evoke his 

childhood sexual trauma. He was encouraged

to speak with his counselor if his anxiety became intolerable and was given a private bedroom. Without offering details, he described to

his primary treatment group that terrible things 

occurred in his childhood that made it hard to 

bond with others; he felt great relief in sharing

part of his secret with others. Plans were made 

for George to continue individual treatment for

PTSD and relapse prevention after successfully 

concluding inpatient treatment. 

TIP 36 (CSAT 2000b) provides information 

on treating male and female survivors of child

abuse and neglect in substance abuse treatment settings. Some basic guidelines are presented in the following text box. 

Family Issues 

Men fill a number of different relationship

roles. They may be employees or employers,

and they may be involved with different 

59 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

systems (e.g., the criminal justice system)—

both topics are discussed in Chapter 4—but

most men have been or currently are members 

of families (either families of origin or those 

they have themselves created). Families can

affect men’s substance abuse in different ways,

but they also can play a powerful role in motivating men to enter and maintain recovery. 

Parenting Responsibilities 

Parenting can be a stressful activity for both 

men and women. Some fathers who abuse 

substances may believe their substance use actually helps them cope with stress associated

with parenting, enhancing their ability to

function as fathers. However, substance use is 

likely to increase child abuse and neglect and

create a much more chaotic environment for 

children in the home (Ammerman et al. 1999;

Reid et al. 1999). Paternal substance abuse has 

also been associated with negative outcomes 

for children, including children’s own abuse of 

substances later in life (McMahon et al. 2005;

Schuckit and Smith 2001); antisocial traits

and higher rates of depression, anxiety, and

mania (Finn et al. 1997); lower intelligence 

quotient (IQ) and school achievement scores 

(Moss et al. 1995b); and increased aggression 

(Moss et al. 1995a). 

Father–child relationships within families affected by paternal substance abuse are not categorically problematic (Eiden et al. 2002), and

there is some evidence that, even in the midst 

of chronic substance abuse, positive father–

child relationships may still help promote positive child development (Brook et al. 2002a, b). 

Still, it is best that fathers contribute to the

well-being of children when they are in a position to maintain close, responsive relationships 

with them, to provide emotional support and

practical assistance to their children’s mothers,

and to contribute economically to the family’s 

welfare, all of which are extremely difficult to

do when abusing substances. 

The importance of child custody for women

and the value of programs that treat women

with their children have been recognized for

some time (CSAT 2004b), but clinicians and

researchers still tend to minimize the roles 

played in the lives of their children by men who

abuse substances (McMahon and Rounsaville 

2002). Losing custody of their children can affect men’s substance use; some men enter

treatment due to their concern for their children (McMahon and Rounsaville 2002), and

men who have children are more likely to complete treatment (Rabinowitz and Marjefsky 

1998). Conversely, lack of contact with one’s 

children is correlated with increased substance 

misuse among men (Grill et al. 2001). 

Although empirical data on how parenting

responsibilities affect the treatment seeking

and retention of men are not readily available,

studies suggest that family can play an important role in motivating a man to enter

treatment. For example, Steinberg and colleagues (1997) found that 53.3 percent of their

sample (105 men in a couples-based outpatient program for alcohol abuse) said they

were motivated by their spouse or family to

enter treatment. In analyzing data from the

Drug Abuse Treatment Outcome Study,

Grella and Joshi (1999) found that opposition

to substance use and support for treatment

from family members had an effect on men’s 

entry into treatment that it did not have on 

women’s entry. The authors also reported that

despite not being as concerned with child custody issues as women, a significant number of

men reported concern that entering treatment 

might affect custody of their children (15.7 of

men compared with 30.5 percent of women)

and that they might lose custody of their children because of their substance abuse (4.2 percent of men versus 16.9 percent of women). 

The consensus panel believes that fatherhood

and the desire to be a good father can serve to 

60 
Chapter 3–Treatment Issues for Men 

motivate a man to enter and remain in treatment as well as potentially hinder treatment

entry. For example, concerns about working to

provide financial support for children may 

prevent some men from seeking treatment in a

timely manner, particularly if treatment requires absence from work. Similarly, internal 

or external pressure to return to work as soon

as possible so that they can provide for their

children may cause some men to leave treatment prematurely. Some fathers, particularly 

single custodial fathers, may avoid seeking

treatment or leave treatment if they believe it

could interfere with their ability to effectively 

parent their children. Also, men living with

their children may be less likely to commit

themselves to an extended period of inpatient,

residential, or maintenance treatment. Men

involved in family court proceedings might 

believe involvement in treatment could be 

used against them in hearings concerning

child custody or visitation rights. For these 

reasons, among others, it is important for fathers to have some contact with their children

during treatment, even if only through supervised visitation. Sensitivity to a father’s visitation schedule helps him maintain contact with

 

 

Advice to Behavioral Health Clinicians: Parenting Issues 

Programs specifically designed to teach men parenting skills are almost universally absent in substance abuse treatment settings. Parental interventions for men with substance use disorders must 

systematically address the motivational, cognitive, behavioral, and interpersonal aspects of parenting 

from the perspective of men: 

• Why men should work to become better parents.

• The benefits clients can receive by becoming better parents.

• Family-of-origin issues that may interfere with effective fathering.

• Legal barriers to greater involvement with children.

• Problem-solving with mothers who typically control access to children.

• Building better communication skills with children.

• Developing specific parenting skills appropriate for use with children of a specific age.

• Relating to children who are grown.

Cogent issues that can emerge for fathers with substance use disorders include: 

• Excessive guilt about being an ineffective parent.

• Family secrets about substance use and HIV/AIDS status.

• Relating to children when both parents are addicted.

• Lack of role models for effective parenting.

his children and ensures that custody exchanges proceed smoothly and both mother and father cooperate with the terms of the

agreement. 

Counseling fathers in substance 

abuse treatment 

When entering treatment, men sometimes 

discover that they lack basic parenting skills—

a problem they did not recognize when they 

were using. Substance abuse programs that

treat male clients should consider adding a

component that teaches parenting skills, as 

many men with children will express an interest in such an option if offered. Although

formal evaluation data are scarce regarding

parenting programs for men in treatment,

criminal justice system providers believe they 

are helpful for both the men and their children; men are interested in such programs and

view them favorably ( Jeffries et al. 2001). 

Given the complex, multidimensional nature of

their problems, fathers who abuse substances 

may need a great deal of support and assistance 

from their counselors to be able to provide for

and have close, healthy relationships with their 

61 
Family Issues: Helpful Resources for Behavioral Health Service Providers 

Programs specifically designed to teach men parenting skills are almost universally absent in substance abuse treatment settings. Parental interventions for men with substance use disorders must 

systematically address the motivational, cognitive, behavioral, and interpersonal aspects of parenting 

from the perspective of men: 

• SAMHSA’s toolkit, Supportive Education for Children of Addicted Parents 

(http://store.samhsa.gov/), provides materials to help substance abuse programs initiate educational support programs for children of clients in substance abuse treatment. The programs teach 

youth skills, such as problem-solving, coping, social competence, autonomy, and sense of purpose. Although the material is oriented toward Native American communities, it can easily be 

adapted for use with non-Native groups. 

• The Center for Substance Abuse Prevention’s guide, Helping Children and Adolescents in Families Affected by Substance Use (http://www.nacoa.net/pdfs/guide%20for%20health.pdf), presents information and tools to help healthcare practitioners ask questions and intervene with 

patients and families experiencing substance-related difficulties. 

• SAMHSA’s National Center on Substance Abuse and Child Welfare has produced a toolkit 

(http://www.ncsacw.samhsa.gov/training/toolkit/) that provides child welfare workers with learning opportunities and baseline knowledge relating to substance use and mental disorders and interventions while motivating and facilitating cross-systems work. The toolkit also addresses 

cultural awareness and offers ways to facilitate cultural competence in child welfare practice. 

Addressing the Specific Behavioral Health Needs of Men 

children. Unfortunately, formal resources for

clinicians interested in helping men become 

more effective parents are somewhat limited.

There are generic parenting interventions,

such as Focus on Families (Catalano et al.

2002) developed for use with both men and

women with substance use disorders, as well as 

gender-specific approaches to parenting for

mothers with substance use disorders that may 

be adapted to address the specific needs of

men with substance dependence (e.g., see 

Luthar and Suchman 1999, 2000). 

Although educating fathers about parenting is 

important, the consensus panel recommends 

that behavioral health clinicians move beyond

education and develop a more comprehensive 

parenting intervention that acknowledges the 

complex nature of parent–child relationships 

and the special needs of fathers. Because the 

parenting problems of men with substance use 

disorders range broadly from decisions to voluntarily terminate parental rights to new responsibilities to care for children as single 

custodial fathers, flexible treatment approaches 

are necessary. In their work with fathers enrolled in methadone maintenance, McMahon

and Giannini (2002) found that parental interventions for men with substance use disorders must systematically address the 

motivational, cognitive, behavioral, and interpersonal aspects of parenting from the perspective of men, including: 

•	 Why men should work to become better

parents. 

•	 The benefits clients can receive by becoming better parents. 

•	 Family-of-origin issues that may interfere 

with effective fathering. 

•	 Legal barriers to greater involvement with

children. 

•	 Problem-solving with mothers who typically control access to children. 

•	 Building better communication skills with

children. 

•	 Developing parenting skills appropriate for

use with children of a specific age. 

•	 Relating to children who are grown. 

When working with fathers who have substance use disorders, behavioral health clinicians should be particularly aware of the 

62 
Chapter 3–Treatment Issues for Men 

 

 

 

possibility of treating men who have excessive 

guilt about being an ineffective parent, have

family secrets about substance use and

HIV/AIDS status, have children with a woman who abuses substances, and/or who are

overwhelmed with sole custody. 

Although both fathers and children stand to

benefit from improvement in father–child relationships, clinicians may encounter situations in which it is not practical, feasible, or

safe to promote a client’s greater involvement 

in his child’s life. Geographic distance, children’s refusal to see their fathers, obstructive 

mothers, and angry members of the extended

family may complicate men’s efforts to improve their relationships with their children.

Ongoing substance use, past or present domestic violence, allegations of child abuse, and

ongoing involvement in criminal activity may

raise ethical questions about promoting involvement that may prove harmful to children

or partners, particularly as ongoing research

begins to better define those circumstances 

( Jaffe et al. 2003). Similarly, when men have 

systematically abused or neglected children for 

a long period of time, clinicians may need to

help them negotiate difficult decisions about

petitions for extended placement of children,

voluntary termination of parental rights,

and/or adoption by others interested in functioning as parents. 

Reproductive Responsibility 

Most interventions focusing on male sexuality 

emphasize the prevention of sexually transmitted diseases—if discussed at all, issues of unwanted paternity seem to be of secondary 

concern. However, what little information exists about patterns of family formation among

men with substance use disorders suggests 

that, as a group, they may have more children

with more partners than do other men, have 

their first child earlier in the lifecycle, and father the majority of their children before the 

onset of their substance use disorders 

(McMahon 2003; McMahon et al. 2005).

Substance abuse treatment programs are an

ideal setting in which to raise and discuss issues about male sexuality, unwanted paternity,

and reproductive responsibility. 

Legal Issues Affecting Families 

Child support 

Fathers with substance abuse problems are 

twice as likely to fail to pay child support as

those without such problems (Garfinkel et al.

1998). The Child Support Enforcement Program links Federal, State, and local authorities

to ensure that orders for child support are followed. A father’s wages may be garnished to

pay for back child support, and drivers’ and 

professional licenses can be revoked, passports 

denied, and financial institution deposits

seized (ACF 2002). All of this may add to the

stress of a father who is in substance abuse 

treatment and unable to meet child support

payments. 

Family court involvement 

Men seeking substance abuse treatment may 

need support and assistance in navigating the 

child welfare and family court systems. As stereotypes involving substance abuse collide 

with traditional ideas about family life, men

involved in family court proceedings may experience bias that labels them as entirely negative influences to be excluded from the family 

(McMahon and Giannini 2003). Stereotypes of 

men who abuse substances may reinforce traditional ideas about gender and family such that

these men, more so than others, are quickly but

inappropriately dismissed as indifferent, uninvolved, irresponsible, and irrelevant (McMahon

and Giannini 2003; Parke and Brott 1999). 

When fathers with substance use disorders are 

involved in family court proceedings, the 

courts use clinical evaluations to inform their 

63 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

decisions. As McMahon and Giannini (2003) 

note, comprehensive, integrated evaluations of

fathers who abuse substances should: 

•	 Characterize the nature of the substance 

use. 

•	 Document the presence of other behavioral health problems. 

•	 Highlight capacity for effective parenting. 

•	 Document compromise of parenting. 

•	 Characterize treatment needs. 

•	 Offer comment about the adequacy of

whatever treatment might be occurring. 

Professionals working with fathers who have

substance use disorders should support, as 

much as possible, the self-defined goals of

their clients and should, with proper authorization, give family courts information about

ongoing treatment to use in making decisions. 

Clinicians providing ongoing substance abuse 

treatment to fathers may have to educate court 

personnel about their ethical obligation to advance the interests of their clients and their 

need to remain, as much as possible, a neutral 

party in family court proceedings. Treating

clinicians should not offer opinions about visitation, custody, termination of parental rights,

or similar matters if they are to continue their

clinical intervention with a given client, regardless of legal outcome. 

Support From Partners, Family, 

and Friends 

The personal relationships of men who abuse 

substances can either help bring about change 

in their lives or contribute to the problem. Associating with friends with whom one used

substances is a common trigger for relapse.

Vaillant and Hiller-Sturmhofel found that 

warm and cohesive environments and close 

relationships were more common among men

who did not develop alcohol use disorders 

than among those who did (1996). Various

studies also indicate that men who have wives 

and/or children tend to use substances less 

frequently and in smaller amounts than those 

without such ties (Blazer and Wu 2009b;

HHS, SAMHSA, Office of Applied Studies 

2008a, 2009b; Kuntsche et al. 2009). Having

friends who drink heavily and/or use drugs is 

strongly associated with such behavior for men

(Weisner et al. 2003), and not having such

friends is associated with better recovery outcomes (Christakis and Fowler 2008; Flynn et

al. 2003; Laudet et al. 2006). Clinicians who

understand the power of family and other personal relationships in men’s lives can actively 

address these issues through couples and/or

family treatment or through building other

social supports (such as mutual-help group

support, discussed in Chapter 5) to help men

struggling with substance use minimize their

likelihood of resuming substance-related behavior. 

Having a partner or family member who supports treatment for substance abuse is likely to

improve its outcome. When men are not in

relationships (or have no children), they are 

less likely to complete treatment (Rabinowitz

and Marjefsky 1998). Counselors can help clients improve marital and family relationships 

through psychoeducational programs, relationally oriented group counseling, and couples 

counseling that emphasizes supporting treatment and recovery efforts, managing interpersonal struggles and crises, and building

relational strengths, such as marital communication and parenting skills. 

Although partner and family support is certainly important, behavioral health clinicians

should not overlook the influence a man’s 

friends have on treatment outcomes. Including 

men’s friends in some aspect of the treatment

process can be of great value if they are supportive and not abusing substances themselves.

Unfortunately, deteriorating or absent friendships can be a barrier to successful substance 

64 
Chapter 3–Treatment Issues for Men 

 

Defining the Difference Between Religion and Spirituality 

It is useful to distinguish between spirituality and religion, as some men seeking treatment view themselves as spiritual but not necessarily religious. Religion is organized, with each religion having its own 

“theology, doctrine, creeds, catechisms, and liturgical practices, all of which are intended to enhance 

each member’s spirituality” (Chappel 2003, p. 970). Spirituality, on the other hand, is a personal matter involving the individual’s search for meaning, and it does not require an affiliation with any religion. People can have spiritual experiences or develop their own spirituality regardless of the 

presence or absence of any religious connection (Chappel 2003). In recovery from substance abuse, 

focusing on spirituality rather than religion can help some people accept the need for a higher power 

or a power greater than themselves (which could be other people, nature, a spiritual being, or a deity) 

when they might otherwise be resistant toward organized religion (Hazelden Foundation 2003). 

abuse treatment. Although men 55 to 65 years 

of age who abuse alcohol were found to experience more support from their spouses, they 

received less support from their “children, extended family members, and friends” (Brennan 

et al. 1993, p. 781). These men also reported

more chronic stress in their lives, in part because of the state of their relationships with 

friends (Brennan et al. 1993). 

Spirituality and Religion 

Most clients in substance abuse treatment 

usually have some religious and/or spiritual 

beliefs, based on research in medical settings 

(Koenig 2001b) and among the general population (Public Broadcasting Service 2002;

Robinson 2003). Spiritual and religious activity should generally be encouraged; research

has repeatedly confirmed that people who participate in spiritual/religious activities are less

likely to abuse substances (Koenig 2001b). 

Also, religious practices and beliefs (at least

those from established religions) seem to affect physical health by improving coping, reducing emotional distress, improving attitude 

and mood, increasing social support, and reducing problem behaviors (Koenig 2001a). 

Due to the influence of 12-Step groups like 

Alcoholics Anonymous, spiritual beliefs play 

an important role in many substance abuse 

treatment programs. Many clients find that

spiritual and/or religious beliefs (the difference 

is defined in the text box below) play an important role in their recovery, so counselors 

should be prepared to discuss these beliefs 

with clients if they so choose. 

Counselors in behavioral health settings can 

use a male client’s religious or spiritual beliefs 

to motivate change and, sometimes, to counter

the negative effects of certain cultural beliefs 

about masculinity and alcohol use. For example, a client who believes that not drinking

will jeopardize his masculinity and status

among his peers may be better able to reconcile his decision to maintain abstinence as a 

culturally appropriate one if it is supported by 

a priest or clergyman. Faith can also help recovering clients as they reenter their communities; support from a church, synagogue,

mosque, or other faith-based institution can

improve their chances of recovery and reduce 

the odds of relapse (CSAT 1999b). 

Although substances (such as wine or peyote)

may be used in some religious rituals, all major 

religions have made adaptations for individuals with substance use disorders, enabling

them to participate in the religion without 

partaking of those substances. 

Behavioral health services providers should

become familiar with their clients’ spiritual

beliefs, practices, and experiences just as they 

learn about their occupations, families, habits,

and mental health. (See Chapter 2 for information on assessing clients’ spiritual/religious 

65 
Addressing the Specific Behavioral Health Needs of Men 

beliefs.) In a therapeutic relationship of mutual respect and tolerance, differences between

counselor and client in spiritual beliefs need

not become problematic. A clinician can serve

as an orchestrator of resources when it comes 

to a client’s religious or spiritual beliefs 

(Koenig 2001b). Just as the clinician or other

appropriate staff person can help clients get

the physical services they need (e.g., housing, 

medical care), they can also help clients meet

their spiritual needs by arranging visits with

spiritual advisors or clergy, as well as by 

providing access to religious services during

treatment upon client request. Clinicians must

be able to refer clients to spiritual advisors 

from many different faiths (reflecting the population with which the clinician works). 

66 
 

 

 

 

Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

IN THIS CHAPTER 

• Introduction 

• Men With Co -Occurring 

Disorders 

• Men With Physical Health 

Problems 

• Men From Different Age 

Groups 

• Gay and Bisexual Men 

• Men With Employment or 

Career -Related Issues 

• Men With Systems -

Related Needs 

• Men From Diverse 

Cultural and Geographic 

Groups 

• Conclusion 

Working With Specific 4 Populations of Men in 

Behavioral Health 

Settings 

Introduction 

The patterns of substance abuse and the treatment needs of adult

men (ages 18 and older) are diverse, as are their conceptions of

masculinity. Men in need of treatment come from all walks of life;

this chapter outlines some of the patterns of substance use and

abuse for specific populations of men, noting areas in which men

differ from women. Clinical examples and tips are offered to guide 

behavioral health clinicians in treating men from these diverse 

populations. 

Men With Co-Occurring Disorders 

Many men in treatment for a substance use disorder have a cooccurring mental disorder. In the general population, men are less 

likely to have serious mental illness than women (Epstein et al.

2004), but a larger percentage (56 percent) of adults in substance

abuse treatment with co-occurring mental disorders are men, just as 

more adults in substance abuse treatment overall are men (Office of

Applied Studies [OAS] 2004a). Among adults with serious mental 

illness, men are more likely than women to have used illicit substances in the past year (Epstein et al. 2004; Substance Abuse and

Mental Health Services Administration [SAMHSA], OAS 2007a). 

Men with co-occurring disorders are more likely than women with

co-occurring disorders to use more than one illicit substance and 

are more likely to report daily use of illicit substances (SAMHSA,

OAS 2007a). Data from 2003 show that, as a group, men with 

67 
 

 

 

 

 

 

Advice to Behavioral Health Clinicians: Screening and Assessment for CoOccurring Disorders in Men 

• Some men, even if already in substance abuse treatment, are reluctant to seek help with cooccurring mental disorders. Programs treating male clients must proactively screen and assess 

such disorders. 

• Thorough medical and mental health assessment at admission can minimize the risk of these disorders going untreated. 

• Ongoing screening and assessment for mental illness is necessary; clients with one type of disorder are at increased risk of developing subsequent disorders of different types. 

• Men tend to emphasize the behavioral, rather than the emotional, symptoms of mental disorders. 

• Symptoms that are common during early recovery from substance abuse (e.g., agitation, sadness, 

feeling overwhelmed) can mask symptoms of mental illness. Counselors should not assume that 

these symptoms will fade with abstinence. 

Addressing the Specific Behavioral Health Needs of Men 

co-occurring disorders are more likely to have 

dropped out of high school than their female

counterparts (17 percent of women versus 28

percent of men), less likely to have health insurance (77 percent of women versus 67 percent of men), and less likely to have received

treatment for substance abuse or a mental disorder in the past year (55.4 percent of women

versus 41 percent of men) (OAS 2004b). 

As noted in Chapter 1, men are more reluctant to seek professional assistance for healthrelated problems, including substance abuse 

and mental illness, than women (Addis and

Mahalik 2003; Grella et al. 2009a). Therefore, 

although people with co-occurring disorders

are more likely to seek mental health services 

than those with just a substance use or mental 

disorder (Wu et al. 1999), a large number of

men with co-occurring disorders still seek no

treatment for either disorder. Masculine gender norms can cause men to feel greater shame 

than women in seeking help for mental illness 

(Addis and Mahalik 2003). The “Counseling

Men Who Feel Excessive Shame” section in 

Chapter 3 of this Treatment Improvement

Protocol (TIP) addresses shame related to the 

failure to meet masculine gender expectations 

and offers advice on addressing shame. 

Even men already in substance abuse treatment may be reluctant to seek assistance with 

co-occurring mental disorders, so programs 

that work with male clients need to be especially proactive in screening and assessing such

disorders (see Chapter 3) and assisting these 

clients in getting the help they need. Conducting a thorough medical and mental health 

assessment at admission can minimize the risk 

of these disorders going untreated, even if the 

program itself cannot provide that treatment.

Screening and assessment for mental illness

must also be ongoing; clients with one type of

disorder are at increased risk of later developing disorders of another type. Moreover, the 

symptoms of a substance use disorder can

mask co-occurring mental disorder symptoms 

at any point in treatment.Treatment Improvement Protocol (TIP) 42, Substance Abuse 

Treatment for Persons With Co-Occurring Disorders (Center for Substance Abuse Treatment

[CSAT] 2005c), details the screening, assessment, and treatment of co-occurring disorders

in male and female clients and offers information on various co-occurring mental disorders (some of which are discussed later in this 

TIP). Chapter 5 of TIP 42 presents strategies 

for treating people with co-occurring disorders. 

When screening for co-occurring disorders

(see advice box below), clinicians may find that

many men are uncomfortable discussing the

emotional aspects of mental illness and will 

focus more on tangible symptoms, such as 

68 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

difficulties in sleeping, changes in appetite,

physical complaints, decreased interest in sex).

For this reason, male clients with co-occurring

disorders may be less interested in psychotherapy than female clients. Male clients may also

present with more behavioral problems than

women (e.g., fighting, lack of compliance with

medication regimen). 

Anxiety Disorders 

In general, men are less likely to have anxiety 

disorders than women (American Psychiatric

Association [APA] 2000; Grant et al. 2009;

Kessler 1998). The only exceptions are social 

phobia and obsessive–compulsive disorder

(OCD), as some research has found that rates 

for those do not vary significantly between

genders (Bekker and van Mens-Verhulst 2007;

Grant et al. 2009). 

However, rates of anxiety disorders among

men with substance use disorders vary from

those found in the general population. For example, OCD appears to be much more common among persons with substance use 

disorders (see discussion later in this chapter).

Rates also vary according to treatment setting

and primary substance of abuse. Even within a 

specific type of setting, rates vary greatly according to the assessment instruments used

and other factors. For example, a study of men

who were incarcerated and receiving substance 

abuse treatment found that 17.8 percent had

met criteria for an anxiety disorder at some 

point during their lives (Zlotnick et al. 2008),

whereas another study of men entering the 

prison system found that 74.6 percent met criteria for a current substance use disorder and 

36.4 percent met criteria for a current anxiety

disorder (Gunter et al. 2008). Other research

comparing rates of anxiety disorders among

individuals with different substance use disorders has found significantly higher rates in

those with cocaine use disorders (Conway et

al. 2006; McRae et al. 2007). 

One significant issue for men with cooccurring anxiety and substance use disorders 

is the use of alcohol and/or drugs to cope with

anxiety symptoms (sometimes called selfmedication). Robinson and colleagues (2009) 

evaluated data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which surveyed over 43,000

adult men and women and inquired about alcohol and/or drug use to reduce symptoms 

associated with specific anxiety disorders.

They found that the frequency of this behavior varied depending on the type of anxiety 

disorder a person had; 35.6 percent of men

and women with generalized anxiety disorder

(GAD) reported self-medicating, but only 7.9

percent of those with social phobia did so. 

Men with anxiety disorders were significantly 

more likely to report such behavior than were 

women with anxiety disorders. 

For men with co-occurring anxiety and substance use disorders, substance abuse may be a

means of coping, but as the substance use disorder progresses, it actually worsens anxiety 

disorder symptoms. Substance abuse treatment

is complicated by subsequent patient resistance toward giving up a drug that he feels 

is necessary for his emotional survival, by anxiety arising from emotionally intense treatment, and, in some cases, by deficits in social

skills important in substance abuse recovery.

Because of masculine social norms, men may 

feel greater pressure to deny anxiety or to use 

avoidance coping methods (such as selfmedication) to address it.This behavior can be

a persistent problem that endangers recovery 

for men with anxiety disorders, and it serves as 

an added impetus for counselors to address 

anxiety in treatment. 

The following sections examine anxietyrelated mental health issues commonly seen

among men in substance abuse treatment, including posttraumatic stress disorder (PTSD), 

69 
 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

social phobia, OCD, GAD, and combat stress 

reaction (CSR). 

Posttraumatic stress disorder 

In the general population, men are exposed to

trauma more often than women, although 

women experience higher rates of PTSD

(Breslau 2002; Kessler et al. 1995). Between 5

and 6 percent of men have had PTSD sometime in their lives (Breslau et al. 1998; Kessler

et al. 1995). However, in certain male populations exposed to greater amounts of trauma,

rates of PTSD are likely to be higher. Studies 

have found rates of trauma exposure between

42 and 95 percent in men seeking treatment

for substance use disorders (Farley et al. 2004)

and equally high rates in populations of men

with serious mental illness (Goodman et al. 

2001) and men who are homeless with cooccurring disorders (Christensen et al. 2004).

Men involved in the criminal justice system 

(Swartz and Lurigio 1999) and men who are 

combat veterans (Kulka et al. 1990) are 2 to 3

times more likely to experience PTSD than

men in the general population. 

Prior trauma exposure may also contribute to

the development of PTSD following a subsequent trauma. Smith and colleagues (2008)

report that individuals who had been the victim of an assault prior to being deployed in

Operation Iraqi Freedom (OIF) were twice as 

likely to develop new-onset PTSD during or

after deployment than were service members 

with no history of assault. Kessler and colleagues (1995) found that men with PTSD

are more likely to have a co-occurring substance use disorder (51.9 percent) than men 

without PTSD (34.5 percent) and are also

more likely to have a co-occurring substance 

use disorder than women with PTSD (27.9 

versus 26.9 percent, respectively). These data

suggest that men in substance abuse treatment

are at particularly high risk for having both

PTSD and a substance use disorder. 

Men and women are typically exposed to different types of trauma and appear to be affected differently by traumatic events. The most

common traumas for men are exposure to

combat; being physically assaulted, shot, or

stabbed; and witnessing killings or serious injuries. Women, however, are most often exposed to sexual assault and rape (Breslau 2002;

Kessler et al. 1995). Men are also more likely 

than women to be victims of violent crime 

(Catalano 2004). In a sample of men with

substance use disorders (both in and out of

treatment), 45 percent had witnessed a killing

or injury, 33 percent had been physically assaulted, 16 percent had been threatened, and

16 percent had experienced a sudden injury or

accident; women were 14 times more likely to

have been raped than men but 3 times less 

likely to have been physically assaulted

(Cottler et al. 2001). 

Among men, rape and combat are the two

types of trauma most likely to lead to PTSD.

In a general population sample of men, rape (a

relatively rare event for adult men) resulted in

PTSD approximately 65 percent of the time; 

combat exposure resulted in PTSD 38.8 percent of the time (Kessler et al. 1995). 

Men are expected to be tough, so their trauma

histories may not be explored in treatment as 

often as those of women, nor are they as likely 

to self-identify as trauma survivors. The problem is complicated by men’s greater tendency to

externalize their experiences of trauma; thus,

men are more likely than women to react to

their own traumatization by victimizing others.

Men are also more likely to report symptoms of

increased alcohol use and irritability as a result

of traumatic experiences (Green 2003). 

Case example: Tim 

Tim is a 30-year-old veteran of OIF. While 

on active duty, he was exposed to several lifethreatening events, including being in a convoy vehicle that hit an improvised explosive 

70 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

 

device (IED) on the roadside. The passenger

in the vehicle’s front seat was killed, and Tim

was thrown from the back, resulting in abrasions and bruises across his body, a broken arm 

and kneecap, and wounds from shrapnel. At

the time of this traumatic event, Tim was

screened for trauma symptoms but was approved to return to combat; as soon as his 

wounds healed, he returned to his unit for another 7 months of active duty. 

Following his discharge from the Army, Tim 

entered college and majored in criminal justice. Although he had exhibited some trauma

symptoms prior to starting college (sleep disturbances, nightmares, anxiety when he saw 

objects on the side of the road), the symptoms 

were not disabling until he began an internship at a local prison. Within the first month 

of the internship, Tim began experiencing disabling PTSD symptoms that were exacerbated

by the noises, sights, and smells in the prison.

The yelling among inmates and the clanging

of metal doors were particularly stressful. He 

began smoking marijuana after work and on

weekends to quell his symptoms, and he tested

positive for marijuana on a routine drug screen.

He was referred to the prison’s employee assistance program, which referred him to a substance abuse treatment program for evaluation. 

The substance abuse program staff identified

Tim’s co-occurring PTSD and substance

abuse and enrolled him in a 2-month assessment group for his substance use. To address 

his PTSD symptoms, the program also arranged regularly scheduled appointments at

the local U.S. Department of Veterans Affairs 

(VA) clinic with a behavioral health counselor

who had been trained in PTSD treatment. 

The planned TIP, Trauma-Informed Care in 

Behavioral Health Services (SAMHSA planned 

g), provides more information on trauma and

PTSD among men and women with substance use disorders and on treating trauma

concurrently with substance use disorders. It

offers more detail regarding all trauma-related

subjects touched on in the following sections 

of this chapter. 

Treating men for PTSD 

Many interventions to address both PTSD

and substance use disorders, even if developed

for both male and female clients, have been

evaluated primarily with women or with men

who have experienced combat-related trauma.

Behavioral health clinicians may need to consider how to adapt these interventions for other populations. In some cases, models created

specifically for women have been adapted for

men; one such example is the Men’s Trauma 

Recovery and Empowerment Model (MTREM). This model appears promising in its 

ability to engage male clients and improve 

their coping skills, and it is a useful example of

how trauma treatment can be adapted for a 

male population (personal communication

with R. D. Fallot, June 10, 2005). However,

research on M-TREM’s effectiveness is ongoing; no recent study reports are available to provide empirical evidence of its potential success. 

The developers who adapted TREM for male 

clients formulated eight basic assumptions 

about how trauma treatment for men should 

differ from that provided to women. These 

assumptions are shown, along with the developers’ responses to them, in Exhibit 4-1. 

71 
 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Exhibit 4-1: Assumptions and Adaptations Used in M-TREM 

Assumption Response 

Men and women understand and respond differently to traumatic experiences. The TREM model emphasizes empowerment for 

women; M-TREM focuses on emotions and relationships (areas in which men have difficulties). 

Male trauma survivors must either disconnect 

from male gender role expectations to feel the 

fear, vulnerability, and powerlessness associated 

with trauma, or else disconnect from those feelings to retain their sense of masculine identity. 

M-TREM focuses on exploring the relationship 

between trauma experiences and masculine 

gender role expectations. 

Many male survivors develop all-or-nothing responses, especially emotional responses (e.g., 

rage or timidity), or ways of being in relationships 

(e.g., dependence or emotional distance). 

M-TREM teaches men a wide range of options 

for expressing emotions and being in relationships. 

In spite of the appearance of independence 

that results from trying to fill masculine roles, 

men with trauma histories feel cut off from their 

families, communities, and selves. 

M-TREM uses reconnecting skills of emotional, 

cognitive, and behavioral self-recognition and 

teaches relational mutuality to improve men’s 

understanding of how to be in relationships. 

Men who were traumatized early in life lost the 

opportunity to develop important skills necessary for adulthood. 

M-TREM uses a psychoeducational and skillsoriented approach to treatment for trauma. 

Men with trauma histories have skills and 

strengths that can help them in recovery. 

M-TREM uses a strengths-based approach. 

As with women, men’s dysfunctional responses 

to trauma (or its symptoms) may have begun as 

useful coping strategies. 

M-TREM helps clients reframe problematic 

behaviors as attempts to cope with trauma. 

Any attempt to cope with trauma is likely to 

have advantages and disadvantages. 

M-TREM helps clients look at the costs and 

benefits of their coping strategies in an objective fashion and reframe problems so they can 

choose the best coping strategies. 

Source: Fallot et al. 2001. Adapted with permission. 

Other researchers and behavioral health clinicians have suggested ways in which treatment

for men with PTSD may need to differ from 

that provided for women with the disorder.

For example, Lisak (2001b) notes that the ideology of masculinity limits the resources available to men to respond to trauma. Therefore,

any treatment for men with trauma must address how men internalize masculine ideology 

concurrently with their trauma histories. Otherwise, the legacies of masculine socialization

can impede the process of healing from trauma by keeping men from connecting with the 

painful feelings that result from it. 

Ruzek (2003) describes several interventions 

for treating veterans with co-occurring PTSD

and substance use disorders; most of this population is male, and the research Ruzek draws 

upon is primarily with male clients. Specifically, he notes that members of this population

often have anger control problems that need

to be addressed in the context of their trauma 

treatment. 

72 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

The Seeking Safety model for treating cooccurring trauma and substance use disorders 

effectively reduced PTSD symptoms and substance use in a small (n=5) study of men with

co-occurring substance use disorders and

PTSD (Najavits et al. 2005). 

Emotionally directed, cognitively oriented

counseling can help men connect with their

feelings and the feelings and experiences of

others (Hardy 2004). Treatment for trauma

and trauma-related disorders typically involves 

the active processing of painful feelings that

expose the individual as vulnerable—an exploration that runs counter to the masculine 

norms of our culture, thus making this process 

potentially more difficult with male clients 

than with female clients. Because of this added impediment, behavioral health clinicians

treating men with trauma histories must explore with them the social processes of masculinization and the ways in which masculine 

norms hinder recovery from trauma (Lisak 

2001b). Treatment for men with histories of

trauma, whether or not they have PTSD, is

discussed later in this chapter. Specific information on treating men exposed to combat

trauma is presented in the following section. 

Combat stress reaction 

CSR is an acute anxiety reaction similar to an

acute stress disorder but only occurring among

combatants (and noncombatants exposed to 

combat events) in an armed combat situation.

Although the the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition,

Text Revision (DSM-IV-TR; APA 2000) 

does not list CSR as a diagnosis, CSR (also

called combat trauma) affects a significant

number of male veterans. Substance use and 

mental disorders are strongly associated with

trauma from combat exposure (Hoge et al.

2006; Ruzek 2003). 

Common causes of CSR often relate to direct 

attacks, as with insurgent small arms fire or 

IEDs, and can also result from being near

combat, handling the bodies of wounded or

dead individuals, being repeatedly exposed to

events with a high risk of death or injury, or

making frequent on-the-spot decisions under

ambiguous conditions—especially when the 

result is death or injury to others. 

CSR can be transient and nondebilitating, or

it can result in major psychological disorganization. Normally, with support and treatment,

symptoms diminish in a relatively brief period

of time (1 to 2 months). If symptoms persist

beyond that time, the person may be diagnosed with PTSD. Typical CSR symptoms 

include hypervigilance, sleeplessness, irritability, anger, and difficulty concentrating. More

severe symptoms may include freezing up,

feelings of impending doom, significant but

unreasonable guilt, unpredictable responses in

ordinary situations, and impaired memory. 

Significant strides have been made in recent

years in addressing CSR in combat zones.

Military personnel are briefed prior to entering a war theater about stressors and coping

strategies. Personnel with combat stress symptoms are more rapidly and efficiently identified, and onsite treatment in the combat zone 

has been remarkably improved. Most treatment for service members is provided in their

assigned camp by members of combat stress 

control teams composed of behavioral health

professionals who use brief and targeted individual, group, and psychoeducational methods.

If service members do not respond to these 

services, they are evacuated from the combat

zone whenever possible to access more specialized resources. A more detailed description of

this process is described in the planned TIP,

Trauma-Informed Care in Behavioral Health 

Services (SAMHSA planned g). Reintegration

efforts for veterans returning to the United

States have been significantly enhanced as 

well. Programs for families, ongoing medical 

73 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

care, and civilian life have been developed and

implemented throughout all service branches. 

Behavioral health clinicians should know that 

veterans are eligible for a variety of services offered by regional VA centers, including readjustment counseling, referral for benefits 

assistance, marital and family counseling, substance abuse information and treatment referral, job counseling and vocational assistance 

referral, and sexual trauma counseling and

treatment referral. The Iraq War Clinician Guide

(National Center for PTSD and Walter Reed

Army Medical Center 2004) is a treatment reference for mental health issues among veterans 

of OIF.This document is available for free on 

VA’s National Center for PTSD Web site 

(http://www.ptsd.va.gov/professional/manuals/

manual-pdf/iwcg/iraq_clinician_guide_v2.pdf). 

Military OneSource also offers veterans and

their families useful resources relating to mental health and substance abuse issues 

(http://www.militaryonesource.mil; 1–800–

342–9647). 

Social phobia 

Social phobia, also called social anxiety disorder, is one of the most common anxiety disorders. It affects women more than men, with a

lifetime occurrence of 15.5 percent for women

and 11.1 percent for men (APA 2000; Kessler

1998). It entails a “marked and persistent fear

of social or performance situations in which

embarrassment may occur” (APA 2000, p.

450). Men with social phobia seek treatment

more often than women, which is opposite the 

norm for most mental disorders (Weinstock 

1999). Men may be more likely to seek treatment for this disorder because it has a greater

impact on them due to the gender role expectation that they be more proactive in social

relations. 

Men are particularly susceptible to using alcohol to combat the symptoms of social phobia.

Some men describe how they drink to be able 

to leave the house, interact with others, or

work in front of others (e.g., when making

presentations). Men with social phobia may

use alcohol at work when confronted with 

stressors that involve interpersonal interaction.

They may drink heavily at unavoidable social 

events and then experience the negative effects 

of heavy use. Social phobia also makes it difficult for men to enter substance abuse treatment, where they fear being overwhelmed

with anxiety. They may be especially fearful of

group sessions or 12-Step participation and

will feign illness or other crises to avoid attending. It can be easy for counselors to equate 

this behavior with clients being resistant or

less motivated. 

Many clients with social phobia have anticipatory anxiety: imagining a worst case scenario

about an upcoming event at which they might 

be the center of attention, interrogated by others, or exposed as a fraud; they then react emotionally as if that event has occurred.

Anticipatory anxiety emotionally validates that

the upcoming event is, indeed, dangerous and

needs to be avoided. Some people cope with

anticipatory anxiety by using drugs or alcohol 

to quell their symptoms. 

Screen clients with social phobia symptoms 

(see DSM-IV-TR for symptoms; APA 2000) 

for the disorder and refer, if necessary, to

qualified behavioral health professionals who

specialize in the treatment of anxiety disorders 

for assessment and discussion of treatment 

options, including counseling (especially cognitive–behavioral therapy) and medication.

Along with confronting limiting beliefs and

perceptions, counseling should build skills in

social interaction, anxiety self-monitoring, and

positive coping options for use during anxietyproducing social situations. 

Obsessive–compulsive disorder 

Although not highly prevalent in the general 

population, OCD almost always co-occurs 

74 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

with other mental disorders and often with 

substance use disorders (Mancebo et al. 2009;

Pinto et al. 2006). A study of people in treatment for OCD found that 27 percent of the 

sample met criteria for a lifetime diagnosis of

a substance use disorder; men were more likely 

than women to have a co-occurring substance 

use disorder. 

For a man with OCD and a co-occurring substance use disorder, the substance use disorder

may have originated in an attempt to cope

with overwhelming and disabling anxiety.

However, as substance use progresses, it actually worsens anxiety symptoms. Substance 

abuse treatment can be complicated by men’s 

resistance to giving up a drug that they believe 

necessary to their emotional survival, by anxiety that arises from the emotional intensity of

treatment, and sometimes, by deficits in social 

skills important for recovery from substance 

abuse. As with other anxiety disorders, a licensed behavioral health service provider with 

specific training in the treatment of anxiety

disorders should diagnose and treat OCD, 

which should be treated concurrently with the 

substance use disorder. In addition to counseling, treatment may include medication. 

Generalized anxiety disorder 

GAD is sometimes associated with substance 

use disorders. In cases of GAD, the origins of

the substance use disorder may lie in attempts 

to cope with overwhelming and disabling anxiety. However, as substance use progresses, it

actually worsens anxiety symptoms. Substance 

abuse treatment can be complicated by men’s 

resistance to giving up a drug that they believe 

necessary to their emotional survival, by anxiety that arises from the emotional intensity of

treatment, and sometimes, by deficits in social 

skills important for recovery from substance 

abuse. As with other anxiety disorders, a licensed behavioral health service provider who

specializes in the treatment of anxiety disorders should conduct diagnosis and treatment;

the anxiety disorder needs to be treated concurrently with the substance use disorder. 

Mood Disorders 

In general, women are more likely to experience mood (i.e., affective) disorders than men

(APA 2000; Kessler et al. 1994), although the

reasons for this difference are unclear. The 

same factors that protect men against certain

disorders may contribute to increased rates of

other disorders or problems, such as an increased rate of death by suicide among men

(see the “Suicidality” section starting on p. 81). 

Furthermore, affective disorders may be more 

common in men than is generally believed,

due to underdiagnosis or misdiagnosis (Levin

and Sanacora 2007). Mood disorders can present with a wide range of symptomatology.

Some of the more common mood disorders 

seen in substance abuse clients include dysthymia, a chronic depressed mood that extends 

over years; major depressive disorder, which 

manifests as recurring, significantly disabling

depressive episodes; bipolar disorder, which can

manifest as recurrent, interspersed manic and

depressive episodes; and cyclothymia, which 

comprises cyclical manic and depressive episodes that do not meet criteria for bipolar disorder or substance-induced mood disorder. For 

more information on assessment and treatment of these disorders, see TIP 48, Managing 

Depressive Symptoms in Substance Abuse Clients 

During Early Recovery (CSAT 2008b). 

Dysthymia and major depressive 

disorder 

According to a number of studies, women are 

from 1.5 to 3 times as likely as men to have a

depressive disorder, and this finding holds true 

in many settings around the world (Chuick et

al. 2009; Kessler 2000a; Levin and Sanacora

2007). However, approximately 12.7 percent of 

all men will experience an episode of major 

75 
 

 

The Nature of Depressive Symptoms 

The term “depressive symptoms” is generally applied to a state of sadness, depressed mood, the 

blues, or related feelings and behaviors that do not meet diagnostic criteria for a DSM-IV-TR (APA 

2000) mood disorder. People with such symptoms may experience considerable emotional pain and 

significantly impaired functioning in some areas. 

Symptoms of depression exist on a continuum ranging from sadness and other depressive symptoms 

occurring at appropriate times and for short periods, during which the individual successfully uses 

coping strategies, to clinical (or major) depression as described in the DSM-IV-TR (APA 2000). The 

line between depressive symptoms and full-blown depressive disorders is a question of degree. Having depressive symptoms differs from having a major depressive disorder in terms of the number or 

severity, but not the type, of symptoms experienced by a client. Only behavioral health professionals 

credentialed to diagnose mental illness can determine whether a client has a serious disorder, such 

as major depression, dysthymia, bipolar disorder, or substance-induced mood disorder. Counselors 

who suspect that a client has a depressive illness should refer him to a behavioral health professional 

for assessment, diagnosis, and treatment. 

Depressive symptoms may become more or less intense over time due to the client’s physiology, 

stressful events in the client’s life, or the client’s stopping or starting substance use. For example, 

someone who drinks heavily may have intense depressive symptoms that seemingly meet criteria for 

depressive illness but lessen dramatically in the weeks after initial abstinence from alcohol. Similarly, 

someone with major depression or dysthymia who has taken antidepressant medication for several 

weeks may show few or no currently debilitating depressive symptoms. Conversely, a client may 

demonstrate only mild depressive symptoms at intake but may be headed toward a significant depressive episode. 

As with substance abuse, although a person may be in remission from his depressive symptoms, the 

depressive disorder may remain. Treatment must address prevention of and early intervention in recurrences, especially during early recovery from substance use disorders. Many depressive disorders 

cycle and recur. If a client has a history of a mood disorder, he and his counselor should be on the 

lookout for a recurrence of symptoms. 

Source: CSAT 2008b, page 5. Adapted from material in the public domain. 

Addressing the Specific Behavioral Health Needs of Men 

depression at least once during their lives 

(Kessler et al. 1994). 

Different explanations have been proposed for

the large difference in rates of depression between genders. Depression seems to manifest

differently in men than in women.This may 

contribute to the higher incidence of substance 

use disorders and antisocial personality disorder

(ASPD) in men than women (National

Institute of Mental Health [NIMH] 2003; 

Pollack 1998c; Real 1997). Others have suggested that the apparent difference may exist

because men are less likely to seek help for

depression, present with different symptoms of

depression than women, and may be diagnosed by behavioral health clinicians and diagnostic instruments that are influenced by 

gender bias. Men tend to be underdiagnosed

with depression, whereas women are overdiagnosed (Levin and Sanacora 2007). However,

conclusive evidence supporting a single explanation is still lacking (Winkler et al. 2004). 

The fact that men are less often diagnosed

with depression than women may also result

from cultural factors that define permissible 

masculine behavior—so that the same gender

roles that shield men from their emotions in 

other areas may keep them from showing

symptoms of depression, alter their symptoms,

or make them less likely to report symptoms. 

76 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

Studies also show that rates of depression are 

nearly the same among some subgroups of

men and women, such as the elderly 

(Bebbington et al. 2003) or certain cultural/ethnic groups (e.g., the Amish, Hassidic

Jews), in which men are less likely than men in

the general population to have substance use 

disorders, ASPD, or other problems that may 

be manifestations of underlying issues that

also cause depression (Cochran 2001). 

A study of patients at a German hospital 

found gender differences in the presentation

of symptoms, but not the severity, of depression—with men who were depressed more 

likely to show emotional rigidity, blunted affect, and decreased libido (Winkler et al.

2004). Men who are depressed may be more 

likely to focus on somatic or physical complaints than women, and depression in men

may manifest in interpersonal difficulties and

conflicts. Notably, men with depression are 

more likely to have a substance use disorder

than women who are depressed (Cochran

2001; Pollack 1998c). 

Depressed mood, whether attributable to a

specific disorder or not, can significantly affect

substance abuse treatment and recovery. For

example, among a group of men who had relapsed during the 12 months following treatment, the most reported reason for relapse—

reported by 26.9 percent of participants—was 

depressed mood (Strowig 2000). Such feelings 

as boredom and anger can cause relapse to

substance use and may also result from underlying depression. TIP 48 (CSAT 2008b) discusses how to address subclinical depressive 

symptoms (for men and women) in substance 

abuse treatment settings. 

Treatment for depressive disorders can be concurrent with substance abuse treatment. It 

usually includes a combination of counseling

and antidepressant medication, which only

behavioral health clinicians specifically trained 

in the treatment of mood disorders should 

provide. 

Bipolar disorder 

Men and women appear to be affected differently by bipolar disorder.The disorder has an

earlier age of onset in men than in women;

men with the disorder also seem to have more 

frequent manic episodes and require a greater

number of weeks of hospitalization for these 

episodes than women with the disorder,

whereas women have more depressive episodes 

than men (Arnold 2003). Men with bipolar

disorder appear more likely than women with

the disorder to have a co-occurring substance 

use disorder, according to a number of studies 

reviewed by Arnold (2003); see also Albanese

and colleagues (2006). 

Many clients in substance abuse recovery who

have been diagnosed with bipolar disorder describe trying to regulate their manic and depressive cycles with substances. For instance, 

in a manic episode, clients may use alcohol or

sedatives to sleep and/or stimulant drugs to

increase the high of the episode (i.e., emotional expansiveness and sense of well-being). In a

depressive cycle, clients may use alcohol (even

though it is a depressive drug) to dull the pain

of their depression and/or stimulants to counteract the effects of the depression. 

Manic symptoms can often be confused with

symptoms of substance abuse, making diagnosis simply by observation difficult. Generally,

bipolar disorder has to be diagnosed by a thorough examination of the client’s mental health 

history, which should be conducted by a licensed behavioral health professional trained

in making such diagnoses. Treatment for the 

substance use and bipolar disorders needs to

be integrated or at least concurrent, as symptoms for one can trigger onset or relapse of the 

other. In addition to counseling, psychotropic 

medication is usually prescribed to regulate 

the bipolar disorder; the use of medication to 

77 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

regulate the illness must be considered in the 

client’s total treatment plan. 

Schizophrenia 

Across cultures, the onset of schizophrenia

begins earlier in men than women (Moriarty 

et al. 2001; Nasser et al. 2002). The DSM-IVTR (APA 2000) notes that the age of onset of 

schizophrenia is typically between 18 and 25

years of age for men and between 25 and the 

mid-30s for women. Some research suggests 

gender differences in the course and presentation of schizophrenia as well. In diagnosing

schizophrenia, clinicians look for positive

symptoms (i.e., an excess or distortion of normal function) and negative symptoms (i.e., a

decrease in or loss of normal functions). Men

appear to have more severe negative symptoms 

(e.g., emotional withdrawal, lack of spontaneity, blunted affect) and less severe positive 

symptoms (e.g., hallucinations, delusions) than

women with schizophrenia (Moriarty et al.

2001). Men with the disorder also seem to

have higher rates of co-occurring substance 

use disorders than women with schizophrenia

(Fowler et al. 1998). One large-scale study of

1,027 veterans with schizophrenia (97 percent

male) found that more than half had a history

of substance abuse (Bailey et al. 1997). 

Men with schizophrenia typically have poorer

treatment outcomes than women (Moriarty et

al. 2001), and they do not always respond as 

well as women to medications or to family involvement in treatment. Haas and colleagues 

(1990) found that an inpatient psychoeducational intervention for clients’ families was associated with improved symptoms and

functioning in women but with worsened

symptoms and functioning in men.The effectiveness of family involvement depends on

how the family is involved. In reviewing three 

studies, Ayuso-Guiterrez and del Rio Vega

(1997) found significantly reduced relapse 

rates for clients with schizophrenia whose 

families received psychoeducational or behavioral interventions. Women with schizophrenia may respond better to certain medications 

than men (Goldstein et al. 2002), but this may 

be due to better medication compliance in 

women (Nasser et al. 2002). 

Some symptoms of schizophrenia may be 

masked by drug use, which can cause the 

schizophrenic illness to be overlooked—

particularly among young men in whom the

illness is just emerging. Symptoms, such as 

blunted affect and other negative symptoms,

poor interpersonal relationships, and poor selfcare, may be seen as by-products of drug use,

with the expectation that these symptoms will 

improve with abstinence. However, with

schizophrenic illness, only temporary remission is typically seen, and the symptoms may 

even appear more pronounced with drug abstinence. Careful mental health evaluation is 

required for differential diagnosis and treatment planning. 

Pathological Gambling 

Pathological gambling is an impulse-control

disorder characterized by “persistent and recurrent” gambling “that disrupts personal, family,

or vocational pursuits” (APA 2000, p. 671).

Two thirds of individuals with this disorder 

are men, in whom it typically begins at an earlier age (early adolescence) than in women

(APA 2000). Men are more likely than women

to be in treatment for pathological gambling

or to attend Gamblers Anonymous (Ladd and

Petry 2002; LairRobinson 1997). In fact, the

DSM-IV-TR estimates that 96 to 98 percent 

of people in treatment for this disorder are 

men (APA 2000). Men who gamble pathologically are significantly more likely than men in

the general population to have a co-occurring

substance use disorder (Kessler et al. 2008;

Scherrer et al. 2007). 

78 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

Pathological gambling is more common

among people with substance use disorders 

than among those who do not have such disorders. One study of 113 patients admitted to

a gambling treatment program found that 

66.4 percent had a lifetime incidence of a substance use disorder (Kausch 2003). Other researchers have found equally high or higher

levels of co-occurring substance use and

pathological gambling disorders, and problem 

gamblers who have alcohol use disorders may 

also have more severe gambling problems than

those who do not abuse alcohol (Stewart and

Kushner 2003). In a study of gambling treatment program admissions, gamblers with substance abuse treatment histories had more 

severe gambling problems than other participants, including greater number of years with

a problem and greater number of days spent

gambling in the month prior to treatment entry (Ladd and Petry 2003). Other risk factors 

for pathological gambling include lower socioeconomic status (SES), gambling at casinos,

and participating in a greater number of different games of chance (Welte et al. 2004).

Appendix D of TIP 42 (CSAT 2005c) addresses pathological gambling in clients with

co-occurring substance use disorders. 

Eating Disorders 

Because of the relative rarity of eating disorders among men, many clinicians may not expect to see or may not recognize eating

disorders in their male clients. However, studies show prevalence rates of bulimia in men

from 0.1 percent to 2.1 percent (Makino et al.

2004). Two studies that administered the Eating Attitudes Test-26 found that 4 and 10

percent of the men in their respective samples 

had abnormal eating attitudes (Makino et al.

2004). General population studies have not

measured the prevalence among men of anorexia nervosa (the other specifically diagnosable eating disorder). However, a study of 135 

men with diagnosable eating disorders who

were treated at a Boston hospital found 22

percent to be anorexic and 46 percent to be

bulimic; 32 percent had an unspecified eating

disorder (Carlat et al. 1997). 

A study by Carlat and colleagues (1997) found

that 37 percent of men with eating disorders 

had a co-occurring diagnosis of substance 

abuse or dependence. A large percentage of

the men sampled were gay or bisexual: 27 percent of the total and 42 percent of the men

with bulimia. Eating disorders are often related to poor body image (Shelton and Liljequist

2002), which is also associated with increased

alcohol use and physical and verbal aggressiveness. Given these data, clinicians should

expect to see men in treatment for substance 

use disorders who also have eating disorders,

and they should be prepared to screen for

these disorders and refer clients for treatment 

when warranted. TIP 42 (CSAT 2005c) explores the treatment of clients who have cooccurring substance use and eating disorders. 

Even men who do not meet criteria for an eating disorder may develop disordered eating

practices (e.g., binge eating, eating to regulate 

mood) in early recovery, and men in later recovery may feel distress about weight gain that

occurs after they stop using substances (Cowan and Devine 2008). 

Personality Disorders 

The DSM-IV-TR (APA 2000) describes 10 

different personality disorders, some of which

seem to affect women more than men (i.e., 

borderline personality disorder, dependent

personality disorder), some of which seem to

affect the genders about equally (i.e., histrionic

personality disorder, avoidant personality disorder), and some of which appear to affect

men more than women (i.e., paranoid personality disorder, schizoid personality disorder,

schizotypal personality disorder, ASPD, 

79 
 

-

Addressing the Specific Behavioral Health Needs of Men 

Exhibit 4-2: Rates of Co-Occurring 

Personality Disorders Among Men 

With a Substance Use Disorder 

Co 

occurring 

disorder 

Men with a 

drug use 

disorder, % 

Men with 

alcohol use 

disorder, % 

Antisocial 8.5 3.5 

Avoidant 5.7 2.4 

Dependent 17.1 4.4 

Histrionic 7.2 4.3 

Paranoid 5.4 3.1 

narcissistic personality disorder, obsessive 

compulsive personality disorder [OCPD]).

The greatest gender differences are in ASPD,

which affects at least three times as many men

as women in the general population; OCPD,

which affects twice as many men as women;

and borderline personality disorder, which affects about three times as many women as 

men (APA 2000). 

Recent epidemiologic research paints a somewhat different picture of the prevalence of personality disorders. NESARC, which surveyed

over 43,000 adult men and women, found that

OCPD was the most common personality 

disorder (affecting 7.9 percent of the population) and was about equally common for men

and women. The survey excluded borderline,

schizotypal, and narcissistic personality disorders because of the greater number of questions needed to assess for those disorders 

(Grant et al. 2005). 

Grant and colleagues (2004b) reviewed

NESARC data and found that avoidant, dependent, and paranoid personality disorders 

were significantly more common among

women than men, but that men were more 

likely to have ASPD. They investigated the 

rates of co-occurring personality and substance use disorders and found that cooccurring personality disorders were much 

more common among people with drug use 

disorders (47.7 percent) than among people 

who had alcohol use disorder (28.6 percent).

Exhibit 4-2 depicts rates of co-occurring personality disorders among men with substance 

use disorders (Grant et al. 2004b). 

Antisocial personality disorder 

The National Comorbidity Study found that 

5.8 percent of men (compared with 1.2 percent of women) had sufficient symptoms to

warrant a diagnosis of ASPD at some point

during their lifetimes (Kessler et al. 1994).

NESARC found similar rates of 5.5 percent

for men and 1.9 percent for women (Grant et

al. 2004b). In a study by Klonsky and colleagues (2002), ASPD was associated with

both self-endorsement of masculine attributes 

and peer reports of masculine attributes 

among a sample of male and female college 

students. In large-scale studies, 80 percent of

ASPD cases in the general population are 

men; this may relate to impulsive aggression,

which characterizes ASPD, being a trait more

common to men than women (Paris 2004).

Most ASPD symptoms are described in terms 

of male behavior, so women may be underdiagnosed if they have ASPD symptoms less 

likely to appear in diagnostic criteria, such as

stealing from an employer or engaging in

prostitution. 

Studies of people in substance abuse treatment

(Compton et al. 2000) and people with substance use disorders who are not in treatment 

(Falck et al. 2004) have found much higher

rates of ASPD for both men and women. 

Moreover, rates of ASPD in treatment settings

tend to be closer between genders than rates 

found in the general population (Millery and

Kleinman 2001), and some researchers have 

even found slightly higher rates among women in treatment than among their male counterparts (Galen et al. 2000). NESARC’s survey 

of the noninstitutionalized population showed 

80 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

a stronger association between ASPD and substance use disorders in women than in men;

however, this may be, in part, because men are 

overrepresented in criminal justice populations 

left out of the sample (Grant et al. 2004b). 

Assessment of possible ASPD in substance 

abuse treatment clients can be confounding.

Many clients have exhibited antisocial behavior

during their drug use that does not justify an

ASPD diagnosis. People may display antisocial 

symptoms in one context, such as prison, but

not another. Diagnosis for ASPD is generally 

based on the client’s history as well as his current behavior. Forrest (1994) describes some of

the difficulties of and alternative approaches to

differential diagnosis in his book, Chemical Dependency and Antisocial Personality Disorder. 

Treatment of men with ASPD in substance 

abuse treatment settings can be difficult. In

fact, certain elements of usual substance abuse 

treatment can make people with ASPD anxious and prone to act out in treatment. Often,

substance abuse treatment emphasizes emotional sharing, personal disclosure, honesty,

and confronting shame—all of which may feel 

provocative and overwhelming to men with

ASPD. Clients who are antisocial may manipulate staff members and other clients, violate 

or flout program rules, be intentionally deceptive, shame or abuse others, attempt to control 

the treatment environment and, as a last resort, leave treatment early. As a result, people 

with ASPD may require special treatment that 

provides a safe and contained environment in 

which to manage their anxiety. In early treatment, counselors may need to emphasize controlling negative behavior and compliance 

with rules while downplaying emotional expression and interpersonal sharing, and they

should establish clear consequences for violating program rules (though these might seem 

draconian in other treatment settings). Treatment programs for co-occurring ASPD and 

substance abuse are often found in prison settings, but many clients who could benefit from 

such programs are not in prison. A community 

alternative is the establishment of long-term 

residential therapeutic communities (TCs), 

although not all TCs are appropriate for people with ASPD. 

Suicidality 

A variety of mental and substance use disorders can increase a man’s risk for committing

suicide; therefore, although it is not a disorder 

per se, suicidality must be addressed. Women

are three times more likely to attempt suicide 

than men, but men are more than four times 

as likely to die from suicide (NIMH 2001). In

fact, researchers have found this to be true 

across cultures, with a few notable exceptions,

such as mainland China (Arsenault-Lapierre

et al. 2004). The highest rate of completed suicide among any demographic group occurs in

White American men ages 65 and older (U.S.

Public Health Service 1999). Higher rates of

suicide completion among men may result, in

part, from the deadlier methods men typically 

choose for suicide. For example, 79 percent of

all suicides using firearms are committed by 

White men, and firearms are involved in most

(58 percent) completed suicides (Antai-Otong

2003). Additionally, men tend to perform fewer suicidal acts but exhibit a higher intent to

die (Nock and Kessler 2006). 

Substance use and abuse are major risk factors 

for suicide; men with substance use disorders 

have high rates of death by suicide (Wilcox et

al. 2004). Approximately 30 to 40 percent of 

suicide attempts and completed suicides involve acute alcohol intoxication (Cherpitel et

al. 2004). Substance-related problems appear

to be more often associated with suicide in 

men than in women, suggesting an even greater need to screen for suicidality among men in

treatment (Arsenault-Lapierre et al. 2004). 

81 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Co-occurring mental disorders increase the 

likelihood of suicide even more than substance 

abuse alone: depression, schizophrenia, bipolar

disorder, and personality disorders all increase 

the chances that someone will both attempt 

and complete suicide (Arsenault-Lapierre et

al. 2004; Blumenthal 1988). Other factors,

such as certain physical ailments (e.g., epilepsy,

cancer, Huntington’s chorea) and a family history of suicide, also appear to increase the 

likelihood of suicide (Blumenthal 1988). 

Rates of death by suicide vary by race and ethnicity. Exhibit 4-3 depicts age-adjusted rates 

of suicide per 100,000 individuals in the year

2006 according to the Centers for Disease 

Control and Prevention’s (CDC’s) National

Center for Injury Prevention and Control

(NCIPC; 2009). 

Appendix D of TIP 42 (CSAT 2005c) recommends that all substance abuse treatment 

clients receive at least a basic screening for suicidality and notes a particularly high risk 

among clients who have relapsed to substance 

use after an extended period of abstinence.

TIP 42 (Chapter 8 and Appendix D) also lists

key questions for evaluating suicide risk and

provides other information on this topic. 

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT 

2009a), provides more data on suicide by men

and women with substance use disorders as 

well as information on and case studies relating 

to addressing this issue in substance abuse 

treatment.TIP 50 proposes that counselors use 

a four-step screening and intervention process 

with clients who may be suicidal: (1) Gather

information, (2) Access supervision, (3) Take 

responsible action, and (4) Extend the action.

These steps, known by the acronym GATE, are

described in the text box on the next page. 

Men With Physical Health 

Problems 

Men with substance use disorders are at increased risk for a wide range of medical conditions either caused or exacerbated by their

substance use, including various cancers, cardiovascular and pulmonary conditions, neurological problems, gastrointestinal disorders,

endocrine syndromes, and hepatic disorders 

(Mannelli and Pae 2007; Ries et al. 2009;

Saitz 2009). They are also at increased risk for

infectious diseases, including viral hepatitis 

(see TIP 53, Addressing Viral Hepatitis in People With Substance Use Disorders [SAMHSA 

2011a]) and HIV/AIDS (see the “Men With 

HIV/AIDS” section on p. 84 of this TIP; see 

also TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS [CSAT 2000c]). Some 

such illnesses (e.g., liver cirrhosis) may result

directly from the substances used, whereas 

others (e.g., HIV/AIDS) may result from the 

method of drug administration or the lifestyle 

that accompanies substance abuse. 

Exhibit 4-3: Age-Adjusted Rates of Suicide per 100,000 Individuals in 2006 by 

Race/Ethnicity 

White Latino 

African 

American 

Asian American/ 

Pacific Islander 

Native 

American 

Men 19.62 8.87 9.40 8.07 18.28 

Women 5.06 1.84 1.39 3.46 5.08 

Source: NCIPC 2009. 

82 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

An Overview of GATE 

G: Gather information. There are two steps to gathering information: (1) screening and spotting 

warning signs and (2) asking follow-up questions. Screening consists of asking brief, uniform questions at intake to determine if further questions about suicide risk are necessary. Spotting warning 

signs consists of identifying telltale signs of potential risk. Counselors should ask follow-up questions 

when clients respond “yes” to one or more screening questions or whenever they notice a warning 

sign. Asking follow-up questions elicits as much information as possible so that counselors and their 

supervisors and/or treatment teams can develop a good plan of action. Counselors should provide 

as much information as possible to other providers upon referring their clients to them. 

A: Access supervision and/or consultation. Counselors should never attempt to manage suicide 

risk alone in clients, even if they have substantial specialized training and education. With suicidal 

clients, two or three heads are almost always better than one. Therefore, counselors should speak 

with a supervisor, an experienced consultant who has been vetted by their agency, and/or their multidisciplinary treatment team when working with a suicidal client. It is a collective responsibility, not 

the counselor’s alone, to formulate a preliminary impression of the seriousness of risk and to determine the action(s) that will be taken. Accessing supervision or consultation provides invaluable input 

that promotes the client’s safety, gives counselors needed support, and reduces personal liability. 

T: Take responsible action(s). A counselor’s action(s) should be responsible and make good sense 

in light of the seriousness of a client’s suicide risk. Some of the potential actions (which cover a 

range of intensity and immediacy) that counselors and their supervisors or teams may take include: 

• Gather more information from the client to develop an accurate clinical picture and treatment plan. 

• Gather additional information from other sources (e.g., spouse, other providers). 

• Arrange a referral: 

­ To a clinician for further assessment of suicide risk. 

­ To a counselor for behavioral health counseling. 

­ To a provider for medication management. 

­ To an emergency provider (e.g., hospital emergency department) for acute risk assessment. 

­ To a mental health mobile crisis team that can provide outreach to a client at his or her 

home (or shelter) and make a timely assessment. 

­ To a more intensive substance abuse treatment setting. 

• Restrict access to means of suicide. 

• Temporarily increase the frequency of care, including more telephone check-ins. 

• Temporarily increase the level of care (e.g., refer to day treatment). 

• Involve a case manager (e.g., to coordinate care, to check on the client occasionally). 

• Involve the primary healthcare provider. 

• Encourage the client to attend (or increase attendance) at 12-Step meetings. 

• Enlist family members or significant others (selectively, depending on their health, closeness to 

the client, and motivation) in observing signs of a return of suicide risk. 

• Observe the client for signs of a return of risk. 

Upon a return to acute suicidality, create a safety card with the client. TIP 50 (CSAT 2009a, p. 21), 

describes this process. 

E: Extend the action(s). Too often, suicide risk is dealt with once, in acute fashion, and then forgotten. As with substance abuse, vulnerable clients may relapse into suicidality. Thus, counselors need to 

continue to observe and check in with clients to identify any possible return of risk. Another common 

problem is referring a suicidal client but failing to coordinate or follow up with the provider. Suicide 

risk management requires a team approach, and a client’s substance abuse counselor is an essential 

part of this team. A counselor should document all actions taken to create a medical and legal account 

of the client’s care: what information was obtained, what actions were taken and when, and how follow-up on the client’s substance abuse treatment and suicidal thoughts and behaviors was conducted. 

This record can be useful for supervisors, consultants, the counselor’s team, and other providers. 

Source: CSAT 2009a, pp. 14–15. Adapted from material in the public domain. 

83 
 

 

Addressing the Specific Behavioral Health Needs of Men 

The consensus panel recommends that all clients entering substance abuse treatment programs have a thorough physical examination

with appropriate laboratory studies. Programs 

should also provide medical services or link to

such services; doing so can improve recovery 

outcomes for clients (Friedmann et al. 2003,

2009). Integrated medical care results in better

abstinence outcomes than independent but

linked services (Weisner et al. 2001), and onsite 

services result in better use of medical care than 

offsite services (Friedmann et al. 2001). 

Men With HIV/AIDS 

The HIV/AIDS epidemic is not uniform in

distribution; prevalence varies considerably 

across the country, not only from region to region, but also within regions, States, and even

communities. However, men have consistently 

been more affected by HIV/AIDs than women. CDC’s HIV/AIDS Surveillance Report estimates that, in 2007, men ages 13 and older 

made up 74 percent of current HIV/AIDs 

cases and 73 percent of cases diagnosed in that

year (CDC 2009). Between 2003 and 2006,

the number of HIV/AIDS cases increased approximately 5 percent for men but decreased 6

percent for women. 

Encouraging men at risk for HIV/AIDS infection to obtain counseling and testing is a

priority. In men, HIV/AIDS is most often 

transmitted by men having sex with other

men, but injection drug use is the second most

common transmission method among men 

(CDC 2009). Men who have sex with men

may also engage in substance abuse and are 

more likely to have unprotected sex if under 

the influence (Purcell et al. 2001). About 17

percent of men ages 13 and older who had 

HIV/AIDS in 2006 may have acquired the disease by injecting drugs (CDC 2008b). 

Men with HIV/AIDS can have great difficulty accessing services. The added complication 

of a substance use disorder can create even 

more troublesome barriers to seeking treatment. Societal attitudes toward men with 

HIV/AIDS in particular areas of the country,

such as certain rural communities, can contribute to even larger gaps in service for this 

population (Heckman et al. 1998; Shernoff

1996). For more information on HIV/AIDS

and substance abuse treatment for men who 

are HIV positive, see TIP 37 (CSAT 2000c). 

Stigma can make men reticent about discussing their HIV/AIDS status with counselors.

Clinicians who know that a client is HIV positive should speak privately with him about

whether he wishes to identify as such to other

group members. Counselors should caution

clients of the possible negative effects of disclosure even in a treatment setting and help

them carefully consider pros and cons. 

Men With Physical Disabilities 

Men with disabilities may experience more 

prejudice than other men because their disabilities keep them from meeting cultural expectations about male bodies and behavior.

This causes gender role stress and makes it

difficult for some men with disabilities to fulfill certain socially defined gender roles. Men

are socialized from an early age to be active,

independent, tough, self-confident, athletic,

and self-reliant—but having a disability can

limit a man’s ability to satisfy some or all of

these roles (Marini 2001). Society typically 

views people with disabilities as helpless, incapable, and inferior (Lyons 1991). Ironically, for

many men with severe disabilities, their substance use, even though problematic, may represent one of the last masculine behaviors 

remaining available to them. TIP 29, Substance 

Use Disorder Treatment for People With Physical 

and Cognitive Disabilities (CSAT 1998e), provides information on substance abuse treatment for people with physical disabilities. 

84 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

Traumatic Brain Injury 

Men are at higher risk for violence in our society, and therefore, they are also at higher risk for traumatic brain injury (TBI). TBI results from a sudden blow to the skull due to collision (causing a concussion), 

sudden penetration of the skull, blast pressure waves, or the head being thrust out of position. The injury may damage a specific part of the brain or diffuse throughout the brain tissue. 

TBI symptoms can be subtle and thus go unrecognized in many people; moreover, the symptoms are 

often similar to those caused by other problems, resulting in misdiagnosis. TBI symptoms may last only 

a few days or weeks, or they may be permanent. Even mild TBI can produce long-lasting cognitive and 

behavioral effects that significantly impair substance abuse recovery. For instance, a person’s ability to 

accept and integrate information in treatment may be compromised by TBI. The injury may also cause 

the person to act impulsively without being able to explain why. TBI symptoms can include: 

• Motor, sensory, and emotional effects. • Impaired attention and concentration. 

• Dizziness, lightheadedness, or vertigo. • Language and communication impairments. 

• Fatigue or lethargy. • Reduced cognitive speed and endurance. 

• Gait disorders. • Reduced multitasking ability. 

• Headaches and other pain symptoms. • Worsened memory. 

• Nausea. • Impulsive, disruptive, or inappropriate behavior. 

• Difficulty regulating emotions. • Aggression and irritability. 

• Sleep disturbances. • Apathy or lack of spontaneity. 

• Weakness. • Personality changes. 

• Cognitive problems. • Anxiety. 

• Executive function problems affecting one’s • Lack of self-awareness (including lack of 

ability to organize thoughts and plans, follow awareness of cognitive deficits). 

through on intentions, do abstract reasoning, • Sensory impairments (e.g., blurred vision, 

solve problems, make judgments, or read. sensitivity to light, ringing ears, itching). 

Treatment should be adapted to meet the specific needs of clients with TBI: 

• Modify psychoeducational and cognitive–behavioral counseling approaches to be sure that clients 

with TBI are able to incorporate the information. 

• Adapt treatment to accommodate the shorter attention span of clients with TBI. 

• Help clients develop and implement coping strategies to manage everyday functioning, such as 

making lists, managing stress, and asking for the support of others. 

• Note that inappropriate affective responses (e.g., anger disproportional to stimulus) may be symptoms of TBI. 

• Educate the client about TBI, its symptoms, and its effects. 

• Work with families to assist clients in their recovery from both TBI and substance use disorders. 

These resources provide more information on recognizing and treating clients with TBI: 

• TIP 29, available at the SAMHSA Store (http://store.samhsa.gov) 

• National Institute of Neurological Disorders and Stroke (http://www.ninds.nih.gov/disorders/tbi/tbi.htm) 

• Brain Injury Association of America (http://www.biausa.org) 

• Brainline.org (http://www.brainline.org) 

• NCIPC’s Traumatic Brain Injury Web site (http://www.cdc.gov/TraumaticBrainInjury/index.html) 

• Defense and Veterans Brain Injury Center (http://www.dvbic.org) 

• The National Institute of Neurological Disorders and Strokes’ Traumatic Brain Injury Information 

Web site (http://www.ninds.nih.gov/disorders/tbi/tbi.htm) 

• Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual (also available in Spanish), available at the SAMHSA Store (http://store.samhsa.gov) 

• Anger Management for Substance Abuse and Mental Health Clients: Participant Workbook (also 

available in Spanish), available at the SAMHSA Store (http://store.samhsa.gov) 

Source: CSAT, 2010b. Adapted from material in the public domain. 

85 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Men From Different Age 

Groups 

Young men often feel great pressure to show 

their masculinity. As men grow older, their

beliefs about masculinity and the social expectations for masculine behavior change. Similarly, men’s substance use/abuse often changes 

over the course of their lives. Age, therefore,

can be a significant factor in determining substance abuse patterns and appropriate treatment for substance abuse. 

Specific Needs of Younger Men 

Entering Treatment 

Young adult men, typically defined as men ages 18 to 24 (Park et al. 2006), have issues related to masculinity and substance abuse that

distinguish them from men in other age 

groups. Drug and tobacco use, binge drinking,

and recent illicit drug use are most common in 

this age group and are more common for men

in this age group than for women (Park et al.

2006). In this age group, men are three times 

more likely than women to die, and high rates 

of death by automobile crashes, homicide, and 

suicide account for much of the difference 

(Park et al. 2006; Pollack 2010). Among young

men in certain cultural/ethnic groups (notably

Native American and African American men),

rates of violent death are considerably higher.

Frequent or binge alcohol use and frequent

drug use have been associated, in diverse samples of young men, with increased risk for being the victims of violence; these behaviors 

appear to increase young men’s likelihood of 

being perpetrators of violence as well (Cooper

et al. 2000; Friedman et al. 1996; Richardson

and Budd 2003). 

For both younger and older adults, binge 

drinking has been associated with significant

alcohol-related problems, and men (15 percent) are more likely than women (4.7 percent) to binge drink (Blazer and Wo 2009a). 

In one study, younger men were five times as

likely to be involved in fighting or violent

crime and seven times as likely to break or

damage something as their counterparts who

drank less frequently and did not binge drink 

(Richardson and Budd 2003). 

High rates of substance use/abuse and violence may reflect the fact that young men are 

often less secure about their masculinity than

older men and therefore may feel a greater

need to engage in behaviors that supposedly 

prove their masculinity to others. Take, for example, the elevated death rate by automobile 

collision among men in this age group. This 

results largely from the fact that young men

are the least likely of men in any age group to

use seatbelts and the most likely of men in any 

age group to be in a crash in which at least one 

driver is alcohol impaired (Park et al. 2006).

Young men also engage in a variety of other

high risk behaviors. For example, young men

who inject drugs are more likely to engage in

practices that put them at high risk for contracting HIV (Rondinelli et al. 2009). 

Heavy drinking and illicit drug use can be 

seen as high risk behaviors that young men

engage in, in part, to demonstrate their masculinity. Research by Peralta (2007) found that 

most undergraduate students (both male and

female) agreed that drinking was generally 

perceived as an activity that expressed masculinity. More White American (76 percent) 

than African American (53 percent) students

held this belief, suggesting that cultural background influences attitudes about masculinity 

and drinking. Students interviewed for the 

study spoke of the beliefs that being able to

hold your liquor was a sign of masculinity and

that bouts of heavy drinking were rites of passage for men (but not women). 

Other types of substance use may also be perceived, in certain cultural contexts, as ways of 

86 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

 

 

 

expressing masculinity. Brown (2010) evaluated methamphetamine use among young Native American and White American men in 

Appalachia and found that use of the drug was 

linked with a strong masculine identity, but

admitting that one had a problem with the

drug (e.g., by entering treatment) was considered a sign of weakness. In other contexts, success in the drug trade is also considered an

expression of a strong masculine identity 

(Bourgois 2003). 

Young men may have some unique substance 

abuse treatment needs, although these vary 

according to cultural and sociodemographic 

factors. For example, young men who have 

made a living from the drug trade or other

criminal activity may need vocational training

and help finding a job, whereas college students 

in recovery value alcohol-free housing (i.e.,

dorms) and social activities (Bell et al. 2009). 

Young men often enter treatment under coercion (by family, the criminal justice system,

schools, and/or employers), and thus more effort may be needed to help them move from 

an early stage of readiness for change (precontemplation) toward embracing and accepting

abstinence. The largest single source of treatment referrals for individuals (both male and

female) in this age group is the criminal justice 

system, which accounted for 52 percent of

first-time admissions and 46 percent of return

admissions in 2006; the percentages for men

alone are likely higher (SAMHSA, OAS

2008a). In comparing young adults to those 

ages 26 to 45 in a largely (85 percent) male,

probation-referred treatment population,

Sinha and colleagues (2003) found that young

adults were significantly more likely to be in

precontemplation but significantly less likely 

to be in contemplation, determination, or

maintenance stages than adults ages 26 to 45.

Young adult male clients may also be more 

resistant to involvement in mutual-help 

groups, especially when groups specifically for

younger people are unavailable. Transferencerelated issues can arise for younger clients who

have older counselors. Some transference may 

be positive and useful for treatment, but much 

may be negative, causing clients to rebel against

the advice and support of older counselors. 

Data on substance abuse treatment programs 

specifically geared toward young adult men are 

limited, but various program models have been

tried with this population (including genderspecific programming), particularly in criminal

justice settings. Research into TCs (see Chapter 5) shows that young adult men are less 

likely than other clients to be involved with or

integrated into the TC (Chan et al. 2004),

perhaps because they have a greater need to

rebel against the high degree of structure offered by TCs. Even so, this should not disqualify the TC approach, which has been found

useful for young men (more so than older

men) in prison settings (Messina et al. 2006). 

Data suggest that adults who begin using substances at a younger age are more likely to be 

classified as substance dependent when they 

get older than those who start using substances later in life. Some boys start using alcohol 

or tobacco in the fifth or sixth grade or even

earlier (SAMHSA 2005; Vega et al. 1993).

Boys may start to use substances at an especially early age because of factors in their

school environments, such as availability of

drugs on or near the school campus (National 

Institute on Drug Abuse 1999), or because of

substance abuse in their homes. 

Specific Needs of Older Men 

Entering Treatment 

Men 55 years of age and older often decrease 

or end their alcohol and drug use, and their

rates of substance use disorders decline as well. 

A number of factors contribute to these 

changes, including early mortality among 

87 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

individuals who drink heavily and/or use illicit

drugs, negative effects of substances on medical problems, additional medical problems 

caused by substance use, decreased desire to

use, potential financial strain, and less participation in social events and activities focused

on substance use (Menninger 2002). However,

other factors, such as loneliness and depression, may cause some older adults to increase 

their drinking (Capraro 2000; Strowig 2000).

Some of these factors may affect men and

women differently. For example, older men

seem less concerned than older women about 

the effects of alcohol on their health (Satre

and Knight 2001), which may help explain

why older age is associated with greater decreases in alcohol consumption for women

than for men (Satre and Areán 2005). 

In SAMHSA’s 2007 National Survey of Drug

Use and Health (NSDUH), a survey of the 

general U.S. population ages 12 and older, 2.6 

percent of men ages 65 and older met criteria

for a past-year alcohol use disorder (U.S.

Department of Health and Human Services 

[HHS], SAMHSA, OAS 2008a). Other studies have found higher rates (see review in Satre 

and Areán 2005). Also in the 2007 NSDUH,

a greater percentage of men than of women

over the age of 65 reported drinking more 

than the amount recommended by the 

National Institute on Alcohol Abuse and 

Alcoholism (NIAAA), which is no more than

one drink per day for older men (NIAAA 

2005). Among those ages 65 and older who

reported drinking at least one drink in the prior month, 48.7 percent of men reported more 

than one drink per day compared with 28.7

percent of women; 17.7 percent of men reported more than two drinks per day (HHS, 

SAMHSA, OAS 2008a). Although rates of

alcohol abuse/dependence declined with age 

for both men and women, the extent of that 

decline was greater for women than for men.

In the 2007 NSDUH, men ages 65 and older 

were 37.5 times more likely to not have a pastyear alcohol problem than to have one; women

in the same age group were 249 times more

likely (HHS, SAMHSA, OAS 2008a). 

Data from SAMHSA’s 2005 and 2006 

NSDUH surveys (Blazer and Wu 2009a)

show that men ages 65 and older were more 

likely to engage in binge drinking if they had

higher incomes; were separated, widowed, or

divorced; smoked; and/or used illicit drugs. As 

with younger men, men ages 65 and older 

were significantly more likely to binge drink 

(14 percent) than were women (3 percent).

Research with older adults who have completed treatment also shows that older men have 

greater difficulty than older women maintaining abstinence after substance abuse treatment

(Satre et al. 2004a; Satre et al. 2004b). 

Although published data on the abuse of substances other than alcohol by adults older than

55 is limited, many researchers have raised

concern about the misuse and abuse of prescription drugs by this population (Blazer and

Wu 2009b; Simoni-Wastila and Yang 2006).

Some studies describe prescription drug abuse 

as less common among older men than older

women (Simoni-Wastila and Yang 2006); others conclude the inverse specifically for pain

medication (Blazer and Wu 2009b). For more 

information, see SAMHSA’s Get Connected! 

Linking Older Adults With Medication, Alcohol,

and Mental Health Resources toolkit (2003). 

Also see TIP 26, Substance Abuse Among Older 

Adults (CSAT 1998d), which recommends 

that substance abuse treatment programs for

both male and female older adults: 

•	 Make use of age-specific groups that are

supportive and nonconfrontational and work

to build or rebuild the client’s self-esteem. 

•	 Focus on coping with depression, loneliness, and loss. 

•	 Help older clients rebuild social support

networks. 

88 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

•	 Have pacing and content that reflect the 

needs of older people. 

•	 Use staff members interested and experienced in working with older people. 

•	 Integrate/link to medical services, older

adult services, and other services used by 

older adults. 

Gay and Bisexual Men 

Gay and bisexual men generally have higher

rates of substance use and substance use disorders than heterosexual men, although some 

research indicates that the rates are becoming

more similar between these groups (Cochran

et al. 2000). NESARC data showed that men

who self-identified as gay were 4.4 times as

likely as heterosexual men to have used marijuana in the past year, 3.5 times as likely to

have used other drugs, 2.9 times as likely to

have past-year alcohol dependence, and 4.2

times as likely to have past-year dependence 

on a drug other than marijuana (McCabe et al.

2009). Odds ratios for bisexual men, compared

with heterosexual men, were even greater.

Cochran and colleagues (2006) found that men

with male partners were significantly more 

likely than men with female partners to report

lifetime illicit drug use (72.8 percent and 54.6

percent, respectively) and were 2.4 times as

likely to meet criteria for problematic drug use. 

Gay and bisexual men entering substance 

abuse treatment, compared with heterosexual 

men, report more frequent use of their primary substance of abuse and are more likely to

primarily abuse methamphetamine, to have

had prior hospitalization for mental health

issues, to be homeless, and to report being victims of domestic abuse; they are less likely to

primarily abuse alcohol or marijuana or to

have current legal problems (Cochran and

Cauce 2006). However, gay and bisexual men

are significantly more likely than heterosexual 

men to seek treatment for substance use 

and/or mental disorders (Grella et al. 2009a). 

Much of the disparity in alcohol and drug

consumption rates between gay/bisexual and

heterosexual men may be connected to the fact

that, within gay culture, clubs, bars, and parties 

at which alcohol and drugs are consumed continue to be important and widely used social 

outlets (CSAT 2001; Weidel et al. 2008). A 

Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and

Transgender Individuals (CSAT 2001) provides more information on substance abuse 

treatment for gay and bisexual men. It recommends that clinicians be sensitive to gay 

cultural norms, prejudices against gay men,

and social expectations related to gay culture 

that may affect substance use. 

The sexual orientation of both client and 

counselor can complicate the issue of gender

bias in the therapeutic relationship. For example, a gay male substance abuse client may expect that a straight male counselor, due to his 

own socialization and bias, will be judgmental 

and potentially shaming. As a result, gay men

in substance abuse treatment settings may be 

more cautious about coming out and discussing issues related to relational/social aspects of

their substance abuse experiences or their primary relationships. As with gender considerations, the sexual orientation of the client and

counselor should be considered when assigning counselors to substance abuse treatment

clients. Gay male clients may feel more comfortable working with a woman or a gay male 

counselor. If a gay client is matched with a gay

counselor, the issue of sexualized transference 

will most likely need to be addressed. It is not

always possible to match clients and counselors with regard to sexual orientation, so counselors need to explore and challenge their own

sexual orientation biases and beliefs to work 

89 
 

 

 

Socioeconomic Status and Men’s Substance Abuse 

Research on men’s economic class and its relation to substance abuse usually focuses on men with 

lower SES. This may be because men of lower SES are overrepresented in substance abuse treatment 

populations, particularly those receiving public funds. However, data supporting the claim that men 

of lower SES are more likely to abuse substances are inconsistent at best. The relationship of substance use and abuse to SES appears to depend, in part, on the type of substance involved. For example, surveys consistently show that men living below the poverty line are more likely to smoke 

cigarettes than those with higher incomes (CDC 2004), and research has associated past-year marijuana use with lower incomes and unemployment (Robertson and Donnermeyer 1998). People of lower 

SES are also more likely to have drinking-related problems (Crum 2003) despite greater consumption 

of alcohol being associated with higher socioeconomic status (Casswell et al. 2003; van Oers et al. 

1999). SES apparently interacts with other factors (e.g., age, gender, acculturation) to influence alcohol consumption. Changes in income or status may also affect substance use and abuse; men who 

unexpectedly or unwillingly move from a higher to a lower SES can experience anxiety and depression, which are associated with substance use and abuse (Hemmingsson et al. 1999; Timms 1998). 

Addressing the Specific Behavioral Health Needs of Men 

effectively with gay men in substance abuse 

treatment settings. 

Men With Employment or 

Career-Related Issues 

Employment-related issues (e.g., type of job,

lack of employment) can strongly affect men’s 

substance use/abuse, and men with substance

use disorders are at greater risk for unemployment.The link between SES and substance 

abuse is more complex (see text box below). 

For men who are employed, their type of profession may affect the pattern and extent of

their substance use. For example, research has 

shown a relationship between drinking and

having positions that are typically male dominated. Men who work in “precision production, craft, and repair jobs, and those who [a]re 

operators, fabricators, and laborers” have higher rates of alcohol use and dependence (OAS

2002, p. 3), and those in physically risky positions (e.g., maintaining heavy machinery, operating light machinery, working with hazardous 

chemicals) are more likely to use substances

than those in less risky positions (Lehman and

Bennett 2002). 

In some professions, use of certain substances 

(usually alcohol) is considered normal behavior and not using is seen as anomalous among

men. In treatment, this can be an issue for

men who must decide whether to return to a 

job or type of employment that may, in some 

ways, promote drinking or drug use. It may be 

difficult for a man to return to such a work 

setting, but it can be equally as difficult for

him to leave a career that has helped define 

who he is. Counselors may find it useful to

discuss work-related concerns with clients and 

to use role-playing and other methods to help

them develop strategies for avoiding substance 

use at work or in other settings where they 

may feel pressure to use. 

Whether a client has a job or not, employment

and work-related issues should be addressed in 

treatment. Ask male clients about positive and

negative aspects of work in their lives and talk 

with them about their work-related goals. Doing so may help them see how substance abuse 

has affected their work and how recovery can

positively influence their careers and offer other means for fulfillment (Lyme et al. 2008). 

Some men with jobs do not have insurance or

sick leave to use for treatment, or they are unwilling to seek treatment for fear of risking

their employment. In SAMHSA’s 2007 

NSDUH, men who needed substance abuse 

treatment were more than 16 times as likely as 

90 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

 

 

 

 

women who needed treatment to express concern that entering treatment would affect their

jobs (HHS, SAMHSA, OAS 2008a). 

Men Who Are Unemployed 

Men without jobs have a surplus of time—and

sometimes, too few constructive activities with

which to fill it. Men, who are traditionally expected to be the breadwinners in American

society, often experience lowered self-esteem 

as a result of unemployment, which can lead

to despair and hopelessness. Men who have 

lost a job often increase their alcohol consumption (Dooley and Prause 1998). When a

man loses his job, is demoted, or loses social 

status in some other way, the resulting anxiety 

may lead him to use problematic coping techniques, such as substance use (Liu 2002). 

Men who are unemployed are more likely to

be currently using a substance than those with 

full-time jobs, and people with substance use 

disorders are more likely to be unemployed

than the general population (Platt 1995). According to 2003 data, 18.2 percent of unemployed adults were currently using illicit drugs

compared with 10.7 percent of those employed part time and 7.9 percent of those employed full time. Current alcohol use was 

slightly greater among people with jobs, but

heavy use (five or more drinks on five or more 

occasions in the past month) was greater

among those without jobs (OAS 2004b). 

Men entering substance abuse treatment are 

more likely to be unemployed than employed.

Data from 2006 showed that 68 percent of 

men admitted to substance abuse treatment 

programs that received State agency funds 

were unemployed or not in the labor force 

(HHS, SAMHSA, OAS 2008a). Unlike men

with jobs, who are sometimes willing to seek 

substance abuse treatment to keep their positions, men who are unemployed may lack important help-seeking resources like employee 

assistance programs and health insurance. 

Employment has been correlated with successful treatment outcomes (Platt 1995). A

study by Arndt and colleagues (2004) found a

positive association between abstinence and

full-time employment for men after treatment.

For more information on the relationship between employment and treatment success, as

well as integrating vocational training into

substance abuse treatment programs, see TIP 

38, Integrating Substance Abuse Treatment and

Vocational Services (CSAT 2000a). 

Men Who Are Veterans 

In 2006, veterans accounted for over 66,000 

admissions (4.9 percent of total admissions) to

substance abuse treatment programs tracked

by SAMHSA’s Treatment Episode Data Set

(TEDS); most (91.4 percent) were men. The 

most common source of referral for male veterans, as it is with all men, is the criminal justice system, accounting for 36.7 percent of

admissions (HHS, SAMHSA, OAS 2008a). 

Estimated rates of substance abuse are similar 

for veterans and nonveterans, but male veterans receiving treatment are more likely than

male nonveterans to report alcohol as the primary substance of abuse (59 percent and 40.4

percent, respectively; HHS, SAMHSA, OAS

2008a). Veterans treated in VA facilities (see 

advice box on the next page) have significantly

more problems than patients in non-VA facilities with employment, education, legal issues,

and co-occurring mental and medical disorders (Veterans Health Administration 1996).

Furthermore, VA programs serve a large number of veterans who are homeles, many of

whom have co-occurring substance abuse and

mental disorders (Kasprow et al. 1999). About

50 percent of VA substance abuse treatment

program clients also have one or more cooccurring mental disorders (Tracy et al. 2004). 

91 
 

 

 

Advice to Behavioral Health Clinicians: Accessing VA Services 

To be eligible for treatment in the VA system, veterans must have served in the U.S. Armed Forces 

and received an honorable military discharge or general discharge under honorable conditions, subject to minimum duty requirements. VA substance abuse treatment facilities provide inpatient, residential, and outpatient services. A variety of VA programs exist to help veterans who are homeless 

obtain health care, vocational rehabilitation, job training, and transitional or permanent housing. 

Veterans can be referred to VA services by any treatment provider and can register for services via 

the member services office at their local VA facility. They must bring a copy of their discharge papers 

and may be charged a copay if their annual gross income exceeds a given amount (exceptions being 

any veteran who served in Vietnam or has a service-connected disability). To reach veterans in rural or 

remote areas, the VA has community-based outpatient clinics linked to major VA medical centers. 

For more information on how to access VA services, find local VA resources, and so forth, visit VA’s 

“New to VA” Web site (http://www1.va.gov/opa/newtova.asp). Real Warriors also offers numerous 

resources for veterans (http://www.realwarriors.net/veterans/treatment/substanceabuse.php; 1-866­

966-1020), including opportunities to speak over the phone or chat live on the Web with a trained 

health resource consultant at the Defense Centers of Excellence Outreach Center. 

Addressing the Specific Behavioral Health Needs of Men 

An analysis of data from the National Survey 

of Homeless Assistance Providers and Clients 

found that, for clients who are homeless, being

male increased the odds of having an alcohol 

problem by nearly 3 times, whereas being a

veteran increased the odds by 1.3 times (Dietz

2007). Being male and/or a veteran similarly

affected the odds of having a drug problem. 

Men With SystemsRelated Needs 

Men enter treatment with multiple needs, as

their substance abuse has likely affected every 

aspect of their lives. Often, a man’s behavior 

involves him with a system (e.g., the criminal 

justice system) that may require his treatment

providers to interact with that system. In other

cases, other systems may be required to provide for a man’s specific needs (e.g., housing).

Some such systems (medical services, VA services, and vocational rehabilitation) have already been covered in this TIP; two more that

involve many men in treatment (housing and

homelessness services and the criminal justice 

system) are discussed in the following sections. 

Men Who Are Homeless 

It is difficult to ascertain the total number of 

men who are homeless in the United States;

nevertheless, the National Survey of Homeless 

Assistance Providers and Clients (the largest

survey of its kind) found that 61 percent of

adults who were homeless and sought services 

in 1999 were men living alone. Another 24

percent were men living with another person.

Of men in the survey who were homeless, 33 

percent were veterans (Burt et al. 1999). 

Men also make up a large percentage of adults 

who are homeless and seek treatment for substance abuse. In SAMHSA’s 2006 TEDS 

study, men comprised 75.6 percent of individuals who were homeless and entered substance 

abuse treatment programs that received funding through State agencies (HHS, SAMHSA,

OAS 2008b). Substance use disorders are especially common among men who are chronically homeless; according to one study, they 

occur in 84 percent of men compared with 58 

percent of women (North et al. 2004). 

Burt and colleagues’ (1999) review of data from

programs that provide homelessness services 

92 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

Advice to Behavioral Health Clinicians: Increasing Retention Among Clients Who 

Are Homeless 

Traditional substance abuse treatment models are often ineffective for individuals who are homeless. 

Dropout rates of two thirds or more are seen in this population; thus, engagement and retention are 

areas that any program working with men who are homeless must address. 

Based on the experiences of eight NIAAA grantees providing treatment to men and women who 

were homeless (six of which served a primarily male client base), Orwin and colleagues (2001) suggested the following ways to increase retention: 

• Eliminate/decrease waiting periods. 

• Strengthen the orientation process (involving a longer and more intensive orientation period). 

• Increase the level of client involvement with case managers. 

• Make the program more accessible. 

• Improve the program environment (e.g., make it more welcoming). 

• Respond to the specific needs of the population (e.g., provide gender-specific services for men 

and women, respond to client feedback). 

• Increase opportunities for recreational and educational activities. 

• Put more effort into relapse prevention. 

found that 73 percent of clients were male.

Out of the total client population, 66 percent

reported at least one alcohol, drug, or mental 

problem in the month prior to their interview,

74 percent reported such a problem in the past

year, and 86 percent reported a problem at

some time during their lives. Alcohol was the 

most commonly abused substance; 38 percent

of clients reported alcohol problems in the 

past month, 46 percent reported such problems in the past year, and 62 percent reported

problems with alcohol during their lifetime. In

terms of other substances of abuse, 26 percent

of clients reported a drug problem during the

past month, 38 percent during the past year,

and 58 percent during their lifetimes. 

In a large survey, 46 percent of men who were 

homeless reported alcohol problems, whereas 

only 22 percent of women who were homeless 

did; men were also 50 percent more likely to

report a problem related to illicit drugs (Burt

et al. 1999). Men who are homeless are more 

likely than other men to have various concurrent problems ranging from high levels of

shame and low self-esteem to HIV/AIDS and

co-occurring disorders. 

A number of specific treatment interventions 

are considered promising for clients who are 

homeless, including modified TCs, intensive

outpatient programs, contingency management approaches, motivational enhancement

techniques (e.g., motivational interviewing),

the provision of transitional and supportive

housing for individuals who were formerly 

homeless, and intensive case management

(Begun 2004; Zerger 2002). Treatment retention is a particular problem for providers

working with men who are homeless (see advice box below). For more on substance abuse 

treatment for clients who are homeless, see 

TIP 55, Behavioral Health Services for People

Who Are Homeless (SAMHSA 2013). 

Researchers have noted the potential benefits 

of gender-specific treatment for women who

are homeless and have substance use disorders 

(Zerger 2002). However, despite the fact that 

men who are homeless outnumber women 

who are homeless in treatment 4 to 1, little 

research has been done to determine the best 

interventions for this specific population.

Kraybill and Zerger (2003) reviewed six substance abuse treatment programs for clients 

who are homeless that they recognized as 

93 
 

Addressing the Specific Behavioral Health Needs of Men 

providing effective services; one of these, Casa

Los Arboles (a component program of

Albuquerque Health Care for the Homeless),

provides services specifically to men. This 6­

to 9-month intensive inpatient program uses 

staff members recovering from substance 

abuse, intensive case management, and a slow 

process of transition to independent living for

clients. In the orientation phase, which lasts 45

days, clients cannot leave the premises on their

own—this and other privileges are introduced

slowly. Overall, the program is much more rulebound than the equivalent program for women

at Albuquerque Health Care for the Homeless. 

Men Involved in the Criminal 

Justice System 

Men who require treatment for substance use 

disorders may hesitate to seek services out of 

fear that acknowledging and seeking help for

problems with substances may complicate 

their legal difficulties; they may fear that their

insurance providers will consequently refuse to

pay for treatment or that they will be turned

over to legal authorities. Other men may be 

reluctant to acknowledge a history of arrest

and incarceration and may fear that this information will be revealed if they enroll in a

treatment program. Thus, many men may resist needed care. Behavioral health counselors 

should not offer legal advice, but they can help

clients recognize when to seek professional 

legal counsel and can refer them appropriately. 

Men are more likely than women to be involved in the criminal justice system, and this 

is reflected in referrals to substance abuse 

treatment from this system. In 2006, referrals 

from the criminal justice system accounted for

41.7 percent of all men entering substance 

abuse treatment programs that received public

funds (compared with 30 percent of all women

entering treatment), making it the largest single source of referral for men entering substance abuse treatment (HHS, SAMHSA, 

OAS 2008a). In addition to the many substance abuse treatment programs available for

men who are incarcerated, 28 percent of all

programs in 2006 offered services for criminal 

justice clients other than those convicted of 

driving under the influence (SAMHSA, OAS

2007a). TIP 44, Substance Abuse Treatment for 

Adults in the Criminal Justice System (CSAT 

2005b), provides more information on treatment options available for men in the criminal 

justice system. TIP 30, Continuity of Offender

Treatment for Substance Use Disorders From Institution to Community (CSAT 1998b), offers 

information on working with clients who are 

making the transition from criminal justice 

institutions to the community. 

Men involved in the criminal justice system 

may be affected differently than women by 

certain factors. For example, a large study of

men and women treated in prison-based TCs 

found that men who were employed prior to

incarceration were significantly less likely to

return to custody in the 2 years after treatment

than those who were unemployed, which was 

not the case for women (Messina et al. 2006).

However, men who were employed were also

less likely to enter continuing care, suggesting

that although having a history of employment 

helped men avoid returning to custody (possibly because it enabled further employment),

employment may have also made them less 

interested in or less able to participate in further treatment following incarceration. 

Men in correctional settings and men on probation or parole often have unique needs in

substance abuse treatment. For instance, men

in prison may have different ways of thinking

about and judging specific behaviors than men

on the outside. These cognitive distortions are 

not necessarily distortions in the context of

prison life, but rather are useful for managing

day-to-day prison life. Criminogenic patterns 

can influence a man’s values, beliefs, attitudes, 

94 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

and emotion management; therefore, the patterns need to be identified and addressed in 

treatment. Adaptations that can help a man

survive in prison may be maladaptive in the 

community or in substance abuse treatment

program settings. Persons entering substance 

abuse treatment after incarceration may benefit from training to build skills for coping and

operating successfully in the free world.

Treatment for men who have been imprisoned

should also address recidivism and relapse. 

Men currently involved with the criminal justice system as well as those who leave it to enter substance abuse treatment may be reluctant

to divulge information, resistant to expressing

vulnerable emotions (e.g., sadness, fear), or 

hesitant to interact in group treatment. Behavioral health counselors should try not to interpret these behaviors as resistance, denial,

uncooperativeness, or unwillingness to participate in recovery. To do so may actually increase the negative, protective behavior. 

Serious, pervasive mental illnesses occur more 

often among men who have been incarcerated

than those who have not (Center for Mental 

Health Services National GAINS Center for 

Systemic Change for Justice-Involved Persons 

with Mental Illness 2007). Men with mental

illnesses are further traumatized in prison, and

although their resulting adaptations may help

them survive there, they can also make substance abuse treatment even more difficult. 

The GAINS Center offers specific suggestions and treatment options for people from 

the criminal justice system who have concurrent mental illness and a substance use disorder; for more information, visit the Center’s 

Web site (http://gains.prainc.com/). 

Men From Diverse 

Cultural and Geographic 

Groups 

Rates and patterns of substance use/abuse vary 

among men according to cultural group. Researchers generally investigate cultural differences using broad racial/ethnic categories;

those categories are thus used here. However,

each broad category encapsulates a diverse set

of cultures, and intragroup differences may be 

greater than intergroup differences in many 

cases. Behavioral health service providers are 

encouraged to investigate the specific cultures 

of their clients and discuss those cultures with 

their clients. 

SAMHSA’s NSDUH showed that among

men in 2007, American Indians/Alaska Natives had the highest rates of past-year substance use disorders (17.6 percent) of any 

single group, and Asians had the lowest rates 

(7 percent). The same survey showed past-year

rates of substance use disorders of 13.0 percent

for non-Hispanic White men, 12.1 percent for

African American men, and 12.2 percent for

Hispanic/Latino men (HHS, SAMHSA,

OAS 2008a). 

SAMHSA’s TEDS surveys individuals when

they enter treatment and thus excludes the 

many men who need but do not receive treatment. Exhibit 4-4 presents data on substance 

preferences for men entering treatment by

ethnic or racial group. Percentages are derived

from State and jurisdiction reports of treatment admissions to programs that received

public funds (directly or indirectly) in the year

2005. With the exception of alcohol plus another substance, only the primary substance of

abuse is indicated (SAMHSA, OAS 2008b). 

These data indicate, to some extent, how culture affects patterns of substance use/abuse. 

95 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Exhibit 4-4: Primary Substance of Abuse According to Cultural/Ethnic Group 

Among Men Admitted for Treatment 

Substance White 

African 

American 

Latino 

(Mexican 

origin) 

Latino 

(Puerto Rican 

origin) 

American Indian 

or Alaska 

Native 

Asian or 

Pacific 

Islander 

Alcohol only 27.7 13.1 31.3 10.5 39.8 22.1 

Alcohol plus other 

substance 19.5 21.2 11.9 16.5 23.9 13.3 

Heroin 11.5 13.5 12.6 47.7 3.6 7.1 

Other opioids 4.5 0.5 0.5 0.8 1.8 2.3 

Smoked cocaine 5.4 20.4 3.4 5.3 2.3 5 

Other cocaine 3.2 4.7 4.0 4.7 1.6 1.9 

Marijuana or 

hashish 15.1 22.8 18 12 12.9 20.2 

Methamphetamines 8.9 0.9 17.1 0.6 7.2 25.5 

Tranquilizers 0.4 0.1 0.1 0.3 0.2 0.2 

Sedatives 0.2 0.1 0.1 0.1 0.1 0.1 

Hallucinogens 0.3 0.1 * * 0.1 0.2 

Phencyclidine 0.1 0.4 0.2 0.2 0.1 0.2 

Inhalants 0.2 * 0.1 * 0.2 0.1 

Other/none 

specified 5.2 2.1 0.5 1.4 6.3 1.9 

*Less than 0.05 percent.
 

Source: SAMHSA, OAS 2008.
 

Information about substance use by diverse

cultural groups of men is given in the following sections, as is information on specific substances and the populations that use them.

Because of the gender rather than cultural focus of this TIP, this discussion of cultural issues is limited. More information can be 

found in the planned TIP, Improving Cultural 

Competence (SAMHSA planned c), which explores cultural and ethnic differences in substance abuse and discusses various culturally 

and ethnically based treatment issues. 

African Americans 

Within-group diversity 

The term African American is a broad denotation for an ethnocultural group of considerable diversity. The history and experience of

African Americans has varied in different 

parts of the United States, and the experience 

of African American people in this country 

varies even more when considering the culture 

and history of more recent immigrants. Today, 

African American culture embodies elements 

of Caribbean, Canadian, Latin American, European, and African cultures. Intragroup diversity among people of African descent is 

further influenced by numerous factors, in96 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

 

 

 

 

 

 

 

 

 

cluding their country or region of origin; their

upbringing; the extent to which their families

conserve and perpetuate Afrocentric values,

rituals, and beliefs; regional mores and customs; gender socialization; and age. The terms 

African American and Black are used synonymously at times, but some recent Black immigrants may not consider themselves African

Americans, assuming that the term applies 

only to people of African descent born in the 

United States. 

African American men’s concept of masculinity may differ depending on their specific cultural background as well as their geographic

location and SES, among other factors. For 

example, a study by Levant and colleagues 

(1998) found that African American men in 

the South endorsed significantly more traditional masculine roles than did African Americans from Northeast/Mid-Atlantic regions 

(the latter groups’ concept of masculinity more 

closely resembled that of White Americans). 

Admission/substance use statistics 

African American men made up 15.5 percent

of all substance abuse treatment admissions to 

programs receiving funds through States in

2005 (SAMHSA, OAS 2008a). According to 

SAMHSA’s NSDUH, in 2006, the rate of 

past-month illicit drug use for African American men (ages 12 and older) was 13.8 percent;

their past-year rate of heavy drinking was 13.4

percent (HHS, SAMHSA, OAS 2007). Rates

of crack cocaine use are higher for African

American men than rates of methamphetamine, inhalant, or prescription drug abuse 

(HHS, SAMHSA, OAS 2008a). 

Although young African American men are 

less likely to use drugs than young White 

American men, older African American men 

are more likely to do so—this is sometimes 

referred to as the crossover effect (French et al.

2002; Watt 2008). A particularly powerful influence on increased drug use in this population is that African American men ages 35 

and older are more likely to be offered drugs 

than are men in that age range from other racial/ethnic groups (Watt 2008). 

American Indians and Alaska 

Natives 

Within-group diversity 

The terms American Indian and Alaska Native refer to the indigenous peoples of North

America, who collectively are often called Native Americans. There are 562 federally recognized American Indian and Alaska Native 

Tribes (SAMHSA, planned a), but there are 

also numerous Tribes recognized only by 

States and still others unrecognized by any government entity. Each represents a distinct culture; although similarities exist among certain

Tribes, there are also significant differences. 

More information on substance abuse treatment for this population is presented in the 

planned TIP, Behavioral Health Services for 

American Indians and Alaska Natives 

(SAMHSA planned a). 

Admission/substance use statistics 

American Indians and Alaska Natives comprise about 1 percent of the population of the

United States (McKinnon 2003). However, in

2000, they constituted approximately 1.4 percent of individuals in substance abuse treatment programs receiving funds through the 

States (SAMHSA, OAS 2008b). Substance 

use patterns vary significantly among Native

American Tribes, but within specific Tribes, 

American Indian and Alaska Native men usually have significantly higher rates of substance 

use disorders than women from the same 

Tribe. Rates of injuries, suicide, and homicide

are disproportionately high among American

Indian men, who are significantly less likely 

than American Indian women to receive medical services (Rhoades 2003). 

97 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

NSDUH data from 2007 show that American 

Indians/Alaska Natives report the heaviest use 

of alcohol, tobacco, and many illicit drugs of

any racial group (SAMHSA 2008). Rates of 

use are especially high for American Indian

and Alaska Native men (HHS, SAMHSA,

OAS 2007). American Indian men as a group

have higher rates of binge drinking than the

general population, but they also have higher

rates of abstaining completely from alcohol 

than the general population (May and

Gossage 2001; OAS 2007b). Drinking starts

at an earlier age among American Indian men 

than their female counterparts (17 years versus 

18.1 years, respectively), and American Indian 

men as a group have a tendency to drink more 

frequently and in larger quantities than American Indian women (May and Gossage 2001). 

Asians, Hawaiian Natives, and 

Other Pacific Islanders 

Within-group diversity 

Asian Americans comprise over 30 diverse

ethnic groups (e.g., Chinese, Filipino, Asian

Indian) who speak different languages, have 

different levels of acculturation, and may have 

different immigration statuses and levels of

income. This complexity is increased by key 

variables, such as reasons for migration, degree 

of acculturation, English proficiency, family 

composition and intactness, education, and

adherence to traditions or religious beliefs. 

Although they come from distinct cultures,

Native Hawaiians and other Pacific Islanders 

are often grouped together with Asian Americans in surveys and other research. They are a

relatively small group; data from the U.S. Census 2000 show that 0.3 percent of the population reported some Native Hawaiian or other

Pacific Islander ancestry (Grieco 2001), and

accurate information concerning patterns of

substance use and abuse is thus difficult to 

come by. Chang and Subramaniam (2008) discuss how Asian American cultural beliefs 

about appropriate masculine behavior influence such factors as male help-seeking and

concepts of health. 

Admission/substance use statistics 

Asian Americans generally use alcohol and

illicit substances less frequently than other

Americans, although there are variations

among subgroups. Asian Americans rank lowest of all racial or ethnic groups in terms of

past-year illicit drug use. According to 2007

data, Asian Americans ages 12 and older were 

also less likely than members of other racial 

groups to report current alcohol use (35.2 percent) or recent binge drinking (12.6 percent).

Asian Americans had a relatively low rate (4.3 

percent) of past-year alcohol use disorders in

2007 (SAMHSA 2008); in 2005, they comprised 1 percent of admissions to substance 

abuse treatment programs receiving State agency funds (SAMHSA, OAS 2008b). Among

those who did enter treatment, methamphetamine and marijuana abuse rates were high. 

Research suggests considerable variations in

substance use/abuse patterns among men from 

diverse Asian American populations. For example, the National Latino and Asian American Study, the largest national study to assess 

substance use disorders among Asian Americans from diverse cultural backgrounds, found

that Filipino American men were 2.38 times 

as likely to have a lifetime substance use disorder as Chinese American men (Takeuchi et al.

2007). Other research indicates significant differences in substance use and abuse patterns 

according to specific Asian cultural group, as 

well as differences related to such factors as 

geographic location and acculturation. 

The use of alcohol and other substances is 

more common among Native Hawaiians than

members of other ethnic and racial groups living in Hawaii. In an adult household survey of

Hawaiian residents conducted in 1998, about 

98 
Chapter 4–Working With Specific Populations of Men in Behavioral Health Settings 

 

36.7 percent of Native Hawaiian men reported

heavy drinking and 15 percent met diagnostic

criteria for either alcohol abuse or dependence 

(Gatrell et al. 2000). 

White Americans 

Within-group diversity 

White Americans (also referred to as Caucasians), like other large cultural groups, are heterogeneous in historical, social, economic, and

personal features, with many subgroups and

subtleties. Many have been in the United

States for three or more generations, but others are recent immigrants (Giordano and

McGoldrick 2005). Many White Americans 

have European cultural roots, but growing 

numbers come from Middle Eastern or North 

African cultures. For many White Americans,

such characteristics as gender, sexual orientation, socioeconomic status, geographic location, occupation, religion, and so forth may be 

more important than race in defining their

sense of cultural identity. 

Admission/substance use statistics 

Recent data show that White Americans are 

the racial group most likely to report current

(i.e., past-month) use of alcohol. Overall,

White Americans report more illicit substance

use and abuse than do most other major racial/ethnic groups, but rates of use and abuse 

of specific substances vary (SAMHSA 2008).

White men made up 39 percent of all substance abuse treatment admissions in 2005,

the largest subset in the treatment population

(SAMHSA, OAS 2008b). 

Alcohol seems to be the primary substance of

abuse among White Americans, but differences in its use do exist among the subpopulations in this community. For example,

O’Dwyer (2001) reviewed a study that found

that 51 percent of Irish-born men admitted to

various psychiatric hospitals in New York had 

alcohol-related diagnoses, whereas only 4 percent of Italian-born men had similar diagnoses 

during the same period. Researchers identify 

two basic drinking patterns in European cultures: a Northern/Eastern European pattern

(more common in the United States) in which

alcohol is consumed only on weekends or during celebrations but often in large quantities 

on those occasions, and a Southern Europe 

pattern in which alcohol is consumed daily or 

almost daily but in smaller quantities and almost always with food (Room et al. 2003).

White American men, on average, begin

drinking and develop alcohol use disorders at a

younger age than men from other racial/ethnic

groups (HHS, SAMHSA, OAS 2008a;

Reardon and Buka 2002). However, certain

White American groups, (e.g., those of Middle Eastern descent) may drink very little if at

all (Arfken et al. 2007). 

Hispanic/Latino Americans 

Within-group diversity 

Hispanic and Latino are terms used to refer to

cultures that originated, at least in part, in

Spain or Portugal, and most often indicate

people from Western Hemisphere cultures 

that have been influenced by Spanish or Portuguese colonization. The term Hispanic

technically refers to people from the Spanishspeaking countries of North, Central, and

South America and the Caribbean. However,

the term Latino refers to people from Latin

America, whether they are from a Spanish or

Portuguese-speaking country. Unlike other

groups described here, Hispanic/Latino is an

ethnic, not a racial, category. Latinos may belong to any race and may include more than

30 national and cultural subgroups (Padilla

and Salgado de Snyder 1992; RodriguezAndrew 1998). Latino Americans are currently the fastest-growing ethnic group in the

United States (Ramirez and de la Cruz 2003;

U.S. Census Bureau 2004). 

99 
 

Addressing the Specific Behavioral Health Needs of Men 

Admission/substance use statistics 

SAMHSA’s TEDS recognizes within-group

diversity among Hispanics/Latinos by reporting admissions for diverse groups of Hispanic

or Latino descent—the largest of these being

Mexican and Puerto Rican. In the 2005 

TEDS survey, Mexican American men made 

up 4.1 percent of treatment admissions; Puerto Rican men made up 3.2 percent of treatment admissions (SAMHSA, OAS 2008b). 

Data about drinking and drug use behaviors 

among various Hispanic/Latino groups, outside of those that enter treatment, do not always present a clear picture (Nielsen 2000).

However, there seem to be significant variations in substance use patterns and disorders 

among diverse groups of Latinos (Alegria et al. 

2008; HHS, SAMHSA, OAS 2000). Studies

have consistently found that more acculturated

Hispanics/Latinos drink more frequently and

in larger quantities than less acculturated individuals (Alegria et al. 2008; Zemore 2005). 

Hispanic/Latino men are considered to be at

high risk for alcohol abuse and dependence 

(Colon 1998; Corbett et al. 1991) and substance abuse (Vega et al. 1998). Among individuals entering substance abuse treatment,

rates of heroin use are high for Puerto Rican 

men, as are rates of methamphetamine use for

Mexican American men (Singer 1999). 

Geographic Regions 

Geographic region can significantly affect the

availability of substances, attitudes toward

substance use, and cultural patterns of use for

men. Each population has its own set of challenges that can contribute to the magnitude of

substance use problems in that region. For example, men in rural settings may have less access to substance abuse prevention and

treatment programs than men in urban settings but also less access to some illicit substances. Lo and Stephens (2002) compared 

arrestees’ perceived needs for substancespecific treatment in rural and urban settings.

The investigators did not discuss gender other

than to note that male detainees dependent on 

cocaine were less likely to express a need for

treatment than female detainees dependent on

cocaine. Nonetheless, they make some pertinent conclusions about urban/rural differences. As a general rule, urban arrestees were 

more likely to perceive a need for treatment 

and to exhibit increased motivation for treatment, whereas rural residents exhibited decreased motivation for treatment. More 

educated rural arrestees were less likely to be 

receptive to alcohol treatment than those who

were less educated, whereas the converse was 

true in urban areas. The authors speculate that

uneducated, unemployed rural residents stood

the least to lose by entering treatment. 

Conclusion 

Behavioral health programs and providers

should consider the variety of factors that influence the significant disparity in substance 

use disorder rates between men and women in 

the United States. These factors range from 

greater opportunity to use substances to increased social pressure and possibly to a greater genetic disposition to use substances. In

addition, men’s reasons for substance use differ 

from those of women and include rites of passage and a greater need to medicate feelings 

and emotions that they have difficulty expressing. The factors at work differ not only between genders, but also among men from 

diverse cultural and ethnic groups; providers

need to consider these various and complex

factors as they undertake the screening and

assessment approaches outlined in Chapter 2. 

100 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 IN THIS CHAPTER 

• Introduction 

• Detoxification 

• Treatment Modalities 

• Treatment Strategies 

• Treatment Settings 

• Mutual -Help Groups 

• Community Influences 

• Helping Men Live With 

the Residual Effects of 

Substance Abuse 

Treatment Modalities 5 and Settings 

Introduction 

The consensus panel believes that substance abuse treatment for

men should take into account the impact of gender on use, abuse,

and recovery. Treatment components in any behavioral health setting should be gender responsive, examine the role of masculinity,

and target the emotional/behavioral issues of most men. This chapter discusses the substance abuse treatment approaches, modalities,

components, and settings that are most effective for use with men.

Not all modalities discussed are specific to men; research on malespecific treatment is in its early stages. However, by focusing on the 

man and his substance use disorder, providers can tailor treatment

to account for the physical, behavioral, and social differences of men. 

Detoxification 

Research on male and female responses to detoxification is mixed;

only a few studies indicate differences between the sexes that

might need to be addressed in this setting. In a study of men and

women in New York, NY, detoxification programs for heroin

and/or cocaine use, Millery and Kleinman (2001) found that levels 

of current depression among men and women in the program were 

about equal (despite depression being more common among women than men in the general population [Kessler 2000a, 2007]).

Similarly, Johnson and colleagues (2007) found similar rates of cooccurring symptoms of mental illness among men and women who

used injection drugs and were entering a detoxification program. 

A comparison of male and female participants in an outpatient alcohol detoxification program found no significant differences in

severity of withdrawal or program completion, although men were 

less likely than women to have had prior treatment for mental 

101 
Addressing the Specific Behavioral Health Needs of Men 

illness or to have used illicit drugs in the 

month before entering the alcohol detoxification program (Strobbe et al. 2003). 

Other research indicates that men may receive 

somewhat different services in detoxification 

programs than women do. Callaghan and

Cunningham (2002) found that even though 

there were few differences in medical conditions between men and women presenting to a

large, hospital-based detoxification program

(N=2,545), women were significantly more 

likely to receive medical evaluation tests and

to be prescribed some medications (i.e., antibiotics and antidepressants). They also found

that men were significantly more likely than

women to refer themselves to detoxification 

and to complete the program but significantly 

less likely, at the time of program entry, to be

unemployed or to have dependent children. In

another study, which investigated men and

women whose detoxification was paid for by 

Medicaid, men who completed the program 

were significantly less likely to enter follow-up 

treatment than their female counterparts

(Stein et al. 2009). Rates of follow-up treatment were low for both groups, but this issue 

deserves particular attention, as detoxification

without follow-up treatment is associated with

higher levels of relapse to substance abuse. 

Providers should expect that men who enter

detoxification, particularly for alcohol dependency, will have multiple substance use disorders.

Men presenting to emergency departments are

more likely than women to be using alcohol in

addition to drugs, such as cocaine, opioids, or

marijuana. (Substance Abuse and Mental 

Health Services Administration [SAMHSA],

Office of Applied Studies [OAS] 2008a). Detoxification, especially from substances like 

alcohol and barbiturates, is a serious undertaking that can pose a significant health risk.

Therefore, on entering a detoxification program, men must be encouraged to give a full 

and honest substance abuse history. 

Physical detoxification from substances usually 

lasts 3 to 5 days; thus, many decisions about

treatment options must be made in a relatively 

short period of time. In medical settings where 

there may be few or no individual or group

psychosocial interventions, behavioral health

service providers and other staff members 

should try to engage men in dialog that allows

them to express their fears and anxieties about

receiving treatment. The staff can then provide

feedback and information that will help these 

men make recovery-oriented decisions. 

Men sometimes seek physical detoxification

from substances because they want to stop

other illegal behaviors and/or avoid their consequences. Many men who engage in criminal 

activities do so to support their substance use,

which can lead to incarceration, loss of public

housing for them and their families, loss of

employment, or loss of child custody or visitation rights. Other men may seek physical detoxification services if they want to give their

bodies a break from substance abuse. The time 

during which these men undergo physical stabilization may be the only real opportunity

behavioral health service providers have to encourage them to seek long-term solutions for

their substance use disorder(s). 

For more information on detoxification for 

men and engaging them in substance abuse 

treatment following detoxification, see Treatment Improvement Protocol (TIP) 45, Detoxification and Substance Abuse Treatment 

(Center for Substance Abuse Treatment

[CSAT] 2006a). 

Treatment Modalities 

Most substance abuse treatment programs use 

a combination of group, individual, or family/couples counseling. Men may present 

102 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 

 

 

unique challenges in treatment, many of which

have been discussed in prior chapters. Another

problem relevant across treatment modalities 

is men’s potential resistance to entering or participating in therapy/counseling; this, along

with challenges specific to the three basic

treatment modalities, are discussed in the following sections. 

Group Therapy 

Group therapy is the most widely used treatment modality in substance abuse treatment

programs (Etheridge et al. 1997; National Institute on Drug Abuse [NIDA] 2003; Weiss et

al. 2004). Groups offer a number of advantages to the treatment program itself (e.g.,

cost effectiveness) and the clients they treat

(e.g., decreasing clients’ sense of isolation,

providing an opportunity to learn social skills,

offering support and encouragement), and research generally indicates that group therapy is 

as effective as individual therapy for treating

substance use disorders (see review by Weiss et

al. 2004). TIP 41, Substance Abuse Treatment: 

Group Therapy (CSAT 2005d), discusses the 

advantages and techniques of group therapy. 

The importance of encouraging and motivating men to participate in group therapy is suggested by an analysis of outcomes of the 

Target Cities Treatment Enhancement Project

in Los Angeles. The study found that, among

330 men and women who completed a treatment program that included both individual 

and group therapy, women had lower relapse 

rates (22 percent) than men (32 percent) in

the 6 months following treatment—despite 

the fact that women in this population showed

more risk factors for relapse than men. After 

controlling for employment, child care, transportation, and several other factors, the only 

variable that seemed to explain the difference 

in relapse rates was that the women had participated significantly more often and for 

longer periods of time in group therapy 

(Fiorentine et al. 1997). 

Single-gender groups for men 

Some research suggests that women may do

better in single-sex, gender-specific groups 

(Grella and Joshi 1999; Hodgins et al. 1997;

Niv and Hser 2007; Orwin et al. 2001; Zilberman et al. 2003); some clinicians believe

that gender-specific groups may also be useful 

for male clients (Lyme et al. 2008; Wexler

2009). Even so, in a study that compared outcomes for men in a mixed-gender program to

men in an all-male program, Bride (2001) did

not find significantly different outcomes for

participants in the single-gender program.

That said, a treatment group that happens to

be composed of men is not the same as a

treatment group that focuses on treating substance abuse in the context of male gender issues (van Wormer 1989). Groups must be

developed to focus on male needs and male approaches to interaction. 

Van Wormer (1989) outlines six basic functions of sex segregation in groups treatment:

1.	 All-male group therapy provides an opportunity for men to relate to other men

without being distracted into game playing

to impress women. Men also learn to take

on caregiving roles, which they might leave 

to women in mixed settings. 

2.	 Men can experience closer relationships

with other men in the pursuit of mutual 

goals and concerns. Caring and friendship

among men are supported. 

3.	 In the absence of women, men can discuss 

controversial topics (such as child custody,

dating, cohabiting patterns) more freely. 

4.	 A male-led men’s therapy group is especially appropriate for working on destructive, restrictive aspects of the masculine 

gender role. Together, men can explore

their relationships with women and thereby learn how other men relate to women. 

103 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

5.	 Personal topics (e.g., male health problems,

sexual needs/dysfunctions) can be explored. 

6.	 Members of the men’s group can become 

sensitized to their feminine as well as masculine characteristics; they can learn to be

more flexible in their sex role definitions. 

Van Wormer cautions that male tendencies to 

intellectualize and to avoid intimacy are major

problem areas for all-male groups, as are dominance issues. Wexler (2009) adds that maleonly groups can become very competitive, and

cynicism and disruptive behavior need to be 

watched. However, this kind of group can also

become a laboratory in which individual

members can experiment with long-repressed

thoughts and feelings that were previously 

numbed with substances. 

Brooks (1996) details some of the ways in

which all-male groups can benefit male clients:

•	 Many men have experiences of bonding

with other male peers in a group setting

(e.g., a sports team) that can help them 

become part of a therapy group. Therapists can use the familiarity and attraction

of such male group bonding to interest

men in the group while not reproducing

the competitiveness and hierarchical structure common in male peer groups. 

•	 Many men only share emotions and emotional intimacy with women. Because of

this, men can become overly dependent on 

women for fulfilling their emotional needs 

or may even experience their own emotions vicariously through women. The 

male-only group offers men an opportunity to express their emotions to other men,

thus building intimacy and trust. 

•	 The group setting can be valuable for encouraging sharing. Men in American society are socialized to avoid self-disclosure,

but in a group composed only of men, the 

male client can see others revealing things 

about themselves and gradually begin to

share his own fears, concerns, and feelings. 

•	 Other men in a group setting provide an

example to the male client of how his life 

can improve with treatment and group involvement, thus instilling hope. 

•	 The male-only group gives men the opportunity to improve their ability to communicate with other men in new and 

improved ways. It also provides a safe environment for learning which communication styles are ineffective. 

Conversely, mixed-gender groups have their

benefits. In these groups, men can develop

healthy, nonsexual relationships with women.

Men may feel more comfortable expressing

emotions when women are present and may

hear responses from female clients that give 

them a different perspective than other men

would give. The use of mixed-gender groups 

has been associated with greater variations in

interpersonal styles for male (but not female)

participants (Hodgins et al. 1997). 

Exhibit 5-1 describes one of the few group

interventions specifically for men in substance 

abuse treatment: a short-term group intervention that helps men with substance use disorders improve intimate relationships.Time Out!

For Men (TOFMEN) can reduce attitudes associated with rigid socialization and gender role 

conflict (Bartholomew et al. 2000); the consensus panel believes that it shows promise. 

Other group activities for men in 

treatment 

In addition to traditional group therapy models, behavioral health counselors should consider organizing other structured group

activities for male clients. Activities like attending a ball game or movie together, working on a group craft project, or playing a sport

can offer opportunities for men to bond with

one another and practice social interactions 

104 
Chapter 5–Treatment Modalities and Settings 

 

Exhibit 5-1: Time Out! For Men 

TOFMEN is a group intervention for male clients in substance abuse treatment that promotes the 

reexamination of gender stereotypes, social pressures, and sexual misconceptions to help men improve their relationships with their partners. TOFMEN was developed in 1996 by Bartholomew and 

Simpson as part of the Drug Abuse Treatment Outcome Study (DATOS) project funded by NIDA. The 

intervention is designed to be run by a substance abuse or other behavioral health counselor; a training module is available online (http://www.ibr.tcu.edu/pubs/trtmanual/tofmen.html). TOFMEN is a 

short-term intervention designed to be implemented over eight sessions. 

• Session 1: This session focuses on creating a bond among group members and exploring male 

and female gender roles. Specifically, group members examine what they need and want in their 

intimate relationships and what role socialization plays in their values and choices. The counselor 

asks each man to create a list of the characteristics that make an ideal man and woman; group 

members use these lists to look at how gender role stereotypes affect their relationships. Men 

are challenged to implement and discuss what they have learned via a take-home assignment. 

After session 1, group members are given worksheets to help them identify their needs and how 

they can meet the needs of their spouses or partners. 

• Session 2: Men start by reviewing their homework from the day before. After, they concentrate 

on building communication skills to achieve and maintain an assertive attitude. They discuss the 

disadvantages of aggressive and passive communication styles and the differences between “Istatements” and “You-statements.” 

• Session 3: This session focuses on listening, a key skill for maintaining good relationships. Group 

members participate in listening exercises to help them decipher common listening problems 

and identify good listening habits. In one exercise, an item (e.g., a mug) is passed to the participant who has the floor. The next group member to receive the item then restates what he heard 

the previous speaker say. 

• Session 4: Participants discuss feelings and how to accept and express them. After making a list 

of feeling words, group members identify and discuss which feelings are hard or uncomfortable 

for them to talk about. 

• Session 5: Men discuss how to resolve conflicts. They are encouraged to seek solutions instead 

of assigning blame when conflict arises and are taught how to fight fairly with others. 

• Session 6: This session uncovers misconceptions about sexual and reproductive health and how 

they can affect attitudes and values about sexuality. Clients are taught how unnecessary concerns about normal body functions, sexual responses, and sexual feelings can cause undue stress 

on relationships. 

• Session 7: This session continues the discussion of sexuality as the men address common concerns about and the effects of substances on sexual functioning. They also examine stereotypes 

concerning the man’s role in sexual relationships and try to devise self-help solutions for sexual 

problems in relationships. 

• Session 8: The last session focuses on increasing self-esteem (e.g., by writing affirmations) and 

reviewing communication skills covered in previous sessions. The men are encouraged to keep 

building these skills. The workshop closes with a graduation celebration; group members are 

awarded certificates for completing the intervention. 

Source: Bartholomew and Simpson 2002. 

while abstinent. Although research on this

topic is limited, Burling and colleagues (1992)

found that male veterans who were homeless,

in a substance abuse treatment program, and

participating in a community-based softball

team were more likely than men who did not 

participate in the sport to complete the program and were also more likely to maintain

abstinence, remain employed, and have housing 3 months after treatment. However, this 

may, in part, reflect the benefits of exercise for

people in treatment, one of which is longer 

105 
 

Addressing the Specific Behavioral Health Needs of Men 

duration of abstinence following treatment for

men who exercise compared with those who

do not (Weinstock et al. 2008). 

Individual Therapy 

Individual counseling has been used extensively in substance abuse treatment but, in most

programs, it is used less commonly than group

therapy. According to DATOS data (Etheridge

et al. 1997), the average number of individual 

sessions offered was significantly less than the

average number of group sessions offered in

most types of treatment (with the exception of

outpatient methadone programs, which offered slightly more individual sessions on average). Etheridge and colleagues (1997) found

that the average ratio of individual to group

sessions per month was smallest for long-term 

residential programs (7.2 group and 4.5 individual sessions) and largest for outpatient

drug-free programs (14.8 group and 3.3 individual sessions). 

Individual therapy is an important intervention for men in substance abuse treatment. In 

the National Treatment Improvement Evaluation Study—which included 2,019 men and

1,123 women from 59 different treatment

sites—89 percent of programs serving men

offered individual counseling at least once a 

week, and men (but not women) in those programs had significantly lower rates of substance use 12 months after treatment than 

men in programs that did not offer individual

counseling (Marsh et al. 2004). 

Individual counseling can offer benefits that

group therapy does not, and the panel encourages programs to make use of both group and

individual therapy options when working with

male clients. In a multisite study that investigated four psychosocial treatments for cocaine 

dependence, Crits-Christoph and colleagues 

(1999) found that participants exposed to various forms of individual counseling and/or 

therapy in addition to group counseling had

significantly better outcomes than those who

participated in group counseling alone. For

some men, it is much easier to discuss sensitive 

issues (e.g., gender-related concerns) and reveal emotions and tears in private with a

trained professional than with a group of peers 

they will have to face again after exposing aspects of themselves that they normally do not

share with other men. The counselor is not 

seen as a peer or potential friend, but as someone providing a service in a way that is personal yet limited. Although group members 

are bound to confidentiality, clients in an individual therapy setting can establish a different

level of trust with their behavioral health 

counselor, given the counselor’s legal and ethical responsibilities. Also, in individual counseling, clients receive individual attention and

can focus on their own needs to a greater degree than in group settings. Some clients (e.g.,

men with social anxiety disorder) may be 

much more comfortable in the presence of one 

other person (the counselor) than in a group.

Research also suggests that men and women

in substance abuse treatment respond better to

different styles of individual counseling:

Fiorentine and colleagues (1999) found that

men generally responded better to a counselor

using a utilitarian style, whereas women generally responded better to a more empathic

style of counseling. 

As with all treatment methods, some potential 

disadvantages to individual therapy exist. For

instance, if a client only participates in individual therapy, much of what occurs in the

course of treatment is solely dependent on the 

skills, knowledge, and experience of the counselor and how they fit with the needs of the 

client. This leaves the client without the opportunity to receive input from his peers. Counselors with little practical information or lifestyle 

knowledge related to a particular substance of

abuse may find it difficult to recognize when 

106 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 

someone is being dishonest. In individual 

treatment, a client might not be held as accountable for problematic behavior as he 

would in a group setting. Group members can

introduce the client to substance-specific coping skills and abstinence strategies of which

the counselor may not be aware. 

Whether men can benefit more from work 

with a male or female counselor is dependent

on a variety of factors, including the expressed

preference of the client, the setting in which

the counseling occurs, and the nature of the 

topics to be discussed. A more extensive overview of the impact of counselor gender is presented in Chapter 3 of this TIP. 

Family and Couples Therapy 

Men are ideal beneficiaries of family or couples therapy, as marriage and family appear to

have a protective function against substance

abuse and relapse for men. Having a family 

role (as either spouse or parent) is associated

with less alcohol consumption for men

(Kuntsche et al. 2009), whereas men who are 

widowed, separated, or divorced are more likely to engage in binge drinking (Blazer and Wu 

2009a). Other research indicates that men

who enter treatment while married are less 

likely to engage in daily substance use than

those who were never married or are divorced,

separated, or widowed; the opposite is true for

women entering treatment (SAMHSA, OAS

2008b). For men who complete treatment, being married is associated with better outcomes 

(Walton et al. 2001). Men who relapse are less 

likely to do so in the presence of romantic

partners than when with male friends,

although the opposite is true for women (Rubin et al. 1996). McCrady and colleagues

(2004) found that marital happiness during

posttreatment follow-up was associated with a

significantly greater percentage of days of abstinence among married men with alcohol use 

disorders; greater marital happiness prior to

treatment had no relation to abstinence rates. 

It may be particularly important for men with

substance use disorders to maintain relationships with their partners and family during

recovery, as there is some evidence that married men who enter substance abuse treatment—particularly those with children under

age 18—are much more likely to stay with

their partner after completing treatment than

are women who complete treatment (Orloff

2001). As noted in Chapter 4, family and

partners can play important roles in motivating men to enter treatment and can help promote recovery during and after treatment. In

addition to promoting abstinence, couples interventions for fathers who have substance use 

disorders and their spouses may also improve 

the emotional state of children living with that

couple, even if the children are not included in

the counseling sessions (Kelley and FalsStewart 2002). 

The National Association for Children of 

Alcoholics (NACOA) produces a variety of

resources for counselors and other helping

professionals on the impact of adverse childhood experiences, including substance abuse in

the family, on childhood development. The

NACOA Web site (http://www.nacoa.org) 

offers counselor resources that support family 

involvement in recovery. 

Couples therapy 

Clients are most likely to accept and complete 

couples therapy (O’Farrell and Fals-Stewart 

1999) if they:

•	 Have a high school or better education. 

•	 Are employed or willing to be employed. 

•	 Live with their partners or are willing to

reconcile for therapy if separated. 

•	 Are older. 

•	 Have substance abuse problems of a longer

duration. 

107 
Addressing the Specific Behavioral Health Needs of Men 

•	 Enter therapy after a crisis, especially one 

that threatens the relationship’s stability. 

•	 Have a partner and other members of their

household who are without substance 

abuse problems. 

•	 Are free of other serious mental or emotional illness. 

•	 Are not violent. 

Not all men are suitable candidates for family 

therapy or want to involve their family in their

treatment. Men under a restraining order from 

a court to refrain from contact with their partners, and those who have inflicted or received

significant physical abuse, should not be considered for couples or family therapy. If there

is current evidence of domestic violence, there 

may even be State regulations prohibiting the 

use of family or couples therapy. 

Family therapists or other behavioral health

counselors who may see men with their female

partners may find the men to be more difficult

to work with than the women. Because therapy relies on verbal communication skills, particularly the discussion of feelings, and because 

men have difficulty asking for help, women

may appear to be more engaged in therapy.

The counselor will thus need to be careful to 

speak to the man’s concerns as well as the 

woman’s and use language that is comfortable 

for the man, such as by making use of his 

words and expressions or talking about behaviors as well as feelings (Shay and Maltas 

1998). Clinicians should be mindful of how

the man does contribute or could contribute if 

an opening were made for him. 

DATOS data indicate that most communitybased treatment programs evaluate the family 

treatment needs of their clients and most offer 

some form of family intervention (Etheridge 

et al. 1997). However, information from these 

surveys also suggests that, despite documentation of need across all treatment modalities,

family interventions occur on a limited basis— 

primarily within short-term inpatient and residential programs (Fals-Stewart and Birchler

2001). As clinicians complete comprehensive 

personal assessments to document their clients’ 

family concerns and problems, they should

consider how family counseling can benefit clients and how to provide it when needed. 

Behaviorally oriented couples interventions

that have been particularly well evaluated and

generally found effective in reducing substance 

use and improving marital relations for men

who have substance use disorders include behavioral couples therapy (BCT) and variations

upon it (behavioral family counseling, alcohol 

behavioral couples therapy, behavioral relationship therapy, and behavioral marital therapy). A meta-analysis of multiple studies on 

BCT (Powers et al. 2008) concluded that immediately after treatment, BCT improves relationships (according to couples self-reports)

and that this, in turn, results in greater longterm substance use reduction compared with

many standard individual treatments. In the

most recent of these studies (not included in

the meta-analysis), Epstein and colleagues 

(2007) found that men who had drug use disorders and received BCT with their female 

partners reported significant decreases in the 

frequency of drug use, alcohol use, and number of drugs used 9 months after treatment; 55

percent reported improved marital functioning.

Variations on BCT have also been found to 

improve outcomes following treatment, especially when added to other services (Epstein et

al. 2007; Fals-Stewart et al. 2000a, 2005; FalsStewart and O’Farrell 2003; Lebow et al.

2005; McCrady et al. 2004; O’Farrell et al. 

1998; Powers et al. 2008). 

Network therapy is another promising intervention that makes use of family (as well as 

friends) and has been associated with better

treatment outcomes for men in treatment for 

cocaine use disorders (Galanter et al. 2002) 

108 
 

 

 

 

Chapter 5–Treatment Modalities and Settings 

and men with opioid use disorders on buprenorphine maintenance (Galanter et al. 2004). 

Other approaches to family and couples therapy can be useful in treatment settings; these 

are discussed in TIP 39, Substance Abuse 

Treatment and Family Therapy (CSAT 2004b). 

Family therapy 

A number of authors (Lazur 1998; Levant and

Philpot 2002; Levant and Silverstein 2001;

Philpot 2001; Philpot and Brooks 1995;

Philpot et al. 1997) have suggested that family

therapy pursued with men must be sensitive to

how gender role socialization affects family

life, from patterns of communication to the

division of household tasks to the parenting of

children. Building on women-centered approaches to family intervention, these authors 

suggest how to use current understanding of

gender, particularly male gender, to successfully engage men in couples and family therapy. 

In one study, an expert panel of male and female family counselors endorsed 131 of 339

proposed techniques as appropriate and potentially effective ways to work with men in

couples and family counseling (Dienhart 2001;

Dienhart and Avis 1994). They agreed that 

clinicians should increase their ability to consider the influence of gender role socialization

on presenting problems, promote shared responsibility for change, and actively challenge 

stereotypical attitudes and behaviors. Some 

specific techniques endorsed by this group of

therapists are listed in Exhibit 5-2. 

Family therapy should acknowledge how gender role socialization may complicate family

problems associated with clients’ substance 

abuse. All types of family-oriented interventions should be sensitive to the ways gender

roles in a family may vary with age, culture,

ethnicity, social class, and sexual orientation

(Greenan and Tunnell 2003; Krestan 2000;

McGoldrick et al. 2005). 

Men with substance use disorders may need

help talking with parents, children, siblings,

and members of their extended family about

their substance abuse and related problems.

When substance use by men is pervasive within a family, it may be useful to hold a familyoriented counseling session with just the male 

members of the family to discuss their common legacy of substance use (Brooks 1998).

These male-only family meetings may help to

secure support for abstinence from substances. 

Substance abuse counselors can consider encouraging relatives, spouses, friends, or others 

affected by a person’s substance abuse to seek 

help and support through such resources as

Al-Anon Family Groups, Nar-Anon, Families 

Anonymous, Co-Anon Family Groups, or

Adult Children of Alcoholics. 

Family interventions to motivate 

men to enter treatment 

A variety of interventions aim to involve family members and others in the process of motivating men to seek treatment. Some of these 

interventions can be implemented relatively 

easily. For example, Garrett and colleagues 

(1999) outline a procedure for responding to

telephone calls from people concerned about 

the substance use of a family member. The 

“concerned other” call is a chance to help them 

leverage a person who appears to have a substance use disorder into treatment. 

The Johnson Institute intervention ( Johnson 

1986) teaches the family to talk actively with

men who have substance use disorders about 

the problematic nature of their substance use 

and their need for treatment. The confronters 

are given formal training and rehearse the intervention. They learn to emphasize their care 

and concern for the target, the damage his

substance use has caused, and the actions they 

will take if he does not accept help. The intervention comes as a surprise for the person who 

109 
 

Exhibit 5-2: Goals and Techniques for Working With Male Clients in Couples and 

Family Therapy 

GOAL—Develop perceptual and conceptual skills: 

• Clarify your own values concerning gender socialization. 

• Become aware that all men are not alike—they are in various stages of transition along a continuum, with some men being open to change and others being more resistant. 

• Define family as inclusive of all the many types of families in America (e.g., traditional families, 

single-parent families, extended families, gay or lesbian families). 

• Become aware of and challenge any tendency to protect men in the system. 

• Familiarize yourself with men’s writing about men. 

• Focus on the anxieties that underlie men’s defensiveness. 

• Be aware of patterns of power assertion on the part of male clients. 

GOAL—Promote mutual responsibility: 

• Ask couples historical questions on the formation and development of responsibility in the presenting family. 

• Have couples evaluate their options for changing the division of responsibilities. 

• Determine who initiates sexual interaction. 

• Use direct teaching to introduce the reciprocal nature of gender interactions and the constraints 

of the larger sociocultural context. 

• Design interventions that are directed at all parts/members of the involved treatment system 

(e.g., helpers, members of the extended family). 

GOAL—Challenge stereotypical behaviors and attitudes: 

• Teach men to ask for help. 

• Discuss the benefits that men can get from changing stereotypical behaviors and adopting new 

attitudes, roles, and behaviors. 

• Encourage father–daughter and mother–son bonding, especially during adolescence. 

• Discuss problems men with absent fathers have in being fathers to their own children. 

• Examine couples’ experience of socioculturally supported behaviors in their own relationships 

(e.g., Are men satisfied with working long hours? Do they long for more time with their children?). 

Source: Dienhart and Avis 1994. 

Addressing the Specific Behavioral Health Needs of Men 

is using substances. This method, using significant others, has proven to be more successful 

than coercion by an employer or judge. It was 

designed to enroll people with substance use 

disorders in inpatient treatment; it is laborintensive and thus more expensive than less 

intensive interventions (Loneck et al. 1996).

The intervention is very limited in its scope 

and may be too confrontational for some

families (Fernandez et al. 2006). 

Garrett and colleagues (1997) developed the 

Albany-Rochester sequence for engagement

(ARISE) method to provide a more supportive, less confrontational approach to involving

significant others in an initial intervention (see 

also Garrett et al. 1998; Landau et al. 2000).

ARISE is more conducive to helping clients 

engage in outpatient treatment. The intervention begins with a call from a concerned other

to the treatment center, which is followed by a

modified Johnson-type intervention. If the

person who is abusing substances enters 

treatment, the members of the intervention

group agree to continue to provide support.

ARISE differs from the Johnson intervention 

in that the planned intervention is not kept 

secret from the potential client, and the treatment plan is negotiated with him during the 

intervention. It is also more flexible and, even 

110 
Chapter 5–Treatment Modalities and Settings 

 

 

though it can use a confrontational approach, 

it need not do so (Fernandez et al. 2006). 

Another intervention that holds promise for

engaging men in treatment is community reinforcement and family training (CRAFT).

Developed by Meyers and colleagues (1996,

2001), CRAFT is based on the community

reinforcement approach to substance abuse 

intervention. In the conceptual model outlined

by Meyers and colleagues, concerned significant others receive training in techniques that:

•	 Promote self-care. 

•	 Decrease the risk of domestic violence. 

•	 Evaluate situational factors promoting

substance use. 

•	 Improve communication between significant others and the individual with a substance use disorder. 

•	 Reinforce the efforts of clients with substance use disorders toward effectively daily functioning. 

•	 Discourage substance use. 

•	 Increase motivation. 

•	 Reinforce awareness of the need for treatment. 

Meyers and colleagues (2001) studied significant others affected by a family member’s substance abuse. They found CRAFT to be more 

acceptable and more effective at getting the 

potential client into treatment than other approaches that were more confrontational or

potentially disengaging. 

Unilateral family therapy (UFT; Thomas and

Ager 1993) is another family-based intervention that uses elements of both the Johnson 

intervention and CRAFT but is more flexible 

and focuses more on improving family functioning (Fernandez et al. 2006). The intervention consists of 11 to 30 sessions delivered 

over 4 to 6 months, and it provides a series of

graded steps the family can use prior to confrontation. UFT helps family members 

strengthen coping skills, enhance family functioning, and facilitate greater abstinence on

the part of the person using substances. 

Chapter 4 of TIP 35, Enhancing Motivation

for Change in Substance Abuse Treatment

(CSAT 1999b), contains more information on 

the Johnson intervention, CRAFT, and other

family interventions designed to motivate 

people to enter treatment. Fernandez and colleagues (2006) review research on these interventions and mutual-help approaches like 

Alcoholics Anonymous (AA), noting both 

benefits and limitations of the use of each. 

Treatment Strategies 

A variety of interventions may help male clients; many (e.g., relapse prevention) are already in use in most treatment programs but

may be improved by adapting them specifically

for men. Others (e.g., money management)

may only be needed for some segments of the 

male treatment-seeking population. 

Enhancing Motivation 

In treatment, motivation has traditionally been

identified as something within a person, some 

type of energy or attitude a person possesses 

that can facilitate change. Motivation—more 

than any other single factor—can determine a 

person’s success in recovery. Lack of motivation is often given as a reason by people who

fail to enter or do not succeed in treatment. 

Men are generally more reluctant to seek substance abuse treatment or counseling than

women and also tend to end treatment earlier 

(Addis and Mahalik 2003; Berger et al. 2005;

Blazina and Watkins 1996; Mansfield et al.

2005; Pederson and Vogel 2007). This may be 

because men use alcohol and drugs as problem-solving strategies. Substance use may be 

considered a more masculine way to deal with

stress than self-disclosure and dialog. The resistance men show to substance abuse treatment is partly a response to their perception 

111 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

that they are being asked to abandon something that helps define their masculinity.

Treatment that addresses how a man’s substance use relates to his concept of himself as a

man may prove more effective in motivating

men than treatment that does not, as increased

stress about male gender roles has been shown

to correlate with increased substance use 

(Blazina and Watkins 1996; Isenhart 1993). 

External factors (such as workplace and family 

relationships) can greatly undermine men’s 

motivation to change substance-related behaviors. In some occupations and workplaces, a

lunchtime cocktail or a drink with coworkers 

after work is considered normal; everyone is 

expected to partake. If drinking or using drugs 

on the job is encouraged or even accepted by 

coworkers, a man’s work environment will decrease his motivation to change. If a man uses 

substances with his spouse or significant other,

that relationship can decrease his motivation

to seek treatment (Fals-Stewart et al. 1999). 

Behavioral health clinicians exert considerable 

influence on enhancing motivation for positive 

change. Counseling style and approach can 

hinder or enhance a man’s motivation. For example, an authoritarian, adversarial, or confrontational style may prove less effective than

more client-centered, reflective approaches 

(Miller et al. 1993, Miller et al. 1998). 

How do behavioral health professionals motivate men to overcome commonly accepted

male attributes that can deter them from seeking help? One approach is to change the way 

treatment programs are structured to make 

them more responsive to the habits and psychosocial needs of men. Programs that allow 

clients to make decisions about their treatment and allow for different levels of involvement in various components of the program—

compared with those where clients have little 

or no input in what they do in treatment—

have proven more effective (CSAT 1999b). 

Motivational interviewing 

The panel believes that motivational interviewing is effective with many male clients (see 

http://www.motivationalinterview.org for more

information). In motivational interviewing:

•	 The clinician has a directive rather than 

authoritative role and builds trust. 

•	 The clinician continually focuses on client

strengths rather than weaknesses. 

•	 Treatment is individualized and client 

centered. 

•	 Clients’ autonomy and decisions are respected. 

•	 Clients are encouraged to discuss mixed

feelings about change openly. 

•	 The clinician helps clients review possible 

strategies for change and initiate and

maintain any change, but the clinician

does not prescribe change. 

•	 Clients decide whether, to what degree, in

what timeframe, and by what means 

change will occur (Isenhart 2001). 

Client-centered approaches can help alleviate 

the feelings of helplessness and lowered selfesteem that men tend to express on entering

treatment and give them a sense of autonomy,

increasing their motivation to change. Motivational interviewing can be especially effective 

for clients who are ambivalent about ending

their substance use (Miller and Rollnick 

2002). TIP 35 (CSAT 1999b) contains more 

detail on motivational interviewing, providing

incentives, and other interventions aimed at

motivating clients; the TIP also explains the 

process of changing substance use behavior in

relation to the stages of change model. 

Coercion in treatment 

Men who are coerced or mandated into treatment do as well as or better than those presenting voluntarily. It is a misconception that

coerced or mandated means forced. Coercion,

whether by an employer acting through an

employee assistance program or by a drug 

112 
Chapter 5–Treatment Modalities and Settings 

 

 

court, means the client was given a choice between treatment and the consequences of continued substance use, such as job loss, loss of

parental rights, or incarceration. Among men,

a choice between two inevitable outcomes is 

qualitatively different from an order by an authority figure and has a far more positive effect

on motivation to enter and stay in treatment

(Miller and Flaherty 2000). 

Behavioral health counselors should be prepared, however, to work with a male client’s 

anger over being coerced or mandated into

treatment. This anger may be expressed directly through verbal tirades about authorities, or

it may be expressed passively through missing

appointments, coming late to sessions, or not

participating in sessions; in other cases, the 

anger may be buried and the man may deny 

negative feelings about being coerced into

treatment. Behavioral health counselors should 

not assume that anger does not exist merely 

because it is not directly expressed, and clients 

should be encouraged to discuss their anger as 

part of treatment. Discussing anger, however,

is different from expressing the anger in ways 

that are destructive to oneself or others. Once 

this anger is resolved, differences in treatment

outcomes between coerced, mandated, and

voluntarily admitted clients is negligible. 

Relapse Prevention and Recovery 

A number of studies have shown that despite 

men and women being about equally likely to

relapse to alcohol use, men are significantly 

more likely to relapse to illicit drug use (see 

review by Walitzer and Dearing 2006). Research has also found that, following treatment, men have higher rates of relapse than

women who attend the same treatment programs (Walitzer and Dearing 2006; Weiss et

al. 1997). Walitzer and Dearing (2006) also

speculate, based on others’ research, that women may recover more quickly from a relapse 

than men. For these reasons, relapse prevention should be a key component of substance 

abuse treatment for men. 

Various studies have attempted to identify the 

determinants of relapse (Chaney et al. 1982; 

Marlatt 1985, 1996; McKay et al. 1996; Miller

et al. 1996; Strowig 2000; Zywiak et al.

2006a). One popular strategy is to distinguish

interpersonal from intrapersonal causes of relapse. Strowig (2000), using a model developed

by Marlatt (1985), categorizes interpersonal 

determinants as high risk events external to the

person (e.g., arguing with someone, being

around others who are drinking) and intrapersonal determinants as events internal to

the individual, referred to as negative emotional states. He found that among White

middle-class men dependent on alcohol, the 

immediate causes of relapse varied significantly; however, depressed mood (an intrapersonal 

cause) was most often endorsed as the primary 

cause. The one interpersonal determinant

identified by study participants as a trigger for

relapse was social pressure. 

McKay and colleagues (1996) studied 98 men

and women dependent on cocaine and found

that negative emotional states were often an

antecedent for relapse among men; however,

their research indicated that men were also 

more likely than women to report positive affect before relapse. This may be because men

have a harder time expressing their negative 

feelings than they do positive ones. In this 

study, men’s relapse episodes were longer than 

women’s; men said they were less likely to seek 

help after initial use because they believed

they could control their cocaine use, could get

away with more cocaine use, and felt entitled

to use more cocaine (McKay et al. 1996). 

Other research has found that men are less 

likely than women to attribute a relapse to

negative affect but more likely than women to

attribute it to social pressure (Zywiak et al.

2006b). This may relate to men being more 

113 
 

 

Addressing the Specific Behavioral Health Needs of Men 

likely to relapse while with friends, whereas 

women are more likely to relapse in the presence of intimate partners (Rubin et al. 1996).

It also, however, reflects the fact that men appear to be exposed to a greater number of negative social influences and offers of alcohol or 

drugs than women, which holds true even after controlling for other background factors

(Walton et al. 2001). For these reasons, men

should be encouraged to seek help quickly if

relapse occurs. Denying or minimizing the potential seriousness of relapse can prolong the 

episode, making help seeking more difficult

(McKay et al. 1996). 

Men and women typically have different coping skills, which can play an important role in

relapse prevention. Women often enter treatment with fewer resources than men, but over

time they appear to do better than men at developing coping skills (Moos et al. 2006;

Timko et al. 2005). These researchers followed

230 women and 236 men who had completed

treatment for alcohol use disorders for a 16­

year period and found that men had worse social resources and coping skills than women

during the follow-up period. For men, but not

women, a longer duration of treatment was 

linked with improved coping skills (whereas 

for women, but not men, continued 12-Step 

participation had a significant effect). Also,

decreases in avoidance coping (i.e., techniques 

that help one avoid a problem) and drinking

to cope were tied to better outcomes for men

but not women. Thus, men may need more 

help developing approach coping skills (i.e.,

techniques that address the problem) to replace 

avoidance coping. 

The findings on relapse determinants for men

are inconsistent, so providers must thoroughly 

assess each client and determine his strengths 

and weaknesses. Considering such factors as

the presence of mental illness, current relationship problems, or employment difficulties 

may give practitioners insight into potential

stumbling blocks for clients in recovery and

allow them to more clearly decide which relapse prevention interventions are likely to be 

most effective for each individual. 

For more information on factors contributing

to relapse and those that promote recovery, see 

the planned TIP, Recovery in Behavioral 

Health Services (SAMHSA planned e), which

covers relapse prevention and recovery promotion techniques and interventions. 

Money Management 

Men in treatment can benefit from financial 

management training, which can include

learning to rely on automatic deposit and bill

paying. The temptation to use a recent

paycheck on alcohol or drugs is strong for

some men; education on profitable, positive

ways to use their money can help curb it. The

literature on this topic generally does not analyze the influences of gender, so it is unclear

what issues men in particular may face and

what forms of money management training

work best with this population. 

Some programs use payers—or money managers—who allocate funds received through Social Security or other benefits. Such programs 

are most common among individuals with cooccurring disorders (Elbogen et al. 2003). The 

utility and ethics of this approach are, however,

debatable (Rosenheck 1997). Rosen and colleagues (2001) found that clients in a mental 

health center formed therapeutic alliances with 

both clinical therapists and money managers, 

although a significant minority reported feeling coerced, which in turn was associated with

a weaker therapeutic alliance. Ries and colleagues (2004) also found some reductions in

substance use as well as improvements in

money management for individuals with cooccurring disorders who were assigned representative payers. However, such programs are 

114 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 

not always available to clients who would benefit from them. In a study of male veterans in

inpatient psychiatric hospitals, Rosen and colleagues (2002b) found that, despite a high need

for money management among substance 

abuse treatment clients with co-occurring disorders, they were often not provided financial 

management training or a representative payer. 

Treatment Settings 

Treatment settings can be broadly defined as 

inpatient (clients live on the premises) and

outpatient (clients reside elsewhere but spend

time each day or week at the treatment facility). A shift of interest from inpatient to outpatient treatment in the 1980s largely evolved in

response to pressure from funding sources 

(e.g., Medicaid, insurance companies) to reduce the cost of treatment. Outpatient programs significantly outnumber inpatient

programs (OAS 2007a), but the debate over

the relative efficiency of inpatient (or residential) versus outpatient programs has continued. 

An important consideration across treatment 

settings is whether the program will treat both

men and women (i.e., mixed-gender programs) or men alone (i.e., male-specific or single-gender programs). The panel was unable 

to find research evaluating the advantages and

disadvantages, for male clients, of singlegender substance abuse treatment settings, despite the fact that many such programs exist

(particularly in criminal justice settings). The 

discussion of single-gender groups for men

(see “Single-Gender Groups for Men” earlier

in this chapter) applies equally to determining

the pros and cons of single-gender programs. 

Outpatient Treatment Services 

Besides offering economic incentives to programs that need to cut costs, outpatient treatment provides several benefits not found in 

inpatient treatment programs. Notably, it enables men to maintain jobs and/or families 

while in treatment. Men who have stable living situations, are employed, have been courtordered to treatment, or have concerned

spouses involved in their treatment do well in

outpatient settings (Finney et al. 1996). Men

ages 50 and above have less severe drinking

problems than men between the ages of 35

and 44 and also tend to do well in outpatient

settings (Neve et al. 1999); older age is also

associated with better retention in outpatient

treatment for men but not women (Mertens 

and Weisner 2000). Men who feel pressure to

provide for their families may be reluctant to

enter inpatient treatment. In any case, men

with substance use disorders can and should 

have a say in determining the type of setting

in which they will receive treatment. 

Intensive outpatient treatment has become 

increasingly popular; it provides a higher level 

of service, along with more frequent and intensive treatment services, than more traditional outpatient programs. Many types of

intensive outpatient programs exist, but in

general, these programs provide 9 to 15 hours

a week of treatment spread over 3 to 5 days per

week (CSAT 2006c). For more information, see 

TIP 46, Substance Abuse: Administrative Issues in 

Intensive Outpatient Treatment (CSAT 2006b), 

and TIP 47, Substance Abuse: Clinical Issues in 

Intensive Outpatient Treatment (CSAT 2006c). 

Men attend a greater average number of outpatient sessions than women (McCaul et al. 

2001), but they are significantly more likely 

to miss outpatient appointments than women

(Coulson et al. 2009). It is likely, however, that

the factors associated with better retention in 

outpatient treatment differ between men and

women. For example, Mertens and Weisner

(2000) found that for women, better retention

in outpatient treatment was associated with 

higher income, being unemployed, being married, and having less severe mental problems, 

115 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

whereas for men, it was associated with being

older, entering treatment as a result of employer suggestion, and having an abstinence goal. 

A European study found that men with alcohol use disorders who completed outpatient

treatment had better abstinence rates than 

women 2 years after treatment (Soyka and

Schmidt 2009). Again, however, factors associated with better outcomes are likely different

for men than for women. Green and colleagues (2004) found that for men (but not

women), the best predictors of abstinence at a

7-month follow-up were the severity of substance abuse, mental problems, and physical 

health problems, whereas for women, social,

sociodemographic, and life history factors were 

the strongest predictors of outcomes. For men,

but not women, living alone was associated

with significantly poorer abstinence outcomes. 

Residential/Inpatient Treatment 

Services 

It makes intuitive sense that isolating men

from environments that expose them to people, surroundings, and opportunities that encourage substance abuse helps them maintain

abstinence. In contrast to residential treatment, outpatient programs allow men with

substance use disorders access to friends, places, and events associated with the use and

abuse of alcohol and/or drugs. On the other

hand, participation in outpatient treatment

enables men to practice coping skills in a realworld environment. Residential programs may 

vary in some ways, but the American Society

of Addiction Medicine (ASAM 2001) defines

them as safe, permanent facilities with 24-hour

staffing that provide treatment according to

“defined policies, procedures, and clinical protocols” (p. 71). Residential programs allow clients to receive the largest, most intense dose 

of treatment. When considering the efficiency 

of inpatient versus outpatient treatment for

men, take the particular circumstances of the 

client’s life into account. Inpatient treatment 

may be preferable for people with more severe 

substance use disorders and those with cooccurring disorders (Rychtarik et al. 2000); men

who are homeless or living in environments 

that encourage or support substance use are

also good candidates for inpatient treatment. 

Residential treatment, compared with outpatient treatment, is associated with significantly 

better abstinence outcomes for men but not 

women, suggesting that it may be an especially 

important option for some men (Hser et al.

2003). Men entering treatment are less likely 

than women to have dependent children living

with them but also more likely to be employed—both factors that need to be considered when selecting inpatient treatment. 

Many residential models exist for men’s treatment. Typically, they involve a 5- to 30-day stay

in a hospital, other medically oriented facility,

or treatment program that provides detoxification and treatment services for all substances of 

abuse. These programs generally offer group

and individual counseling, psychoeducational 

classes that address substance abuse and related health issues, and a variety of other treatment experiences, including 12-Step groups. 

Therapeutic communities (TCs) are a type of

residential program that became popular in

the 1960s. These usually provide treatment

lasting at least 9 months, and often require 

participants to make progress through specified treatment phases. TCs reward treatment

progress by allowing clients progressively more 

privileges and less structure. TCs have been

successfully implemented in criminal justice 

environments, wherein TC participants can be 

physically segregated from the at-large prison

population and their activities closely prescribed and monitored (for more information,

see TIP 44, Substance Abuse Treatment for 

Adults in the Criminal Justice System [CSAT 

2005b]). Although many modifications exist, 

116 
Chapter 5–Treatment Modalities and Settings 

 

traditional TCs are defined by their comparatively confrontational treatment approach. For

clients with co-occurring disorders or other 

special needs, a modified TC approach is sometimes needed (see TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring Disorders [CSAT 2005c], for more information). 

Few studies have investigated gender differences in TC outcomes; most are older and

may not reflect current conditions (see review 

in Messina et al. 2000). Messina and colleagues (2000) compared outcomes for men

and women who had participated in a TC

program (participants were interviewed, on

average, 19 months after treatment) and found

few significant differences. At follow-up, men

were significantly more likely to be employed

and to have had a recent arrest, which reflected the same patterns seen at baseline, but

there were no significant differences in program completion or in substance use for completers. However, Chan and colleagues (2004)

found that men, especially those ages 18 to 25,

had significantly lower scores on a composite 

measure of community involvement and integration into the TC, suggesting that men had

poorer engagement in the TC than women. 

As with other treatment settings, program

completion is associated with better outcomes 

in residential treatment. In a study of predominantly male clients dependent on heroin,

treatment completion as well as greater reliance on coping skills were related to being

able to avoid full relapse to heroin use (i.e.,

regular use as opposed to a single instance of

use) at follow-up (Gossop et al. 2002). A study 

(Maynard et al. 1999) of residential treatment

completers, most of whom were men, found

that they needed fewer expensive acute care 

services for medical and mental health needs 

than before treatment. Male prisoners in an

in-prison TC and a community-based transitional TC had significantly reduced recidivism 

rates after being released, particularly if they 

participated in residential continuing care

(Hiller et al. 1999). 

A combination of inpatient and outpatient

treatment may be just as successful as longterm inpatient approaches. In a study of 296

men who sought treatment for cocaine abuse,

half entered a standard program of 10 months 

of inpatient treatment followed by 2 months 

of outpatient treatment. The others received 6

months of inpatient treatment followed by 6

months of outpatient treatment. Client outcomes for both programs were similar; the one

factor linked with reduced recidivism was program completion. Men who finished either

program were significantly less likely to have 

been arrested and more likely to be drug free 

and employed at 12-month follow-up than

those who did not finish (Messina et al. 2000). 

Comparing Inpatient and 

Outpatient Treatment Services 

In Finney and colleagues’ (1996) review of research on the effects of treatment settings, 13

studies on alcohol dependency were analyzed

across several variables related to successful 

treatment outcomes. Seven of the studies reviewed found a significant difference in outcome favoring inpatient over outpatient

services, and two found more favorable outcomes for day-treatment outpatient settings 

than for inpatient programs. No distinction

was made between intensive outpatient treatment and traditional outpatient approaches,

although behavioral health professionals in the 

field usually consider day treatment programs 

to be a form of intensive outpatient treatment.

Finney et al. suggest that most rationales promoting inpatient over outpatient programs

involve emphasis on why or how each setting

produces positive effects. However, the authors 

advise examining, instead, what type of person

benefits most from one setting or another.

More specifically, the extent of a man’s abuse 

117 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

of substances, along with his home environment, social competence, physical health, cooccurring mental disorders, and other factors,

can affect treatment outcomes relative to setting. Finney and colleagues (1996) note that 

although some of these mediator variables are 

represented in ASAM patient placement criteria, which match clients to treatment options, more research is needed to determine 

the validity and relative usefulness of these 

criteria. 

Although Finney and colleagues’ (1996) review supports better outcomes for inpatient

programs in general, the authors also note that

outpatient clients who had neither a detoxification period nor another brief respite from

their usual environment had poorer outcomes 

than those who did. Variations in treatment 

intensity and duration also affected outcomes.

Inpatients generally received extensive services 

every day; outpatients may have received only 

a few hours of services per week. In addition,

more inpatients completed treatment than

outpatients. Six of the seven studies reviewed

found significant differences between the settings, with the more effective setting providing

the most intensive treatment regimen. 

Research with a largely (91 percent) male 

group of veterans found that, for individuals 

with less severe drug use disorders (as determined by Addiction Severity Index scores),

outpatient treatment was associated with better outcomes than inpatient treatment. For

those with less severe alcohol use disorders,

there were no significant differences based on

setting, but for those with more severe problems, inpatient treatment was associated with

better outcomes (Tiet al. 2007). 

Rychtarik and colleagues (2000) found that

matching clients with alcohol use disorders to

the specific setting that could best meet their

needs created the best outcomes. Specifically,

they found that people with high alcohol 

involvement (e.g., greater obsession with

drinking, more severe withdrawal, more loss of

control when drinking) fared best with inpatient treatment, whereas people with low involvement benefited most from the outpatient

program (Rychtarik et al. 2000). However,

other studies (Gottheil et al. 1998; Weinstein

et al. 1997) failed to show any significant differences for treatment outcomes when comparing traditional and intensive outpatient

programs. Providers should expect some problems (e.g., serious health concerns) to be better

handled in an inpatient program and others

(e.g., less severe substance abuse) to be better

treated in outpatient settings. 

Mutual-Help Groups 

Mutual-help groups encompass a variety of

groups organized by people in recovery to help

others recover from substance abuse and dependence. These groups generally focus on one

type or group of substances but are often accepting of people who have abused other substances. Groups are also available to support

family and friends of the person with a substance use disorder. These groups are not

treatment interventions, but many treatment

programs use them as a support for clients.

Mutual-help groups also offer benefits that 

may be lacking in treatment settings but are

useful in building new social networks for clients, enabling them to get advice and moral 

support from others who have experienced the 

same types of problems they are facing. 

Mutual-help groups benefit many men recovering from substance use disorders (Humphreys

et al. 2004; Isenhart 2001; Moos 2008), especially when attended in addition to treatment

(Ritsher et al. 2002), but they may not be as 

effective for particularly ambivalent men. The 

planned TIP, Recovery in Behavioral Health 

Services (SAMHSA planned e), contains more 

information on the effectiveness of these 

118 
Chapter 5–Treatment Modalities and Settings 

 

 

 

Advice to Behavioral Health Clinicians: Helping Men Transition Into Mutual-Help 

Groups 

• Take time to review with the client where and when the most convenient meetings for the client 

to attend are held, as well as what type of meetings are available for him. 

• Do not force a client to attend a mutual-help group in which he does not feel comfortable; the 

behavioral health clinician should also be able to suggest other possibilities if one type of group 

is not working for the client. 

• A client may be hesitant to attend a meeting where spiritual principles may be discussed (as in a 

12-Step group); in such cases, the behavioral health counselor can encourage the client to explore, with other group members, the meaning of spirituality as expressed in the program. 

• Help clients prepare for their first meeting by discussing concerns the client has about attending. 

• In most areas, behavioral health counselors can contact the local AA Intergroup (a regional organizing body) to bring AA orientation meetings to the treatment facility, if desired, or arrange 

for group members to accompany new clients to their first meeting. 

• Each treatment facility should at least have a current meeting list of 12-Step meetings that focus 

on alcohol and drug use. Behavioral health clinicians are advised to attend both 12-Step and 

other mutual-help meetings in their area to learn about such groups and to better understand 

the recovery stories of their clients and others. 

• The general public may attend any AA meetings listed as open. Closed meetings are reserved 

for those who have a desire to quit drinking. 

• Men with co-occurring disorders may feel more comfortable in meetings designed specifically for 

this population (discussed in greater detail later in this chapter). 

groups in improving recovery rates for people

with substance use disorders. CSAT’s (2008a)

fact sheet on mutual-help groups offers more 

detail on some groups mentioned here. 

Behavioral health counselors can facilitate a 

more comfortable transition for clients into 

mutual-help groups (see advice box below) by

preparing them for what to expect. It is important that the counselor take time to review

with the client where and when the most convenient meetings for the client to attend are 

held, as well as what type of meetings are 

available for him. For example, 12-Step programs often offer meetings for men only.

Some clients may express hesitation about attending a meeting where spiritual principles 

may be discussed; in such cases, the counselor

can encourage the client to try both 12-Step 

and more secular meetings until he finds the 

combination of meetings he prefers. No client

should be forced to attend a mutual-help

group in which he feels uncomfortable; the

behavioral health clinician should be able to 

suggest other possibilities if one type of group

is not working for the client. Even so, a client

should be encouraged to attend enough meetings to become familiar and assimilate with 

the group before deciding that the group is 

not working for him. 

The next section focuses on 12-Step groups 

but is not meant to promote or represent one 

group structure over another, nor to imply 

limitations for one recovery group compared

with others. Given their widespread availability, 12-Step groups appear more in the literature, and a more extensive body of research 

exists to support their use when combined

with a treatment program (Fiorentine 1999;

Fiorentine and Hillhouse 2000; Humphreys 

and Moos 2007; Timko and DeBenedetti

2007; Vaillant 2005; Weiss et al. 2005). Other

mutual-help groups are also examined. 

12-Step Programs 

The best known mutual-help groups are 12­

Step programs like AA, Narcotics Anonymous 

119 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

(NA), and Cocaine Anonymous. These mutual-help programs make use of the 12 Steps for

recovery originally developed by AA. Attendance at 12-Step groups is often recommended

to men in recovery and can be successful in

helping them abstain from substance use and

sustain their recovery—either alone or in

combination with treatment programs. The

12-Step community teaches men and women

how to overcome dependence on substances or 

behaviors by developing reliance on the group

for support. (Sandoz 2000; Vaillant 2005). 

One survey (AA World Services [AAWS]

2008) showed that men outnumber women

attending AA (67 percent of attendees were

male; 33 percent were female). This reflects, in

part, the higher incidence of substance use 

disorders among men (as discussed in Chapter

1). Findings are mixed on whether men are 

more likely than women to attend 12-Step 

groups. Simons and Giorgio (2008) found that

men entering a substance abuse treatment

program were significantly more likely to have 

previously attended 12-Step groups than were 

women entering the same program. However,

Moos and Moos (2006) found that after treatment, women were more likely to attend AA

and attended a greater number of meetings. 

Many men feel comfortable with the 12-Step 

model, and it was originally developed by men

for other men. However, particularly ambivalent male clients may have trouble with the

only acceptable goal being abstinence, especially with regard to alcohol consumption.

Others may have difficulty with the spiritual 

aspects of these programs (see Chapter 3 and

discussion below) or with admitting powerlessness and submitting to a higher power,

which can conflict with some masculine 

norms (Isenhart 2001). 

Attending 12-Step meetings (and other mutual-help groups) is free, and meetings are readily available throughout the country, with some 

groups designated for men only. There are also

meetings for gay men, people who speak 

Spanish, and people with impaired hearing. 

Counseling men on beginning a 12­

Step program 

Men attending 12-Step meetings frequently 

hear “Don’t use, go to meetings, and ask for

help.”These simple directions provide a basic

explanation of how to practice a 12-Step program with men who are new to it. Coming

into a 12-Step meeting for the first time can

be an unnerving experience involving fear,

doubt, and insecurity (AAWS 2001)—feelings 

that most men were never taught how to deal 

with effectively. Our society’s idea of masculinity suggests to men that they should not 

have such feelings, let alone talk about them 

(Pollack 1998a; Real 1997). Yet at 12-Step 

meetings, an open discussion of such feelings 

is encouraged. Attending 12-Step meetings 

and admitting one’s fears and doubts through

fellowship with other 12-Step members is a

way for men to grow closer to others safely 

and to maintain abstinence. For men who have 

never been able to trust others, let alone reveal 

their real feelings, mutual-help fellowship (not

just in 12-Step groups) is a wonderful means 

for learning how to do so. 

Sponsorship 

From childhood on, most men are taught to

compete, which leads them to compare themselves to others. Thus, many men with substance use disorders use the self-centeredness 

that competing and comparing produces as a 

coping mechanism. This attitude can become 

a major stumbling block, often causing the 

man who is new to recovery to resist listening

to the others in a group or to refuse to admit 

that others might have helpful insights to offer

about recovery. AA encourages members to

learn how to include, rather than exclude,

themselves from fellowship with others. One 

way in which this is accomplished is through 

120 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 

sponsorship. A sponsor is a program participant on whom a group member relies for support and encouragement, especially when new 

to the program. 

Behavioral health clinicians can aid clients by

educating them about 12-Step sponsorship.

12-Step programs normally advise newcomers 

to look for a sponsor with at least one year of

abstinence. During treatment, the counselor

can suggest that clients look for sponsors with

positive attributes, such as humility, gratitude 

for abstinence, a nurturing personality, or an

admirable sense of humor. Men are normally 

asked to seek male sponsors. The counselor’s 

suggestions for choosing sponsors should be 

offered to clients in a manner that does not 

interfere with 12-Step program autonomy.

Treatment facilities may be able to use program 

alumni (with their consent) as temporary sponsors for clients entering a 12-Step program. 

12-Step programs and spirituality 

In a 12-Step program, steps 2, 3, and 11 are 

dedicated to spirituality. AA, NA, and similar

groups are based on the idea of changing not

only behavior, but also beliefs. Spirituality in

this context is understood as a three-part relationship: with oneself, with others, and with a

higher power sometimes called God (AAWS

2001). Groups promote spiritual awakening

and revive hope among the men who participate in them. Men with substance use disorders are often isolated because their disorder 

has destroyed most or all of their relationships.

They often think their past and current life 

circumstances are unique and hopeless. As 

these men participate in 12-Step groups, they 

quickly discover that they are not unique, and

they reclaim hope. Thus, the spiritual/religious 

aspects of life are revived and assist in recovery 

(Calamari et al. 1996; Connors et al. 2008;

Vaillant 2005; Zemore 2008). 

AA is not a religious organization, nor is it

allied with any religious organization, but 

most AA members believe that the key to

overcoming substance abuse is not through 

individual willpower but through a power

greater than themselves, which group members are encouraged to define for themselves.

The program derives some principles and

practices (e.g., saying the Lord’s Prayer) from 

the Christian tradition. Although AA’s emphasis on turning to a higher power seems, at

first glance, to conflict with the therapeutic

axiom that clients are responsible for their

own recovery, men who attend AA also develop a sense of responsibility for their own actions as they work through the 12 Steps (Page 

and Berkow 1998). 

Clients who are apprehensive about joining a

12-Step program because of the spiritual element may benefit from a discussion of the difference between spirituality and religion (see 

the “Spirituality and Religion” section in Chapter 4) and the role spirituality can play in recovery. However, such clients should be 

reassured that their concerns are common and 

that AA will not demand that they hold beliefs to which they are opposed (AAWS 2001).

Alternatively, in many areas, there are other

mutual-help groups that do not make use of

spiritual principles or that use principles better

suited for a specific tradition of faith. 

Other Mutual-Help Groups 

Antipathy toward the spiritual aspects of 12­

Step programs is a major reason some men

wish to attend a different type of mutual-help

group. Organizations like Self-Management

and Recovery Training (SMART Recovery) 

and Secular Organizations for Sobriety (SOS) 

remove the spiritual overtones found in 12­

Step groups but still focus on fellowship and

the importance of helping one another maintain abstinence. Other groups are available

that are more sensitive to particular individuals’ religious or cultural backgrounds as well. 

121 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Some substance abuse mutual-help groups 

that do not use the 12-Step model are:

•	 SMART Recovery

(http://smartrecovery.org/). 

•	 SOS (http://www.cfiwest.org/

sos/index.htm). 

•	 Jewish Alcoholics, Chemically Dependent

Persons, and Significant Others

(http://www.jacsweb.org/). 

•	 LifeRing Secular Recovery

(http://lifering.org). 

Mutual-Help Groups for CoOccurring Disorders 

Men who have both a substance use and a 

mental disorder (or have certain physical disabilities) may find groups composed of individuals who share similar difficulties beneficial. 

For instance, Double Trouble in Recovery 

(http://www.bhevolution.org/public/

doubletroubleinrecovery.page) and Dual Recovery Anonymous (http://www.draonline.org) 

are organizations that expand upon and/or

adapt the traditional 12 Steps. Dual Disorders 

Anonymous, Dual Diagnosis Anonymous, and

others also use variations of the 12-Step model.

For more information on mutual-help and other types of assistance for people with cooccurring disorders, see TIP 42 (CSAT 2005c). 

Community Influences 

Many forces in the community influence 

treatment success for men. These include the 

availability of drugs in the community and the 

attitudes of the community toward substance 

abuse and recovery, especially in terms of

community and workplace support for recovery. In addition, there is a growing recognition

of the severe effects of underage drinking, in

terms of both the effect of alcohol on the developing brain and the fourfold increase in the 

likelihood of having symptoms of alcohol dependency in adulthood for those who drink 

before 15 years of age compared with those 

who do not drink until they are 21 years old

(Grant and Dawson 1997; Grant et al. 2004a;

Masten et al. 2008; U.S. Department of

Health and Human Services [HHS] 2007).

Community support and understanding of the

importance of reducing underage drinking can

help reduce the rate of alcohol dependency in

adulthood. Prevention programs that influence 

the response of communities to drinking prior

to adulthood work toward the long-term outcome of reduced rates of alcohol use disorders 

in adult men. SAMHSA’s interagency portal 

(http://www.stopalcoholabuse.gov), for example, is representative in its role with regard to

community efforts that bring together HHS

partners and other Departments in an effort to

address underage alcohol use. 

Community Attitudes and 

Perspectives 

Community attitudes toward 

substance use, substance abuse 

treatment, and recovery 

Community attitudes toward and understanding of substance use and abuse, substance 

abuse treatment, and recovery from substance 

use disorders vary widely. In 2001, the Centers 

for Disease Control and Prevention (CDC)

established its Alcohol Team to strengthen

research efforts in the prevention of excessive 

drinking, binge drinking, and underage drinking and to better understand the health outcomes of these behaviors. The Alcohol Team 

conducts public health surveillance of risky behaviors and the impact of disease, reviews the 

effectiveness of population-based interventions,

and helps State-based epidemiologists draw

attention to these harmful behaviors and strategies to prevent them. CDC also supports experts in evaluating and recommending

interventions for community responses to alcohol use; currently, recommendations are available for regulating alcohol outlet density, 

122 
Chapter 5–Treatment Modalities and Settings 

 

 

 

 

 

 

 

 

 

limiting days/hours of sale, increasing alcohol 

taxes, and enhancing enforcement of underage 

drinking laws (http://thecommunityguide.org/

alcohol/index.html). 

The impact of the employee assistance field

over the past four decades has significantly

changed community attitudes toward substance abuse treatment and recovery. By 

providing an understanding of substance use 

disorders as treatable illnesses to employees and

their families and by fostering treatment and

recovery in companies of all sizes (Attridge et 

al. 2009), employee assistance programs have 

affected community attitudes and workplace 

culture (National Institute on Alcohol Abuse 

and Alcoholism [NIAAA] 1999). Still, stigma

remains widespread. An epidemiologic study 

(Perron et al. 2009) of barriers to seeking

treatment found that roughly a quarter of 

those who admitted the need for treatment 

but did not seek it stated that being too embarrassed was a factor in their decision. 

Community perspectives on men’s 

roles, expectations, and obligations 

A man’s recovery from addictive illness does 

not end when he completes treatment. Renewed support for a view of substance use disorders as chronic illnesses (e.g., McLellan et 

al. 2000) has initiated interest in long-term 

recovery and extended ongoing systems of

care. SAMHSA’s Recovery-Oriented Systems 

of Care (ROSC) initiative helps build resources for men in ongoing recovery and includes initiatives for stronger community 

support of health care, career development,

criminal justice services, relapse prevention,

spirituality, and wellness. ROSC increases a 

community’s capacity to address the needs of

clients in ongoing recovery from substance use 

disorders. For information on this process, see

SAMHSA’s Partners for Recovery Web site

(http://www.partnersforrecovery.samhsa.gov/

rosc.html). 

Drug Availability, Marketing, and 

Pricing 

Conducting research on the ways in which

drug availability, drug marketing, and the prices of drugs are associated with drug use and

substance use disorder outcomes can be challenging. Researchers often comment on the

complex phenomena related to cumulative effects (Hastings et al. 2005) and on the impossibility of absolute certainty or precision,

although there is enough evidence to show

that addictive goods are sensitive to price 

(Grossman 2004; Kilmer et al. 2010; Müller et

al. 2010). These complexities place a thorough

examination of drug availability, marketing,

and pricing considerations outside the scope 

of this TIP, but brief mention of this research

in the context of men’s substance abuse treatment needs and outcomes is warranted. 

Studying three decades of data, Grossman

(2004) concluded that cigarette smoking, alcohol consumption, binge drinking, marijuana

and cocaine use, and probably other illicit drug

use are all price sensitive, especially for high

school seniors. For example, after accounting

for changes in the minimum legal drinking

age and in the lowering of the maximum permissible blood alcohol concentration in terms 

of drunk driving laws, the 7 percent rise in the 

real price of beer in the early 1990s due to a

hike in the Federal excise tax could still account for nearly the entire 4-percentage-point

reduction in binge drinking during that time. 

Similarly, Hastings and colleagues (2005) 

warned against categorical statements of cause 

and effect in social science research but concluded that a compelling picture is developing

of the effects that alcohol marketing has on

drinking in early adulthood. 

In terms of general availability, the evergrowing problem of prescription drug misuse 

over the past decade is a clear example of how 

availability may foster substance use disorders. 

123 
Addressing the Specific Behavioral Health Needs of Men 

However, rigorous research on the multiple 

factors related to availability and use produces

complex findings that are not easily summarized. One finding directly related to men is 

that in counties in Kentucky that limit or ban

the sale of alcohol, those convicted of driving

while under the influence in those counties 

were more likely to be male (Webster et al.

2008). From a study of New Orleans evacuees 

following Hurricane Katrina, it seems as if

lack of availability may have played a positive

role for some men and women in terms of 

both cessation and short-term relapse prevention (Dunlap et al. 2009). 

With the growth of new forms of social media, the ever-changing aspects of supply and

price, and major changes in community attitudes, laws, and regulations, the impact of

community influences on substance use in

men is likely to be significant. Ongoing studies of drug availability, price, and community

responses to prevention and treatment may 

add to an understanding of these relationships 

and play a role in policy development and delivery of care for substance use disorders (e.g.,

NIAAA’s Alcohol Policy Information System 

[http://www.alcoholpolicy.niaaa.nih.gov/];

Kilmer et al. 2010). 

Helping Men Live With 

the Residual Effects of 

Substance Abuse 

The effects of substance abuse are long lasting

and extend well into recovery for most men.

Many men, particularly those who began using substances in adolescence and young

adulthood, lack the interpersonal and psychosocial skills necessary for negotiating adult life 

in recovery. Additionally, depression, anxiety,

trauma syndromes, and other mental illness 

symptoms may extend well beyond the substance use. In fact, some problems may be 

more obvious when the recurring crises of

substance use have subsided. Problems with 

relationships, employment, career, management of finances, physical health, and the

criminal justice system may likewise extend

well into recovery. 

As men move beyond initial treatment and

early recovery, treatment needs do not diminish; their focus simply changes. Treatment may 

be more about overcoming developmental lags, 

managing and maintaining success in life, and

coming to grips with psychological trauma. It

may involve building on new strengths, taking

carefully considered risks, and developing and

enhancing new aspects of relationships. It may 

also include new or altered definitions of 

manhood and masculine roles. Counselors may 

shift from leading the client to walking alongside him in a supportive, validating manner. 

In a similar vein, recovery does not end when

treatment terminates. Recovery and personal 

growth are lifelong processes. Men in recovery 

will find new needs emerging continually, such

as identifying themselves as parents and developing new parenting skills; becoming involved as citizens in community activities like

drug-free coalitions or other community resources; participating more actively in faithbased activities and redefining their sense of

spirituality; growing as part of a primary and

extended family; rethinking career choices and

goals; developing new recreational pursuits;

and, above all, recognizing that their histories

of struggle and success have led them to be 

who they are in the present. 

124 
 

 

Appendices 

Appendix A—Bibliography 

Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, 

E., and Alegria, M. Use of mental health-related services among immigrant and U.S.-born

Asian Americans: Results From the National Latino and Asian American Study. American 

Journal of Public Health 97(1):91–98, 2007. 

Abueg, F.R., and Fairbank, J.A. Behavioral treatment of posttraumatic stress disorder and cooccurring substance abuse. In: Saigh, P.A., ed. Posttraumatic Stress Disorder: A Behavioral 

Approach to Assessment and Treatment (pp. 111–146). Needham Heights, MA: Allyn and 

Bacon, 1992. 

Adams, W.L., and Cox, N.S. Epidemiology of problem drinking among elderly people.

International Journal of the Addictions 30(13–14):1693–1716, 1995. 

Addis, M.E., and Mahalik, J.R. Men, masculinity, and the contexts of help seeking. American 

Psychologist 58(1):5–14, 2003. 

Administration for Children and Families. Child Support Enforcement Program Fact Sheet. 

Washington, DC: U.S. Department of Health and Human Services, 2002. 

Administration for Children and Families. Child Maltreatment 2002: Reports From the States to

the National Center on Child Abuse and Neglect. Washington, DC: National Clearinghouse on 

Child Abuse and Neglect Information, 2004. 

Aguirre-Molina, M., Molina, C.W., and Zambrana, R.E. Health Issues in the Latino Community. 

San Francisco: Jossey-Bass, 2001. 

Albanese, M.J., Clodfelter, R.C., Jr., Pardo, T.B., and Ghaemi, S.N. Underdiagnosis of bipolar

disorder in men with substance use disorder. Journal of Psychiatric Practice 12:124–127, 2006. 

Alcoholics Anonymous World Services. The AA Member—Medications and Other Drugs: A Report 

From a Group of Physicians in AA. New York: Alcoholics Anonymous World Services, 1984. 

Alcoholics Anonymous World Services. Alcoholics Anonymous: The Story of How Many Thousands 

of Men and Women Have Recovered From Alcoholism, 4th ed. New York: Alcoholics 

Anonymous World Services, 2001. 

125 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Alcoholics Anonymous World Services. Alcoholics Anonymous 2007 Membership Survey. New 

York: Alcoholics Anonymous World Services, 2008. 

Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C.N., Takeuchi, D., Jackson, J., and Meng, 

X.L. Disparity in depression treatment among racial and ethnic minority populations in the 

United States. Psychiatric Services 59(11):1264–1272, 2008. 

Alexander, P.C., and Morris, E. Stages of change in batterers and their response to treatment.

Violence and Victims 23(4):476–492, 2008. 

Allen, J.P., and Columbus, M., eds. Assessing Alcohol Problems: A Guide for Clinicians and 

Researchers, 2nd ed. NIH Publication No. 03-3745. Bethesda, MD: National Institute on

Alcohol Abuse and Alcoholism, 2003. 

Alvarez, L.R., and Ruiz, P. Substance abuse in the Mexican American population. In: 

Straussner, S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 111–136). 

New York: Guilford Press, 2001. 

Amaro, H., Arévalo, S., Gonzalez, G., Szapocznik, J., and Iguchi, M.Y. Needs and scientific

opportunities for research on substance abuse treatment among Hispanic adults. Drug and 

Alcohol Dependence 84(Suppl. 1):S64–S75, 2006. 

American Lung Association. Trends in Tobacco Use. New York: American Lung Association, 2006. 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., 

Text Revision. Washington, DC: American Psychiatric Association, 2000. 

American Society of Addiction Medicine. Patient Placement Criteria for the Treatment of 

Substance-Related Disorders: ASAM PPC-2R, 2nd ed. Chevy Chase, MD: American Society 

of Addiction Medicine, 2001. 

Ammerman, R.T., Kolko, D.J., Kirisci, L., Blackson, T.C., and Dawes, M.A. Child abuse 

potential in parents with histories of substance use disorder. Child Abuse and Neglect 

23(12):1225–1238, 1999. 

Amodeo, M., Peou, S., Grigg-Saito, D., Berke, H., Pin-Riebe, S., and Jones, L.K. Providing

culturally specific substance abuse services in refugee and immigrant communities: Lessons 

from a Cambodian treatment and demonstration project. Journal of Social Work Practice in the 

Addictions 4(3):23–46, 2004. 

Andersson, T., Mahoney, J.L., Wennberg, P., Kuhlhorn, E., and Magnusson, D. The cooccurrence of alcohol problems and criminality in the transition from adolescence to young

adulthood: A prospective longitudinal study on young men. Studies on Crime and Crime 

Prevention 8:169–188, 1999. 

Andrews, B., Qian, M., and Valentine, J.D. Predicting depressive symptoms with a new measure 

of shame: The Experience of Shame Scale. British Journal of Clinical Psychology 41(Pt. 1):29– 

42, 2002. 

126 
 

 

 

Appendices 

Angrist, B.M. Clinical effects of central nervous system stimulants: A selective update. In:

Engel, J., and Oreland, L., eds. Brain Reward Systems and Abuse (pp. 109–127). New York: 

Raven Press, 1987. 

Antai-Otong, D. Suicide: Life span considerations. Nursing Clinics of North America 38(1):137– 

150, 2003. 

Araujo, N.P., and Monteiro, M.G. Family history of alcoholism and psychiatric co-morbidity in

Brazilian male alcoholics and controls. Addiction 90(9):1205–1211, 1995. 

Archer, J. Sex differences in physically aggressive acts between heterosexual partners: A metaanalytic review. Aggression and Violent Behavior 7:313–351, 2002. 

Arfken, C.L., Kubiak, S.P., and Koch, A.L. Health issues in the Arab American community.

Arab Americans in publicly financed substance abuse treatment. Ethnicity and Disease 17(2

Suppl. 3):S3, 2007. 

Arndt, S., Black, D.W., Schmucker, A., and Zwick, J. Association among outcomes in a

naturalistic statewide assessment of substance user treatment. Substance Use & Misuse 

39(8):1215–1234, 2004. 

Arnold, L.M. Gender differences in bipolar disorder. Psychiatric Clinics of North America 

26(3):595–620, 2003. 

Arsenault-Lapierre, G., Kim, C., and Turecki, G. Psychiatric diagnoses in 3275 suicides: A

meta-analysis. BMC Psychiatry 4(1):37, 2004. 

Atkinson, R.M., Tolson, R.L., and Turner, J.A. Factors affecting outpatient treatment

compliance of older male problem drinkers. Journal of Studies on Alcohol 54(1):102–106, 1993. 

Attridge, M., Amaral, T., Bjornson, T., Goplerud, E., Herlihy, P., McPherson, T., Paul, R., 

Routledge, S. Sharar, D., Stephenson, D., and Teems, L. History and growth of the EAP

field. EASNA Research Notes 1(1): August 2009. 

Awalt, R.M., Reilly, P.M., and Shopshire, M.S. The angry patient: An intervention for managing

anger in substance abuse treatment. Journal of Psychoactive Drugs 29(4):353–358, 1997. 

Awalt, R.M., Shopshire, M.S., Reilly, P.M., Hall, S.M., and Harris, L.S., eds. Anger Problems in 

Substance Abuse Treatment. NIH Publication No. 00-4737. Bethesda, MD: National Institute 

on Drug Abuse, 1999. 

Ayuso-Gutierrez, J.L., and del Rio Vega, J.M. Factors influencing relapse in the long-term 

course of schizophrenia. Schizophrenia Research 28(2–3):199–206, 1997. 

Bacaner, N., Kinney, T.A., Biros, M., Bochert, S., and Casuto, N. The relationship among

depressive and alcoholic symptoms and aggressive behavior in adult male emergency 

department patients. Academic Emergency Medicine 9(2):120–129, 2002. 

Baetz, M., Griffin, R., Bowen, R., Koenig, H.G., and Marcoux, E. The association between

spiritual and religious involvement and depressive symptoms in a Canadian population.

Journal of Nervous and Mental Disease 192(12):818–822, 2004. 

127 
 

Addressing the Specific Behavioral Health Needs of Men 

Bailey, L., Maxwell, S., and Brandabur, M.M. Substance abuse as a risk factor for tardive

dyskinesia: A retrospective analysis of 1,027 patients. Psychopharmacology Bulletin 33(1):177– 

181, 1997. 

Barbara, A.M., and Chaim, G. Asking about sexual orientation during assessment for drug and 

alcohol concerns: A pilot study. Journal of Social Work Practice in the Addictions 4(4):89–109, 

2004. 

Barnes, J.S., and Bennett, C.E. The Asian Population: 2000. Washington, DC: U.S. Census 

Bureau, 2001. 

Barret, R.L. Gay fathers in groups. In: Andronico, M.P., ed. Men in Groups: Insights, 

Interventions, and Psychoeducational Work (pp. 257–268). Washington, DC: American 

Psychological Association, 1996. 

Bartholomew, K., Regan, K.V., Oram, D., and White, M.A. Correlates of partner abuse in male 

same-sex relationships. Violence and Victims 23(3):344–360, 2008. 

Bartholomew, N.G., Hiller, M.L., Knight, K., Nucatola, D.C., and Simpson, D.D.

Effectiveness of communication and relationship skills training for men in substance abuse 

treatment. Journal of Substance Abuse Treatment 18(3):217–225, 2000. 

Bartholomew, N.G., and Simpson, D.D. Time Out! for Men: A Communications Skills and 

Sexuality Workshop for Men. Fort Worth, TX: Texas Christian University, Institute of

Behavioral Research, 2002. 

Bebbington, P., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., and Meltzer, H. The

influence of age and sex on the prevalence of depressive conditions: Report from the National 

Survey of Psychiatric Morbidity. International Review of Psychiatry 15(1–2):74–83, 2003. 

Begun, A., ed. Module 10D: Alcohol Use Disorders in Homeless Populations. Bethesda, MD: 

National Institute on Alcohol Abuse and Alcoholism, 2004. 

Begun, A.L., Brondino, M.J., Bolt, D., Weinstein, B., Strodthoff, T., and Shelley, G. The

Revised Safe at Home instrument for assessing readiness to change intimate partner violence.

Violence and Victims 23(4):508–524, 2008. 

Bekker, M.H., and van Mens-Verhulst, J. Anxiety disorders: Sex differences in prevalence,

degree, and background, but gender-neutral treatment. Gender Medicine 4(Suppl. B):S178– 

S193, 2007. 

Bell, N.J., Kanitkar, K., Kerksiek, K.A., Watson, W., Das, A., Kostina-Ritchey, E., Russell,

M.H., and Harris, K. “It has made college possible for me”: Feedback on the impact of a

university-based center for students in recovery. Journal of American College Health 57(6):650– 

657, 2009. 

Bennett, L.W. Substance abuse and the domestic assault of women. Social Work 40(6):760–771, 

1995. 

128 
 

Appendices 

Bennett, L., and Lawson, M. Barriers to cooperation between domestic violence and substanceabuse programs. Families in Society 75:277–286, 1994. 

Berger, J.M., Levant, R., McMillan, K.K., Kelleher, W., and Sellers, A. Impact of gender role 

conflict, traditional masculinity ideology, alexithymia, and age on men’s attitudes toward 

psychological help seeking. Psychology of Men & Masculinity 6(1):73–78, 2005. 

Bergman, B., and Brismar, B. Characteristics of imprisoned wife-beaters. Forensic Science 

International 65(3):157–167, 1994. 

Bergman, S.J. Men’s psychological development: A relational perspective. In: Levant, R.F., and

Pollack, W.S., eds. A New Psychology of Men (pp. 69–90). New York: Basic Books, 1995. 

Bernstein, D.P., and Fink, L. Childhood Trauma Questionnaire: A Retrospective Self-Report 

Questionnaire and Manual. San Antonio, TX: The Psychological Corporation, 1998. 

Bernstein, D.P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E.,

and Ruggiero, J. Initial reliability and validity of a new retrospective measure of child abuse 

and neglect. American Journal of Psychiatry 151(8):1132–1136, 1994. 

Bernstein, D.P., Stein, J.A., Newcomb, M.D., Walker, E., Pogge, D., Ahluvalia, T. et al. 

Development and validation of a brief screening version of the Childhood Trauma

Questionnaire. Child Abuse & Neglect 27:169–190, 2003. 

Bertakis, K.D. The influence of gender on the doctor-patient interaction. Patient Education and 

Counseling 76(3):356–360, 2009. 

Bertakis, K.D., Franks, P., and Azari, R. Effects of physician gender on patient satisfaction.

Journal of the American Medical Women’s Association 58(2):69–75, 2003. 

Betcher, R.W., and Pollack, W.S. In a Time of Fallen Heroes: The Re-Creation of Masculinity. 

New York: Atheneum, 1993. 

Betz, N.E., and Fitzgerald, L.F. Individuality and diversity: Theory and research in counseling

psychology. Annual Review of Psychology 44:343–381, 1993. 

Bhasin, S., Gabelnick, H.L., Spieler, J.M., Swerdloff, R.S., Wang, C., and Kelly, C. 

Pharmacology, Biology, and Clinical Applications of Androgens: Current Status and Future

Prospects. Proceedings of the Second International Androgen Workshop, Long Beach, CA.

February 17–20, 1995. New York: Wiley-Liss, 1996. 

Biddle, L., Gunnell, D., Sharp, D., and Donovan, J.L. Factors influencing help-seeking in

mentally distressed young adults: A cross-sectional survey. British Journal of General Practice 

54(501):248–253, 2004. 

Bielawski, D.M., Zaher, F.M., Svinarich, D.M., and Abel, E.L. Paternal alcohol exposure

affects sperm cytosine methlytransferase messenger RNA levels. Alcoholism: Clinical and 

Experimental Research 26(3):347–351, 2002. 

129 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Black, D.W., Carney, C.P., Forman-Hoffman, V.L., Letuchy, E., Peloso, P.M., Woolson, R.F.,

and Doebbeling, B.N. Depression in veterans of the first Gulf War and comparable military 

controls. Annals of Clinical Psychiatry 16(2):53–61, 2004. 

Black, M.M., and Krishnakumar, A. Children in low-income, urban settings: Interventions to

promote mental health and well-being. American Psychologist 53(6):635–646, 1998. 

Blake, W.M., and Darling, C.A. The dilemmas of the African American male. Journal of Black 

Studies 24(4):402–415, 1994. 

Blazer, D.G., and Wu, L.T. The epidemiology of at-risk and binge drinking among middleaged and elderly community adults: National Survey on Drug Use and Health. American 

Journal of Psychiatry 166(10):1162–1169, 2009a. 

Blazer, D.G., and Wu, L.T. Nonprescription use of pain relievers by middle-aged and elderly 

community-living adults: National Survey on Drug Use and Health. Journal of the American 

Geriatric Society 57(7):1252–1257, 2009b. 

Blazina, C., and Watkins, C.E., Jr. Masculine gender role conflict: Effects on college men’s 

psychological well-being, chemical substance usage, and attitudes towards help-seeking.

Journal of Counseling Psychology 43(4):461–465, 1996. 

Blumenthal, D.J. Suicide: A guide to risk factor, assessment, and treatment of suicidal patients.

Medical Clinics of North America 72(4):937–971, 1988. 

Bock, R. Understanding Klinefelter Syndrome: A Guide for XXY Males and Their Families. NIH 

Publication No. 93-3202. Bethesda, MD: National Institute of Child Health and Human

Development, 1993. 

Boer, D.P., Wilson, R.J., Gauthier, C.M., and Hart, S.D. Assessing risk for sexual violence:

Guidelines for clinical practice. In: Webster, C.D., and Jackson, M.A., eds. Impulsivity, 

Theory, Assessment and Treatment (pp. 326–342). New York: Guilford Press, 1997. 

Booth, A., Johnson, D.R., and Granger, D.A. Testosterone and men’s depression: The role of 

social behavior. Journal of Health and Social Behavior 40(2):130–140, 1999. 

Bourgois, P. In Search of Respect: Selling Crack in El Barrio, 2nd ed. New York, NY: Cambridge 

University Press, 2003. 

Brady, K.T., and Randall, C.L. Gender differences in substance use disorders. Psychiatric Clinics 

of North America 22(2):241–252, 1999. 

Brannon, L. Gender: Psychological Perspectives, 4th ed. Boston: Allyn & Bacon, 2005. 

Brannon, R. The male sex role: Our culture’s blueprint for manhood. What it’s done for us 

lately. In: David, D.S., and Brannon, R., eds. The Forty-Nine Percent Majority: The Male Sex 

Role (pp. 1–48). Reading, MA: Addison-Wesley, 1976. 

Brannon, R., and Juni, S. A scale for measuring attitudes about masculinity. Psychological 

Documents 14(1):Document No. 2612, 1984. 

130 
 

 

Appendices 

Braun-Harvey, D.K. Sexual dependence among recovering substance-abusing men. In:

Straussner, S.L.A., and Zelvin, E., eds. Gender and Addictions: Men and Women in Treatment 

(pp. 361–384). Northvale, NJ: Jason Aronson, 1997. 

Brennan, P.L., Moos, R.H., and Kim, J.Y. Gender differences in the individual characteristics and 

life contexts of late-middle-aged and older problem drinkers. Addiction 88(6):781–790, 1993. 

Breslau, N. Gender differences in trauma and posttraumatic stress disorder. Journal of Gender 

Specific Medicine 5(1):34–40, 2002. 

Breslau, N., Kessler, R.C., Chilcoat, H.D., Schultz, L.R., Davis, G.C., and Andreski, P. 

Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey 

of Trauma. Archives of General Psychiatry 55(7):626–632, 1998. 

Bride, B.E. Single-gender treatment of substance abuse: Effect on treatment retention and

completion. Social Work Research 25(4):223–232, 2001. 

Brook, D.W., Brook, J.S., Richter, L., Whiteman, M., Arencibia-Mireles, O., and Masci, J.R.

Marijuana use among the adolescent children of high-risk drug-abusing fathers. American 

Journal on Addictions 11(2):95–110, 2002a. 

Brook, D.W., Brook, J.S., Whiteman, M., Arencibia-Mireles, O., Pressman, M.A., and

Rubenstone, E. Coping in adolescent children of HIV-positive and HIV-negative substanceabusing fathers. Journal of Genetic Psychology 163(1):5–23, 2002b. 

Brook, D.W., Brook, J.S., Zhang, C., Cohen, P., and Whiteman, M. Drug use and the risk of

major depressive disorder, alcohol dependence, and substance use disorders. Archives of 

General Psychiatry 59(11):1039–1044, 2002c. 

Brooks, G.R. Rituals and celebrations in men’s lives. SPSMM Bulletin 1:3, 1995. 

Brooks, G.R. Treatment for therapy-resistant men. In: Andronico, M.P., ed. Men in Groups: 

Insights, Interventions, and Psychoeducational Work (pp. 7–19). Washington, DC: American 

Psychological Association, 1996. 

Brooks, G.R. A New Psychotherapy for Traditional Men. San Francisco: Jossey-Bass, 1998. 

Brooks, G.R. Masculinity and men’s mental health. Journal of American College Health 49(6):285– 

297, 2001. 

Brooks, G.R., and Good, G.E., eds. The New Handbook of Psychotherapy and Counseling With 

Men: A Comprehensive Guide to Settings, Problems, and Treatment Approaches, Vols. 1 & 2. San 

Francisco: Jossey-Bass, 2001. 

Brooks, G.R., and Silverstein, L.B. Understanding the dark side of masculinity. In: Levant, R.F.,

and Pollack, W.S., eds. A New Psychology of Men (pp. 280–333). New York: Basic Books, 

1995. 

Brower, K.J., and Carey, T.L. Racially related health disparities and alcoholism treatment

outcomes. Alcoholism, Clinical and Experimental Research 27(8):1365–1367, 2003. 

131 
 

Addressing the Specific Behavioral Health Needs of Men 

Brown, B.S., O’Grady, K., Battjes, R.J., and Farrell, E.V. Factors associated with treatment

outcomes in an aftercare population. American Journal of Addiction 13(5):447–460, 2004. 

Brown, K., and Bradley, L.J. Reducing the stigma of mental illness. Journal of Mental Health 

Counseling 24(1):81–87, 2002. 

Brown, L.S., Jr., Alterman, A.I., Rutherford, M.J., Cacciola, J.S., and Zaballero, A.R. Addiction

Severity Index scores of four racial/ethnic and gender groups of methadone maintenance 

patients. Journal of Substance Abuse 5(3):269–279, 1993. 

Brown, R.A. Crystal Methamphetamine Use Among American Indian and White Youth in

Appalachia: Social Context, Masculinity, and Desistance. Bethesda, MD: National Institutes of 

Health, 2010. 

Brown, T.G., Caplan, T., Werk, A., and Seraganian, P. The comparability of male violent

substance abusers in violence or substance abuse treatment. Journal of Family Violence 

14(3):297–312, 1999. 

Brunswick, A.F., and Messeri, P.A. Life stage, substance use and health decline in a community 

cohort of urban African Americans. Journal of Addictive Diseases 18(1):53–71, 1999. 

Burda, P.C., Tushup, R.J., and Hackman, P.S. Masculinity and social support in alcoholic men.

Journal of Men’s Studies 1(2):187–193, 1992. 

Bureau of Justice Statistics. Drugs and Crime Facts. Drug Use and Crime. Washington, DC: 

Bureau of Justice Statistics, 2005. 

Burke, L.K., and Follingstad, D.R. Violence in lesbian and gay relationships: Theory,

prevalence, and correlational factors. Clinical Psychology Review 19(5):487–512, 1999. 

Burke, M. Real men don’t drink. New Scientist 22(14):58–62, 1999. 

Burling, T.A., Seidner, A.L., Robbins-Sisco, D., Krinsky, A., and Hanser, S.B. Batter up! 

Relapse prevention for homeless veteran substance abusers via softball team participation.

Journal of Substance Abuse 4(4):407–413, 1992. 

Burns, P.C., and Wilde, G.J.S. Risk taking in male taxi drivers: Relationships among

personality, observational data and driver records. Personality and Individual Differences 

18(2):267–278, 1995. 

Burt, M.R., Aron, L.Y., Douglas, T., Valente, J., Lee, E., and Iwen, B. Homelessness: Programs 

and the People They Serve. Findings of the National Survey of Homeless Assistance Providers and

Clients. Washington, DC: The Urban Institute, 1999. 

Buss, T.F., Abdu, R., and Walker, J.R. Alcohol, drugs, and urban violence in a small city trauma

center. Journal of Substance Abuse Treatment 12(2):75–83, 1995. 

Button, T.M., Rhee, S.H., Hewitt, J.K., Young, S.E., Corley, R.P., and Stallings, M.C. The

role of conduct disorder in explaining the comorbidity between alcohol and illicit drug

dependence in adolescence. Drug and Alcohol Dependence 87(1):46–53, 2007. 

132 
 

Appendices 

Caetano, R. Alcohol use among Hispanic groups in the United States. American Journal of Drug 

and Alcohol Abuse 14(3):293–308, 1988a. 

Caetano, R. Alcohol use among Mexican Americans and in the U.S. population. In: Gilbert,

M.J., ed. Alcohol Consumption Among Mexicans and Mexican Americans: A Binational

Perspective (pp. 53–84). Los Angeles: University of California, 1988b. 

Caetano, R., Schafer, J., and Cunradi, C.B. Alcohol-related intimate partner violence among

White, Black, and Hispanic couples in the United States. Alcohol Research and Health 

25(1):58–65, 2001. 

Calamari, J.E., Cox, W.M., and Roth, J.D. Group treatments for men with alcohol problems.

In: Andronico, M.P., ed., Men in Groups: Insights, Interventions, and Psychoeducational Work

(pp. 305–321). Washington, DC: American Psychological Association, 1996. 

Callaghan, R.C., and Cunningham, J.A. Gender differences in detoxification: Predictors of

completion and re-admission. Journal of Substance Abuse Treatment 23(4):399–407, 2002. 

Capraro, R.L. Why college men drink: Alcohol, adventure, and the paradox of masculinity.

Journal of American College Health 48(6):307–315, 2000. 

Carlat, D.J., Camargo, C.A.J., and Herzog, D.B. Eating disorders in males: A report on 135

patients. American Journal of Psychiatry 154(8):1127–1132, 1997. 

Carlson, N. Male client – female therapist. Personal and Guidance Journal 60:228–231, 1981. 

Carter, R.E., Haynes, L.F., Back, S.E., Herrin, A.E., Brady, K.T., Leimberger, J.D., Sonne,

S.C., Hubbard, R.L., and Liepman, M.R. Improving the transition from residential to

outpatient addiction treatment: Gender differences in response to supportive telephone calls.

American Journal of Drug and Alcohol Abuse 34(1):47–59, 2008. 

Case, A., and Paxson, C. Sex differences in morbidity and mortality. Demography 42(2):189– 

214, 2005. 

Casswell, S., Pledger, M., and Hooper, R. Socioeconomic status and drinking patterns in young

adults. Addiction 98(5):601–610, 2003. 

Castro, F.G., Proescholdbell, R.J., Abeita, L., and Rodriguez, D. Ethnic and cultural minority 

groups. In: McCrady, B.S., and Epstein, E.E., eds. Addictions: A Comprehensive Guidebook

(pp. 499–526). New York: Oxford University Press, 1999. 

Catalano, R.F., Haggerty, K.P., Fleming, C.B., Brewer, D.D., and Gainey, R.R. Children of

substance-abusing parents: Current findings from the Focus on Families project. In:

McMahon, R.J., and Peters, R.D., eds. The Effects of Parental Dysfunction on Children (pp. 

179–204). New York: Kluwer Academic/Plenum Publishers, 2002. 

Catalano, S.M. Criminal Victimization, 2003. Bureau of Justice Statistics Special Report.

Washington, DC: Bureau of Justice Statistics, 2004. 

Cates, J.A., and Markley, J. Demographic, clinical, and personality variables associated with male 

prostitution by choice. Adolescence 27(107):695–706, 1992. 

133 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Caulkins, J.P., and Renter, P. What price data tells us about drug markets. Journal of Drug Issues 

28(3):593, 1998. 

Center for Mental Health Services National GAINS Center for Systemic Change for JusticeInvolved Persons with Mental Illness. Sensitizing Providers to the Effects of Incarceration on 

Treatment and Risk Management (SPECTRM): Expanding the Mental Health Workforce

Response to Justice-Involved Persons With Mental Illness. Rockville, MD: Center for Mental 

Health Services, 2007. 

Center for Substance Abuse Prevention. Communication Strategy Guide: A Look at 

Methamphetamine Use Among Three Populations. HHS Publication No. (SMA) 00-3423.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000. 

Center for Substance Abuse Treatment. Improving Treatment for Drug-Exposed Infants.

Treatment Improvement Protocol (TIP) Series 5. HHS Publication No. (SMA) 95-3057.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 1993a. 

Center for Substance Abuse Treatment. Pregnant, Substance-Using Women. Treatment 

Improvement Protocol (TIP) Series 2. HHS Publication No. (SMA) 93-1998. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 1993b. 

Center for Substance Abuse Treatment. Screening for Infectious Diseases Among Substance Abusers. 

Treatment Improvement Protocol (TIP) Series 6. HHS Publication No. (SMA) 95-3060. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 1993c. 

Center for Substance Abuse Treatment. Practical Approaches in the Treatment of Women Who 

Abuse Alcohol and Other Drugs. HHS Publication No. (SMA) 94-3006. Washington, DC:

U.S. Government Printing Office, 1994a. 

Center for Substance Abuse Treatment. Simple Screening Instruments for Outreach for Alcohol and

Other Drug Abuse and Infectious Diseases. Treatment Improvement Protocol (TIP) Series 11.

HHS Publication No. (SMA) 94-2094. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1994b. 

Center for Substance Abuse Treatment. Alcohol and Other Drug Screening of Hospitalized Trauma 

Patients. Treatment Improvement Protocol (TIP) Series 16. HHS Publication No. (SMA) 95­

3041. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1995a. 

Center for Substance Abuse Treatment. Combining Alcohol and Other Drug Treatment With 

Diversion for Juveniles in the Justice System. Treatment Improvement Protocol (TIP) Series 21.

HHS Publication No. (SMA) 95-3051. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1995b. 

Center for Substance Abuse Treatment. Developing State Outcomes Monitoring Systems for Alcohol 

and Other Drug Abuse Treatment. Treatment Improvement Protocol (TIP) Series 14. HHS

Publication No. (SMA) 95-3031. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 1995c. 

134 
Appendices 

Center for Substance Abuse Treatment. The Role and Current Status of Patient Placement Criteria 

in the Treatment of Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 

13. HHS Publication No. (SMA) 95-3021. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1995d. 

Center for Substance Abuse Treatment. The Tuberculosis Epidemic: Legal and Ethical Issues for

Alcohol and Other Drug Abuse Treatment Providers. Treatment Improvement Protocol (TIP)

Series 18. HHS Publication No. (SMA) 95-3047. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 1995e. 

Center for Substance Abuse Treatment. Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing. Treatment Improvement Protocol (TIP) Series 23.

HHS Publication No. (SMA) 96-3113. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1996. 

Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care 

Clinicians. Treatment Improvement Protocol (TIP) Series 24. HHS Publication No. (SMA)

97-3139. Rockville, MD: Substance Abuse and Mental Health Services Administration,

1997a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment and Domestic Violence. 

Treatment Improvement Protocol (TIP) Series 25. HHS Publication No. (SMA) 97-3163.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 1997b. 

Center for Substance Abuse Treatment. Comprehensive Case Management for Substance Abuse 

Treatment. Treatment Improvement Protocol (TIP) Series 27. HHS Publication No. (SMA)

98-3222. Rockville, MD: Substance Abuse and Mental Health Services Administration,

1998a. 

Center for Substance Abuse Treatment. Continuity of Offender Treatment for Substance Use 

Disorders From Institution to Community. Treatment Improvement Protocol (TIP) Series 30.

HHS Publication No. (SMA) 98-3245. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1998b. 

Center for Substance Abuse Treatment. Naltrexone and Alcoholism Treatment. Treatment 

Improvement Protocol (TIP) Series 28. HHS Publication No. (SMA) 98-3206. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 1998c. 

Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Treatment 

Improvement Protocol (TIP) Series 26. HHS Publication No. (SMA) 98-3179. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 1998d. 

Center for Substance Abuse Treatment. Substance Use Disorder Treatment for People With Physical 

and Cognitive Disabilities. Treatment Improvement Protocol (TIP) Series 29. HHS

Publication No. (SMA) 98-3249. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 1998e. 

135 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance 

Abuse. Treatment Improvement Protocol (TIP) Series 34. HHS Publication No. (SMA) 99­

3353. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999a. 

Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse 

Treatment. Treatment Improvement Protocol (TIP) Series 35. HHS Publication No. (SMA)

99-3354. Rockville, MD: Substance Abuse and Mental Health Services Administration,

1999b. 

Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use 

Disorders. Treatment Improvement Protocol (TIP) Series 31. HHS Publication No. (SMA)

99-3282. Rockville, MD: Substance Abuse and Mental Health Services Administration,

1999c. 

Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Use Disorders. 

Treatment Improvement Protocol (TIP) Series 32. HHS Publication No. (SMA) 99-3283.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999d. 

Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Treatment 

Improvement Protocol (TIP) Series 33. HHS Publication No. (SMA) 99-3296. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 1999e. 

Center for Substance Abuse Treatment. Integrating Substance Abuse Treatment and Vocational 

Services. Treatment Improvement Protocol (TIP) Series 38. HHS Publication No. (SMA) 00­

3470. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Child Abuse 

and Neglect Issues. Treatment Improvement Protocol (TIP) Series 36. HHS Publication No.

(SMA) 00-3357. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2000b. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With HIV/AIDS. 

Treatment Improvement Protocol (TIP) Series 37. HHS Publication No. (SMA) 00-3459.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000c. 

Center for Substance Abuse Treatment. A Provider’s Introduction to Substance Abuse Treatment for 

Lesbian, Gay, Bisexual, and Transgender Individuals. HHS Publication No. (SMA) 12–4104.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2001. 

Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the 

Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. HHS

Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2004a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy.

Treatment Improvement Protocol (TIP) Series 39. HHS Publication No. (SMA) 04-3957.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004b. 

136 
 

 

 

Appendices 

Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in 

Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. HHS

Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2005a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Adults in the Criminal 

Justice System. Treatment Improvement Protocol (TIP) Series 44. HHS Publication No.

(SMA) 05-4056. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2005b. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring 

Disorders. Treatment Improvement Protocol (TIP) Series 42. HHS Publication No. (SMA)

05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005c. 

Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment 

Improvement Protocol (TIP) Series 41. HHS Publication No. (SMA) 05-4056. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 2005d. 

Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Treatment 

Improvement Protocol (TIP) Series 45. HHS Publication No. (SMA) 06-4131. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 2006a. 

Center for Substance Abuse Treatment. Substance Abuse: Administrative Issues in Intensive 

Outpatient Treatment. Treatment Improvement Protocol (TIP) Series 46. HHS Publication

No. (SMA) 06-4151. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2006b. 

Center for Substance Abuse Treatment. Substance Abuse: Clinical Issues in Intensive Outpatient 

Treatment. Treatment Improvement Protocol (TIP) Series 47. HHS Publication No. (SMA)

06-4182. Rockville, MD: Substance Abuse and Mental Health Services Administration,

2006c. 

Center for Substance Abuse Treatment. An introduction to mutual support groups for alcohol 

and drug abuse. Substane Abuse in Brief Fact Sheet 5(1):1–5, 2008a. 

Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients 

During Early Recovery. Treatment Improvement Protocol (TIP) Series 48. HHS Publication

No. (SMA) 08-4353 Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2008b. 

Center for Substance Abuse Treatment. Addressing Suicidal Thoughts and Behaviors in Substance 

Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50. HHS Publication No.

(SMA) 09-4381. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2009a. 

Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies Into Medical 

Practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09­

4380. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009b. 

137 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of 

Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA)

09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration,

2009c. 

Center for Substance Abuse Treatment. Supervision and the Professional Development of the 

Substance Abuse Counselor. Treatment Improvement Protocol (TIP) Series 52. HHS

Publication No. (SMA) 09-4435. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2009d. 

Center for Substance Abuse Treatment. Protracted withdrawal. Substance Abuse Treatment 

Advisory 9(1), 2010a. 

Center for Substance Abuse Treatment. Treating clients with traumatic brain injury. Substance 

Abuse Treatment Advisory 9(2), 2010b. 

Centers for Disease Control and Prevention. Cigarette Smoking Among Adults—United States,

2002. Morbidity and Mortality Weekly Report 53(20):427–431, 2004. 

Centers for Disease Control and Prevention. Alcohol-attributable deaths and years of potential 

life lost among American Indians and Alaska Natives—United States, 2001–2005. Morbidity 

and Mortality Weekly Report 57(34):938–941, 2008a. 

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2006. Atlanta, GA: 

Centers for Disease Control and Prevention, 2008b. 

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2007, Vol. 19 

(pp.1–63). Atlanta, GA: Centers for Disease Control and Prevention, 2009. 

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

WISQARS Injury Mortality Reports, 1999–2006. Atlanta, GA: Centers for Disease Control 

and Prevention, 2009. 

Chae, D.H., Takeuchi, D.T., Barbeau, E.M., Bennett, G.G., Lindsey, J.C., Stoddard, A.M., 

and Krieger, N. Alcohol disorders among Asian Americans: Associations with unfair

treatment, racial/ethnic discrimination, and ethnic identification (The National Latino and

Asian Americans Study, 2002–2003). Journal of Epidemiology and Community Health 

62(11):973–979, 2008. 

Chan, K.S., Wenzel, S., Orlando, M., Montagnet, C., Mandell, W., Becker, K., and Ebener, P. 

How important are client characteristics to understanding treatment process in the 

therapeutic community? American Journal of Drug and Alcohol Abuse 30(4):871–891, 2004. 

Chaney, E.F., Roszell, D.K., and Cummings, C. Relapse in opiate addicts: A behavioral 

analysis. Addictive Behaviors 7(3):291–297, 1982. 

Chang, P. Treating Asian/Pacific American addicts and their families. In: Krestan, J.A., ed.

Bridges to Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 192–218). 

New York: Free Press, 2000. 

138 
 

 

 

 

Appendices 

Chang, T., and Subramaniam, P.R. Asian and Pacific Islander American men’s help-seeking: 

Cultural values and beliefs, gender roles, and racial stereotypes. International Journal of Men’s 

Health 7(2):121–136, 2008. 

Chaplin, T.M., Hong, K., Bergquist, K., and Sinha, R. Gender differences in response to

emotional stress: An assessment across subjective, behavioral, and physiological domains and

relations to alcohol craving. Alcoholism: Clinical and Experimental Research 32(7):1242–1250, 

2008. 

Chappel, J.N. Spiritual components of the recovery process. In: Graham, A.W., and Wilford,

B.B., eds. Principles of Addiction Medicine, 3rd ed. (pp. 969–974). Chevy Chase, MD:

American Society of Addiction Medicine, 2003. 

Chase, K.A., O’Farrell, T.J., Murphy, C.M., Fals-Stewart, W., and Murphy, M. Factors

associated with partner violence among female alcoholic patients and their male partners.

Journal of Studies and Alcohol 64(1):137–149, 2003. 

Chemtob, C.M., Hamada, R.S., Roitblat, H.L., and Muraoka, M.Y. Anger, impulsivity, and

anger control in combat-related posttraumatic stress disorder. Journal of Consulting and 

Clinical Psychology 62(4):827–832, 1994. 

Chermack, S.T., Fuller, B.E., and Blow, F.C. Predictors of expressed partner and non-partner 

violence among patients in substance abuse treatment. Drug and Alcohol Dependence 58(1­

2):43–54, 2000. 

Cherpitel, C.J., Borges, G.L., and Wilcox, H.C. Acute alcohol use and suicidal behavior: A review 

of the literature. Alcoholism: Clinical and Experimental Research 28(Suppl. 5):18S–28S, 2004. 

Cherry, D.K., and Woodwell, D.A. National Ambulatory Medical Care Survey: 2000 Summary. 

Advance Data From Vital and Health Statistics, No. 328. Hyattsville, MD: National Center

for Health Statistics, 2002. 

Chi, I., Lubben, J.E., and Kitano, H.H. Differences in drinking behavior among three Asian

American groups. Journal of Studies on Alcohol 50(1):15–23, 1989. 

Christakis, N.A., and Fowler, J.H. The collective dynamics of smoking in a large social network.

New England Journal of Medicine, 358(21):2249–2258, 2008. 

Christensen, R.C., Hodgkins, C.C., Estlund, K., Miller, M.D., and Garces, L. Prevalence of 

Trauma in Homeless Men With Co-Occurring Disorders. Poster presented at Complexities of

Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental,

Substance Use, and Medical/Physical Disorders. Washington, DC: June, 2004. 

Chuick, C.D., Greenfeld, J.M., Greenberg, S.T., Shepard, S.J., Cochran, S.V., and Haley, J.T.

A qualitative investigation of depression in men. Psychology of Men & Masculinity 10(4):302– 

313, 2009. 

Clark, R., Anderson, N.B., Clark, V.R., and Williams, D.R. Racism as a stressor for African

Americans: A biopsychosocial model. American Psychologist 54(10):805–816, 1999. 

139 
Addressing the Specific Behavioral Health Needs of Men 

Cochran, B.N., and Cauce, A.M. Characteristics of lesbian, gay, bisexual, and transgender 

individuals entering substance abuse treatment. Journal of Substance Abuse Treatment 

30(2):135–146, 2006. 

Cochran, S.A. Assessing and treating depression in men. In: Brooks, G.R., and Good, G.E.,

eds. The New Handbook of Psychotherapy and Counseling With Men: A Comprehensive Guide to

Settings, Problems, and Treatment Approaches, Vol. 1 (pp. 229–245). San Francisco: JosseyBass, 2001. 

Cochran, S.D., Keenan, C., Schober, C., and Mays, V.M. Estimates of alcohol use and clinical 

treatment needs among homosexually active men and women in the U.S. population. Journal 

of Consulting and Clinical Psychology 68(6):1062–1071, 2000. 

Cochran, S.V. Evidence-based assessment with men. Journal of Clinical Psychology 61(6):649– 

660, 2005. 

Cohen, J.B., Dickow, A., Horner, K., Zweben, J.E., Balabis, J., Vandersloot, D., and Reiber, C.

Abuse and violence history of men and women in treatment for methamphetamine 

dependence. The American Journal on Addictions 12(5):377–385, 2003. 

Cole, S.W., Kemeny, M.E., Taylor, S.E., and Visscher, B.R. Elevated physical health risk 

among gay men who conceal their homosexual identity. Health Psychology 15(4):243–251, 

1996. 

Collins, G.B., McAllister, M.S., and Ford, D.B. Patient-provider e-mail communication as an 

adjunctive tool in addiction medicine. Journal of Addictive Diseases 26(2):45–52, 2007. 

Collison, M. In search of the high life: Drugs, crime, masculinities and consumption. British 

Journal of Criminology 36(3):428–444, 1996. 

Colon, E. Alcohol use among Latino males: Implications for the development of culturally 

competent prevention and treatment services. Alcoholism Treatment Quarterly 16(1–2):147– 

161, 1998. 

Compton, W.M., III, Cottler, L.B., Ben Abdallah, A., Phelps, D.L., Spitznagel, E.L., and

Horton, J.C. Substance dependence and other psychiatric disorders among drug dependent

subjects: Race and gender correlates. American Journal on Addiction 9(2):113–125, 2000. 

Connors, G.J., Walitzer, K.S., and Tonigan, J.S. Spiritual change in recovery. In: Research on 

Alcoholics Anonymous and Spirituality in Addiction Recovery: Recent Developments in Alcoholism

(pp. 209–227). New York: Springer Science and Business Media, 2008. 

Conway, K.P., Compton, W., Stinson, F.S., and Grant, B.F. Lifetime comorbidity of DSM-IV

mood and anxiety disorders and specific drug use disorders: Results from the National 

Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry 

67(2):247–257, 2006. 

Cook, D.R. Internalized Shame Scale. North Tonawanda, NY: MHS, Inc., 2000. 

140 
 

 

Appendices 

Cook, T.A.R., Luczak, S.E., Shea, S.H., Ehlers, C.L., Carr, L.G., and Wall, T.L. Associations

of ALDH2 and ADH1B genotypes with response to alcohol in Asian Americans. Journal of 

Studies on Alcohol 66(2):196–204, 2005. 

Cooper, C., Eslinger, D., Nash, D., Al Zawahri, J., and Stolley, P. Repeat victims of violence:

Report of a large concurrent case-control study. Archives of Surgery 135:837–843, 2000. 

Cooper, A., Morahan-Martin, J., Mathy, R.M., and Maheu, M. Toward an increased 

understanding of user demographics in online sexual activities. Journal of Sex and Marital 

Therapy 28(2):105–129, 2002. 

Cooper, A., Galbreath, N., and Becker, M.A. Sex on the internet: Furthering our understanding

of men with online sexual problems. Psychology of Addictive Behaviors 18(3):223–230, 2004. 

Copenhaver, M.M., Lash, S.J., and Eisler, R.M. Masculine gender-role stress, anger, and male 

intimate abusiveness: Implications for men’s relationships. Sex Roles 42(5–6):405–414, 2000. 

Copes, H., and Hochstetler, A. Situational construction of masculinity among male street

thieves. Journal of Contemporary Ethnography 32(3):279–304, 2003. 

Corbett, K., Mora, J., and Ames, G. Drinking patterns and drinking-related problems of

Mexican American husbands and wives. Journal of Studies on Alcohol 52(3):215–223, 1991. 

Cottler, L.B., Nishith, P., and Compton, W.M. Gender differences in risk factors for trauma

exposure and posttraumatic stress disorder among inner-city drug abusers in and out of

treatment. Comprehensive Psychiatry 42(2):111–117, 2001. 

Coulson, C., Ng, F., Geertsema, M., Dodd, S., and Berk, M. Client-reported reasons for nonengagement in drug and alcohol treatment. Drug and Alcohol Review 28(4):372–378, 2009. 

Courtenay, W.H. College men’s health: An overview and a call to action. Journal of American 

College Health 46(6):279–290, 1998. 

Courtenay, W.H. Constructions of masculinity and their influence on men’s well-being: A 

theory of gender and health. Social Science and Medicine 50(10):1385–1401, 2000. 

Courtenay, W.H. Key determinants of the health and well-being of men and boys. International 

Journal of Men’s Health 2(1):1–30, 2003. 

Courtenay, W.H., McCreary, D.R., and Merighi, J.R. Gender and ethnic differences in health

beliefs and behaviors. Journal of Health Psychology 7(3):219–231, 2002. 

Cowan, J., and Devine, C. Food, eating, and weight concerns of men in recovery from substance 

addiction. Appetite 50(1):33–42, 2008. 

Coxell, A., King, M., Mezey, G., and Gordon, D. Lifetime prevalence, characteristics, and

associated problems of non-consensual sex in men: Cross sectional survey. British Medical 

Journal 318:846, 1999. 

Craddock, A., Collins, J.J., and Timrots, A. Fact Sheet: Drug-Related Crime. Drugs & Crime 

Data. Washington, DC: Bureau of Justice Statistics, 1994. 

141 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L.S., Muenz,

L.R., Thase, M.E., Weiss, R.D., Gastfriend, D.R., Woody, G.E., Barber, J.P., Butler, S.F., 

Daley, D., Salloum, I., Bishop, S., Najavits, L.M., Lis, J., Mercer, D., Griffin, M.L., Moras, 

K., and Beck, A.T. Psychosocial treatments for cocaine dependence: National Institute on

Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry 

56(6):493–502, 1999. 

Crocker, J., and Major, B. Social stigma and self-esteem: The self-protective properties of

stigma. Psychological Review 96(4):608–630, 1989. 

Crosby, G.M., Stall, R.D., Paul, J.P., and Barrett, D.C. Alcohol and drug use patterns have 

declined between generations of younger gay-bisexual men in San Francisco. Drug and 

Alcohol Dependence 52(3):177–182, 1998. 

Crosby, R., and DiClemente, R.J. Use of recreational Viagra among men having sex with men.

Sexually Transmitted Infections 80(6):466–468, 2004. 

Crum, R.M. The epidemiology of addictive disorders. In: Graham, A.W., Schultz, T.K., MayoSmith, M.F., Ries, R.K., and Wilford, B.B., eds. Principles of Addiction Medicine (pp. 17–31). 

Chevy Chase, MD: American Society of Addiction Medicine, 2003. 

Cunradi, C.B., Caetano, R., and Schafer, J. Alcohol-related problems, drug use, and male 

intimate partner violence severity among U.S. couples. Alcoholism: Clinical and Experimental 

Research 26(4):493–500, 2002. 

Curtis, K.M., Savitz, D.A., and Arbuckle, T.E. Effects of cigarette smoking, caffeine 

consumption, and alcohol intake on fecundability. American Journal of Epidemology 

146(1):32–41, 1997. 

Czuchry, M., and Dansereau, D. A model of the effects of node-link mapping on drug abuse 

counseling. Addictive Behaviors 28(3):537–549, 2003. 

Darke, S., and Ross, J. Suicide among heroin users: Rates, risk factors and methods. Addiction 

97(11):1383–1394, 2002. 

Davis, K.C., Schraufnagel, T.J., George, W.H., and Norris J. The use of alcohol and condoms 

during sexual assault. American Journal of Men’s Health 2(3):281–290, 2008. 

Dawson, G. The African American male: Brief insights on health, drugs, and incarceration. Part

1. Journal of the National Medical Association 89(9):580–584, 1997. 

Dearing, R.L., Stuewig, J., and Tangney, J.P. On the importance of distinguishing shame from guilt:

Relations to problematic alcohol and drug use. Addictive Behaviors 30(7):1392–1404, 2005. 

Dees, S.M., and Dansereau, D.F. Using schematic organizers to help college students organize 

personal concepts and behavior related to alcohol and cocaine use. Addictive Behaviors 

18(6):645–657, 1993. 

Dees, S.M., and Dansereau, D.F. TCU Guide Maps: A Resource for Counselors. Bloomington, IL: 

Lighthouse Institute, 2000. 

142 
 

Appendices 

Degenhardt, L., Chiu, W.T., Sampson, N., Kessler, R.C., and Anthony, J. Epidemiological patterns 

of extra-medical drug use in the United States: Evidence from the National Comorbidity

Survey Replication, 2001–2003. Drug and Alcohol Dependence 90(2–3):210–223, 2007. 

DeMaria, R., Weeks, G., and Hof, L. Focused Genograms: Intergenerational Assessment of 

Individuals, Couples, and Families. Philadelphia: Brunner/Mazel, 1999. 

de Miranda, J. Treatment services offer limited access for people with disabilities. The Counselor 

(May/June):24–25, 1999. 

de Miranda, J. Testimony for the ABA/Join Together Policy Panel Hearing on Discrimination Against

Individuals in Treatment Recovery. Manuscript presented at Medication Prohibitions as a 

Barrier to Treatment Access, August 10, 2002, Washington, DC. 

Department of Veterans Affairs, Office of Congressional and Legislative Affairs. Statement of 

Thomas L. Garthwaite, MD, Under Secretary for Health, Veterans Health Administration, Before 

the Subcommittee on Health Committee on Veterans’ Affairs, U.S. House of Representatives, June 

20, 2001. Washington, DC: Department of Veterans Affairs Central Office, Office of

Congressional and Legislative Affairs, 2001. 

Dhaliwal, G.K., Gauzas, L., Antonowicz, D.H., and Ross, R.R. Adult male survivors of

childhood sexual abuse: Prevalence, sexual abuse characteristics, and long-term effects.

Clinical Psychology Review 16(7):619–639, 1996. 

Dick, D.M., and Foroud, T. Candidate genes for alcohol dependence: A review of genetic evidence 

from human studies. Alcoholism: Clinical and Experimental Research 27(5):868–879, 2003. 

Dienhart, A. Engaging men in family therapy: Does the gender of the therapist make a

difference? Journal of Family Therapy 23(1):21–45, 2001. 

Dienhart, A., and Avis, J.M. Working with men in family therapy: An exploratory study. Journal 

of Marital and Family Therapy 20(4):397–417, 1994. 

Dietz, T.L. Predictors of reported current and lifetime substance abuse problems among a

national sample of U.S. homeless. Substance Use & Misuse 42:1745–1766, 2007. 

Dixon, L., Adler, D., Braun, D., Dulit, R., Goldman, B., Siris, S., Sonis, W., Bank, P., Hermann, 

R., Fornari, V., and Grant, J. Reexamination of therapist self-disclosure. Psychiatric Services 

52(11):1489–93, 2001. 

Dobkin, P.L., Tremblay, R.E., and Sacchitelle, C. Predicting boys’ early-onset substance abuse 

from father’s alcoholism, son’s disruptiveness, and mother’s parenting behavior. Journal of 

Consulting and Clinical Psychology 65(1):86–92, 1997. 

Donovan, B., Padin-Rivera, E., and Kowaliw, S. Transcend: Initial outcomes from a posttraumatic

stress disorder/substance abuse treatment program. Journal of Traumatic Stress 14(4):757–772, 

2001. 

Dooley, D., and Prause, J. Underemployment and alcohol misuse in the National Longitudinal 

Survey of Youth. Journal of Studies on Alcohol 59(6):669–680, 1998. 

143 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Dore, J. A model of time-limited group therapy for men: Its use with recovering addicts. Group 

for Recovering Addicts 18(4):243–258, 1994. 

Doweiko, H.E. Concepts of Chemical Dependency, 5th ed. Pacific Grove, CA: Brooks/Cole, 2002. 

Downs, W.R., Smyth, N.J., and Miller, B.A. Relationship between childhood violence and

alcohol problems among men who batter: An empirical review and synthesis. Aggression and 

Violent Behavior 1(4):327–344, 1996. 

Drug Enforcement Administration. Steroid Abuse in Today’s Society: A Guide for Understanding 

Steroids and Related Substances. Washington, DC: Drug Enforcement Administration, 2004. 

Dube, S.R., Anda, R.F., Felitti, V.J., Chapman, D.P., Williamson, D.F., and Giles, W.H. 

Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the 

life span: Findings from the Adverse Childhood Experiences Study. The Journal of the 

American Medical Association 286(24):3089–3096, 2001. 

Duck, W. Black male sexual politics: Avoidance of HIV/AIDS testing as a masculine health

practice. Journal of African American Studies 13(3):283–306, 2009. 

Dunlap, E., Johnson, B.D., Kotarba, J., and Fackler, J. Making connections: New Orleans 

evacuees’ experiences in obtaining drugs. Journal of Psychoactive Drugs 41(3): 219–226, 2009. 

Easton, C., Swan, S., and Sinha, R. Motivation to change substance use among offenders of

domestic violence. Journal of Substance Abuse Treatment 19(1):1–5, 2000. 

Eaton, W.W., Kramer, M., Anthony, J.C., Dryman, A., Shapiro, S., and Locke, B.Z. The

incidence of specific DIS/DSM-III mental disorders: Data from the NIMH Epidemiologic

Catchment Area Program. Acta Psychiatrica Scandinavica 79(2):163–178, 1989. 

Egeland, B., Jacobvitz, D., and Sroufe, L.A. Breaking the cycle of abuse. Child Development 

59:1080–1088, 1988. 

Eiden, R.D., Edwards, E.P., and Leonard, K.E. Mother-infant and father-infant attachment 

among alcoholic families. Development and Psychopathology 14(2):253–278, 2002. 

Eisler, R.M. The relationship between masculine gender role stress and men’s health risk: The 

validation of a construct. In: Levant, R.F., and Pollack, W.S., eds. A New Psychology of Men 

(pp. 207–225). New York: Basic Books, 1995. 

Eisler, R.M., and Skidmore, J.R. Masculine gender role stress: Scale development and component

factors in the appraisal of stressful situations. Behavior Modification 11(2):123–136, 1987. 

Eisler, R.M., Skidmore, J.R., and Ward, C.H. Masculine gender role stress: Predictor of anger,

anxiety, and health-risk behaviors. Journal of Personality Assessment 52(1):133–141, 1988. 

Elbogen, E.B., Swanson, J.W., Swartz, M.S., and Wagner, H.R. Characteristics of third-party

money management for persons with psychiatric disabilities. Psychiatric Services 54(8):1136– 

1141, 2003. 

144 
 

 

 

 

 

 

 

 

Appendices 

Emanuele, M.A., and Emanuele, N. Alcohol and the male reproductive system. Alcohol Research 

and Health 25(4):282–287, 2001. 

EMERGE. Guidelines for talking to abusive husbands. In: Domestic Violence: The Alcohol and 

Other Drug Connection (pp. 160–162). Rensselaer, NY: New York State Office for Prevention

of Domestic Violence, 1995. 

Epstein, E.E., McCrady, B.S., Morgan, T.J., Cook, S.M., Kugler, G., and Ziedonis, D. Couples 

treatment for drug-dependent males: Preliminary efficacy of a standalone outpatient model.

Addictive Disorders & Their Treatment 6(1):21–37, 2007. 

Epstein J., Barker, P., Vorburger, M., and Murtha, C. Serious Mental Illness and Its Co-Occurrence 

With Substance Use Disorders: 2002. HHS Publication No. (SMA) 04-3905. Analytic Series

A-24. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. 

Ersche, K.D., Clark, L., London, M., Robbins, T.W., and Sahakian, B.J. Profile of executive and

memory function associated with amphetamine and opiate dependence.

Neuropsychopharmacology 31(5):1036–1047, 2006. 

Etheridge, R.M., Hubbard, R.L., Anderson, J., Craddock, S.G., and Flynn, P.M. Treatment

structure and program services in the Drug Abuse Treatment Outcome Study (DATOS).

Psychology of Addictive Behavior 11(4):244–260, 1997. 

Evren, C., Sar, V., Evren, B., Semiz, U., Dalbudak, E., and Cakmak, D. Dissociation and

alexithymia among men with alcoholism. Psychiatry and Clinical Neurosciences 62(1):40–47, 

2008. 

Ewing, R. Profile of Clinicians in the National Treatment Improvement Evaluation Study (NTIES).

NEDS Analytic Summary No. 26. Fairfax, VA: Caliber Associates, 2001. 

Fagan, J., and Hawkins, A.J., eds. Clinical and Educational Interventions With Fathers. 

Binghamton, NY: Haworth Clinical Practice Press, 2001. 

Falck, R.S., Wang, J., and Carlson, R.G. Among long-term crack smokers, who avoids and who

succumbs to cocaine addiction? Drug and Alcohol Dependence 98(1–2):24–29, 2008. 

Falck, R.S., Wang, J., Siegal, H.A., and Carlson, R.G. The prevalence of psychiatric disorder

among a community sample of crack cocaine users: An exploratory study with practical 

implications. Journal of Nervous & Mental Disease 192(7):503–507, 2004. 

Falicov, C.J. Mexican Families. In: McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds. 

Ethnicity and Family Therapy, 3rd ed. (pp. 229–241). New York: Guilford Press, 2005. 

Fallot, R.D., Harris, M., Affolter, H.U., Anglin, J., Arledge, E., Bebout, R., Dende, J., Freeman,

D., Green, W., and Lee, M. Men’s Trauma Recovery and Empowerment Model (M-TREM): A 

Clinician’s Guide to Working With Male Trauma Survivors in Groups. Washington, DC: 

Community Connections, 2001. 

Fals-Stewart, W. The occurrence of partner physical aggression on days of alcohol consumption:

A longitudinal diary study. Journal of Consulting and Clinical Psychology 71(1):41–52, 2003. 

145 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Fals-Stewart, W., and Birchler, G.R. A national survey of the use of couples therapy in substance 

abuse treatment. Journal of Substance Abuse Treatment 20(4):277–283, 2001. 

Fals-Stewart, W., Birchler, G.R., and O’Farrell, T.J. Drug-abusing patients and their intimate

partners: Dyadic adjustment, relationship stability, and substance use. Journal of Abnormal 

Psychology 108(1):11–23, 1999. 

Fals-Stewart, W., Golden, J., and Schumacher, J.A. Intimate partner violence and substance use:

A longitudinal day-to-day examination. Addictive Behaviors 28(9):1555–1574, 2003. 

Fals-Stewart, W., Klostermann, K., Yates, B.T., O’Farrell, T.J., and Birchler, G.R. Brief

relationship therapy for alcoholism: A randomized clinical trial examining clinical efficacy

and cost-effectiveness. Psychology of Addictive Behaviors 19(4):363–371, 2005. 

Fals-Stewart, W., and O’Farrell, T.J. Behavioral family counseling and naltrexone for male 

opioid-dependent patients. Journal of Consulting and Clinical Psychology 71(3):432–442, 2003. 

Fals-Stewart, W., O’Farrell, T.J., Feehan, M., Birchler, G.R., Tiller, S., and McFarlin, S.K.

Behavioral couples therapy versus individual-based treatment for male substance-abusing

patients: An evaluation of significant individual change and comparison of improvement

rates. Journal of Substance Abuse Treatment 18(3):249–254, 2000a. 

Fals-Stewart, W., O’Farrell, T.J., Freitas, T.T., McFarlin, S.K., and Rutigliano, P. The timeline 

followback reports of psychoactive substance use by drug-abusing patients: Psychometric

properties. Journal of Consulting and Clinical Psychology 68(1):134–144, 2000b. 

Farber, B.A. Patient self-disclosure: A review of the research. Journal of Clinical Psychology 

59(5):589–600, 2003. 

Farber, B.A., and Hall, D. Disclosure to therapists: What is and is not discussed in psychotherapy.

Journal of Clinical Psychology 58(4):359–370, 2002. 

Farley, M., Golding, J.M., Young, G., Mulligan, M., and Minkoff, J.R. Trauma history and relapse 

probability among patients seeking substance abuse treatment. Journal of Substance Abuse 

Treatment 27(2):161–167, 2004. 

Felix-Ortiz, M., Abreu, J.M., Briano, M., and Bowen, D. A critique of machismo measures in

psychological research. In: Advances in Psychology Research, Vol. 3 (pp. 63–90). Hauppauge, 

NY: Nova Science Publishers, 2001. 

Fernandez, A.C., Begley, E.A., and Marlatt, G.A. Family and peer interventions for adults: Past

approaches and future directions. Psychology of Addictive Behaviors 20(2):207–213, 2006. 

Fernandez, E., and Scott, S. Anger treatment in chemically-dependent inpatients: Evaluation of

phase effects and gender. Behavioural and Cognitive Psychotherapy 37(4):431–447, 2009. 

Finlayson, R.E. Misuse of prescription drugs. International Journal of the Addictions 30(13– 

14):1871–1901, 1995. 

146 
 

 

 

 

 

 

 

 

Appendices 

Finn, P.R., Sharkansky, E.J., Viken, R., West, T.L., Sandy, J., and Bufferd, G.M. Heterogeneity in

the families of sons of alcoholics: The impact of familial vulnerability type on offspring

characteristics. Journal of Abnormal Psychology 106(1):26–36, 1997. 

Finney, J.W., Hahn, A.C., and Moos, R.H. The effectiveness of inpatient and outpatient

treatment for alcohol abuse: The need to focus on mediators and moderators of setting

effects. Addiction 91(12):1773–1796, 1996. 

Fiorentine, R. After drug treatment: Are 12-Step programs effective in maintaining abstinence?

American Journal of Drug and Alcohol Abuse 25(1):93–116, 1999. 

Fiorentine, R., and Anglin, M.D. Does increasing the opportunity for counseling increase the 

effectiveness of outpatient drug treatment? American Journal of Drug and Alcohol Abuse 

23(3):369–382, 1997. 

Fiorentine, R., Anglin, M.D., Gil-Rivas, V., and Taylor, E. Drug treatment: Explaining the

gender paradox. Substance Use and Misuse 32(6):653–678, 1997. 

Fiorentine, R., and Hillhouse, M.P. Drug treatment and 12-Step program participation: The

additive effects of integrated recovery activities. Journal of Substance Abuse Treatment 

18(1):65–74, 2000. 

Fiorentine, R., and Hillhouse, M.P. Drug treatment effectiveness and client-counselor empathy:

Exploring the effects of gender and ethnic congruency. Journal of Drug Issues 29(1):59–74, 1999. 

Fiorentine, R., Nakashima, J., and Anglin, M.D. Client engagement in drug treatment. Journal of 

Substance Abuse Treatment 17(3):199–206, 1999. 

Flynn, P.M., Joe, G.W., Broome, K.M., Simpson, D.D., and Brown, B.S. Recovery from opioid

addiction in DATOS. Journal of Substance Abuse Treatment, 25(3):177–186, 2003. 

Foote, J.A., Harris, R.B., Gilles, M.E., Ahner, H., Roice, D., Becksted, T., Messinger, T., Bunch,

R., and Bilant, K. Physician advice and tobacco use: A survey of 1st-year college students.

Journal of American College Health 45(3):129–132, 1996. 

Foran, H.M., and O’Leary, K.D. Alcohol and intimate partner violence: A meta-analytic review.

Clinical Psychology Review 28(7):1222–1234, 2008. 

Forbes, D., Creamer, M., Hawthorne, G., Allen, N., and McHugh, T. Comorbidity as a predictor

of symptom change after treatment in combat-related posttraumatic stress disorder. Journal of 

Nervous and Mental Disease 191(2):93–99, 2003. 

Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., and Hopwood, M. Mechanisms of

anger and treatment outcome in combat veterans with posttraumatic stress disorder. Journal of 

Traumatic Stress 21(2):142–149, 2008. 

Forrest, G.G. Chemical Dependency and Antisocial Personality Disorder: Psychotherapy and

Assessment Strategies. New York: Haworth Press, 1994. 

Forrest, G.G. Self-Disclosure in Psychotherapy and Recovery. Lanham, MD: Jason Aranson, Inc., 

2010. 

147 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Fortenberry, J.D., McFarlane, M., Bleakley, A., Bull, S., Fishbein, M., Grimley, D.M., Malotte,

C.K., and Stoner, B.P. Relationships of stigma and shame to gonorrhea and HIV screening.

American Journal of Public Health 92(3):378–381, 2002. 

Fowler, I.L., Carr, V.J., Carter, N.T., and Lewin, T.J. Patterns of current and lifetime substance 

use in schizophrenia. Schizophrenia Bulletin 24(3):443–455, 1998. 

Fracher, J.C., and Kimmel, M.S. Hard issues and soft spots: Counseling men about sexuality. In: 

Scher, M., and Stevens, M., eds. Handbook of Counseling and Psychotherapy With Men (pp. 83– 

96). Thousand Oaks, CA: Sage Publications, 1987. 

Fragoso, J.M., and Kashubeck, S. Machismo, gender role conflict, and mental health in Mexican

American men. Psychology of Men and Masculinity 1(2):87–97, 2000. 

Frank, J.B., Weihs, K., Minerva, E., and Lieberman, D.Z. Women’s mental health in primary 

care: Depression, anxiety, somatization, eating disorders, and substance abuse. Medical Clinics 

of North America 82(2):359–389, 1998. 

Freeman-Longo, R.E., and Blanchard, G.T. Sexual Abuse in America: Epidemic of the 21st Century. 

Brandon, VT: Safer Society Press, 1998. 

French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefit-cost

analysis of a modified therapeutic community for mentally ill chemical abusers. Evaluation 

and Program Planning 25(2):137–148, 2002. 

French, M.T., Salome, H.J., Krupski, A., McKay, J.R., Donovan, D.M., McLellan, A.T., and

Durell, J. Benefit-cost analysis of residential and outpatient addiction treatment in the State

of Washington. Evaluation Review 24(6):609–634, 2000. 

Friedman, A.S. Substance use/abuse as a predictor to illegal and violent behavior: A review of the 

relevant literature. Aggression and Violent Behavior 3(4):339–355, 1998. 

Friedman, A.S., Granick, S., Bransfield, S., Kreisher, C., and Schwartz, A. The consequences of

drug use/abuse for vocational career: A longitudinal study of a male urban African American

sample. American Journal of Drug and Alcohol Abuse 22(1):57–73, 1996. 

Friedman, M.J., Schnurr, P.P., and McDonagh-Coyle, A. Posttraumatic stress disorder in the 

military veteran. Psychiatric Clinics of North America 17(2):265–277, 1994. 

Friedmann, P.D., Lemon, S.C., Stein, M.D., Etheridge, R.M., and D’Aunno,T.A. Linkage to 

medical services in the Drug Abuse Treatment Outcome Study. Medical Care 39:284-295, 2001. 

Friedmann, P.D., Phillips, K.A., Saitz, R., and Samet, J.H. Linking addiction treatment with

other medical and psychiatric treatment systems. In: Ries, R.K., Fiellin, D.A., Miller, S.C.,

and Saitz, R., eds. Principles of Addiction Medicine, 4th ed. (pp. 401–412). Philadelphia:

Wolters Kluwer/Lippincott Williams & Wilkins, 2009. 

Friedmann, P.D., Zhang, Z., Hendrickson, J., Stein, M.D., and Gerstein, D.R. Effect of primary 

medical care on addiction and medical severity in substance abuse treatment programs.

Journal of General Internal Medicine 18(1):1–8, 2003. 

148 
 

 

 

 

 

Appendices 

Frost, J.C. Countertransference considerations for the gay male when leading psychotherapy 

groups for gay men. International Journal of Group Psychotherapy 48(1):3–24, 1998. 

Frueh, B.C., Elhai, J.D., Grubaugh, A.L., Monnier, J., Kashdan, T.B., Sauvageot, J.A., Hamner,

M.B., Burkett, B.G., and Arana, G.W. Documented combat exposure of U.S. veterans seeking

treatment for combat-related post-traumatic stress disorder. British Journal of Psychiatry 

186(6):467–472, 2005. 

Fu, Q., Heath, A.C., Bucholz, K.K., Lyons, M.J., Tsuang, M.T., True, W.R., and Eisen, S.A.

Common genetic risk of major depression and nicotine dependence: The contribution of

antisocial traits in a United States veteran male twin cohort. Twin Research and Human 

Genetics 10(3):470–478, 2007. 

Gaes, G.G., and Goldberg, A.L. Prison Rape: A Critical Review of the Literature, Working Paper. 

Washington, DC: National Institute of Justice, 2004. 

Galanter, M., Dermatis, H., Glickman, L., Maslansky, R., Sellers, M.B., Neumann, E., and

Rahman-Dujarric, C. Network therapy: Decreased secondary opioid use during

buprenorphine maintenance. Journal of Substance Abuse Treatment 26(4):313–318, 2004. 

Galanter, M., Dermatis, H., Keller, D., and Trujillo, M. Network therapy for cocaine abuse: Use 

of family and peer supports. The American Journal on Addictions 11:161–166, 2002. 

Galanter, M., Spiro, H.R., Hohl, P.C., Dobbs-Wiggins, P.C., Harding, G.T., Jr., Barnhouse, R.T., 

Thurrell, R.J., and Tuyl, C.V. Guidelines Regarding Possible Conflict Between Psychiatrists’ 

Religious Commitments and Psychiatric Practice. Resource Document. APA Document 

Reference No. 890011. Arlington, VA: American Psychiatric Association, 1989. 

Galen, L.W., Brower, K.J., Gillespie, B.W., and Zucker, R.A. Sociopathy, gender and treatment

outcome among outpatient substance abusers. Drug and Alcohol Dependence 61(1):23–33, 2000. 

Garfinkel, I., McLanahan, S.S., Meyer, D.R., and Seltzer, J.A., eds. Fathers Under Fire: The 

Revolution in Child Support Enforcement. New York: Russell Sage Foundation, 1998. 

Garrett, J., Landau, J., Shea, R., Stanton, M.D., Baciewicz, G., and Brinkman-Sull, D. The 

ARISE Intervention: Using family and network links to engage addicted persons in

treatment. Journal of Substance Abuse Treatment 15(4):333–343, 1998. 

Garrett, J., Landau-Stanton, J., Stanton, M.D., Stellato-Kabat, J., and Stellato-Kabat, D. ARISE

(Albany-Rochester Interventional Sequence for Engagement): A method for engaging

reluctant alcohol- and drug-dependent individuals in treatment. Journal of Substance Abuse 

Treatment 14(3):235–248, 1997. 

Garrett, J., Stanton, M.D., Landau, J., Baciewicz, G., Brinkman-Sull, D., and Shea, R. The 

“concerned other” call: Using family links and networks to overcome resistance to addiction

treatment. Substance Use and Misuse 34(3):363–382, 1999. 

Gatrell, J., Wood, D.W., and Ovenden, A. Substance Abuse in Hawaii: Adult Population Household 

Telephone Survey (1998). Kapolei, HI: Hawaii Department of Health, Alcohol and Drug 

Abuse Division, 2000. 

149 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Geisner, I.M., Larimer, M.E., and Neighbors, C. The relationship among alcohol use, related

problems, and symptoms of psychological distress: Gender as a moderator in a college sample.

Addictive Behaviors 29(5):843–848, 2004. 

George, M.J. Invisible touch. Aggression and Violent Behavior 8:23–60, 2003. 

George, W.H., Davis, K.C., Schraufnagel, T.J., Norris, J., Heiman, J.R., Schacht, R.L., Stoner, 

S.A., and Kajumulo, K.F. Later that night: Descending alcohol intoxication and men’s sexual 

arousal. American Journal of Men’s Health 2(1):76–86, 2008. 

Gerson, K. Moral dilemmas, moral strategies, and the transformation of gender: Lessons from 

two generations of work and family change. In: The Kaleidoscope of Gender: Prisms, Patterns, 

and Possibilities, 2nd ed. (pp. 388–396). Thousand Oaks, CA: Pine Forge Press/Sage 

Publications Co., 2008. 

Giancola, P.R. Irritability, acute alcohol consumption and aggressive behavior in men and women.

Drug and Alcohol Dependence 68(3):263–274, 2002a. 

Giancola, P.R. The influence of trait anger on the alcohol-aggression relation in men and women.

Alcoholism: Clinical and Experimental Research 12(9):1350–1358, 2002b. 

Giancola, P.R., and Zeichner, A. An investigation of gender differences in alcohol-related

aggression. Journal of Studies on Alcohol 56(5):573–579, 1995. 

Gilmore, D.D. Manhood in the Making: Cultural Concepts of Masculinity. New Haven, CT: Yale 

University Press, 1990. 

Ginsberg, B.G. Together in group therapy: Fathers and their adolescent sons. In: Andronico,

M.P., ed. Men in Groups: Insights, Interventions, and Psychoeducational Work (pp. 269–282). 

Washington, DC: American Psychological Association, 1996. 

Giordano, J., and McGoldrick, M. Families of European origin: An overview. In: McGoldrick,

M., Giordano, J., and Garcia-Preto, N., eds. Ethnicity and Family Therapy, 3rd ed. (pp. 501– 

519). New York: Guilford Press, 2005. 

GlaxoSmithKline New Zealand. Methadone Syrup: Glaxo Smith Kline Information for Health 

Professionals Data Sheet. Auckland, New Zealand: GlaxoSmithKline New Zealand, 2005. 

Goldstein, J.M., Cohen, L.S., Horton, N.J., Lee, H., Andersen, S., Tohen, M., Crawford, A., and

Tollefson, G. Sex differences in clinical response to olanzapine compared with haloperidol.

Psychiatry Research 110(1):27–37, 2002. 

Gomberg, E.S.L. Medication problems and drug abuse. In: Turner, F.J., ed. Mental Health and the 

Elderly (pp. 355–374). New York: Free Press, 1992. 

Good, G.E., Borst, T.S., and Wallace, D.L. Masculinity research: A review and critique. Applied 

and Preventive Psychology 3(1):3–14, 1994. 

Good, G.E., Dell, D.M., and Mintz, L.B. Male role and gender role conflict: Relations to helpseeking in men. Journal of Counseling Psychology 36(3):295–300, 1989. 

150 
 

 

 

 

 

 

Appendices 

Good, G.E., and Mintz, L.B. Gender role conflict and depression in college men: Evidence for 

compounded risk. Journal of Counseling and Development 69(1):17–21, 1990. 

Good, G.E., Robertson, J.M., Fitzgerald, L.F., and Stevens, M. The relation between masculine 

role conflict and psychological distress in male university counseling center clients. Journal of 

Counseling and Development 75(1):44–49, 1996. 

Good, G.E., and Sherrod, N.B. Men’s resolution of nonrelational sex across the lifespan. In:

Levant, R.F., and Brooks, G.R., eds. Men and Sex: New Psychological Perspectives (pp. 181– 

204). New York: John Wiley and Sons, 1997. 

Good, G.E., and Sherrod, N.B. Men’s problems and effective treatments: Theory and empirical 

support. In: Brooks, G.R., and Good, G.E., eds. The New Handbook of Psychotherapy and

Counseling With Men: A Comprehensive Guide to Settings, Problems, and Treatment Approaches,

Vols. 1 & 2 (pp. 22–40). San Francisco: Jossey-Bass, 2001. 

Good, G.E., Sherrod, N.B., and Dillon, M.G. Masculine gender role stressors and men’s health. 

In: Eisler, R.M., and Hersen, M., eds. Handbook of Gender, Culture, and Health (pp. 63–81). 

Mahwah, NJ: Lawrence Erlbaum Associates, 2000. 

Good, G.E., Thomson, D.A., and Brathwaite, A.D. Men and therapy: Critical concepts,

theoretical frameworks, and research recommendations. Journal of Clinical Psychology 

61(6):699–711, 2005. 

Good, G.E., and Wood, P.K. Male gender role conflict, depression, and help seeking: Do college 

men face double jeopardy? Journal of Counseling and Development 74(1):70–75, 1995. 

Goodman, L.A., Salyers, M.P., Mueser, K.T., Rosenberg, S.D., Swartz, M., Essock, S.M., Osher,

F.C., Butterfield, M.I., and Swanson, J. Recent victimization in women and men with severe 

mental illness: Prevalence and correlates. Journal of Traumatic Stress 14(4):615–632, 2001. 

Gorey, K.M., and Leslie, D.R. The prevalence of child sexual abuse: Integrative review 

adjustment for potential response and measurement biases. Child Abuse and Neglect 

21(4):391–398, 1997. 

Gorman, E.M., and Carroll, R.T. Substance abuse and HIV: Considerations with regard to

methamphetamines and other recreational drugs for nursing practice and research. Journal of 

the Association of Nurses in AIDS Care 11(2):51–62, 2000. 

Gorman, E.M., Nelson, K.R., Applegate, T., and Scrol, A. Club drug and polysubstance abuse 

and HIV among gay/bisexual men: Lessons gleaned from a community study. Journal of Gay 

& Lesbian Social Services 16(2):1–17, 2004. 

Gorsuch, R.L., and Miller, W.R. Assessing spirituality. In: Miller, W.R., ed. Integrating 

Spirituality Into Treatment: Resources for Practitioners (pp. 47–64). Washington, DC: American 

Psychological Association, 1999. 

Gossop, M., Stewart, D., Browne, N., and Marsden, J. Factors associated with abstinence, lapse or

relapse to heroin use after residential treatment: Protective effect of coping responses.

Addiction 97:1259–1267, 2002. 

151 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Gottheil, E., Weinstein, S.P., Sterling, R.C., Lundy, A., and Serota, R.D. A randomized

controlled study of the effectiveness of intensive outpatient treatment for cocaine 

dependence. Psychiatric Services 49(6):782–787, 1998. 

Grant, B.F., and Dawson, D.Z. Age at onset of alcohol use and its association with DSM-IV

alcohol abuse and dependence: Results from the national longitudinal alcohol epidemiologic 

survey. Journal of Substance Abuse 9:103–110, 1997. 

Grant, B.F., Dawson, D.A., Stinson, F.S., Chou, S.P., Dufour, M.C., and Pickering, R.P. The 12­

month prevalence and trends in DSM-IV alcohol abuse and dependence: United States,

1991–1992 and 2001–2002. Drug and Alcohol Dependence 74(3):223–234, 2004a. 

Grant, B.F., Goldstein, R.B., Chou, S,P,, Huang. B,, Stinson, F.S., Dawson, D.A., Saha, T.D.,

Smith, S.M., Pulay, A.J., Pickering, R.P., Ruan, W.J., Compton, W.M. Sociodemographic and

psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety 

disorders: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related

Conditions. Molecular Psychiatry 14(11):1051–1066, 2009. 

Grant, B.F., Hasin, D.S., Stinson, F.S., Dawson, D.A., Chou, S.P., Ruan, W.J., and Pickering, R.P. 

Prevalence, correlates, and disability of personality disorders in the United States: Results 

from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of 

Clinical Psychiatry 65(7):948–958, 2004b. 

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., and Ruan, W.J. Co-occurrence of DSM-IV

personality disorders in the United States: Results from the National Epidemiologic Survey 

on Alcohol and Related Conditions. Comprehensive Psychiatry 46 (1):1–5, 2005. 

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Ruan, W.J., and Pickering, R.P. Cooccurrence of 12-month alcohol and drug use disorders and personality disorders in the 

United States. Archives of General Psychiatry 61(4):361–368, 2004c. 

Grant, J.E., and Potenza, M.N. Textbook of Men’s Mental Health. Washington, DC: American 

Psychiatric Publishing, Inc., 2007. 

Green, B. Post-traumatic stress disorder: symptom profiles in men and women. Current Medical 

Research and Opinion 19:200–204, 2003. 

Green, C.A., Polen, M.R., Lynch, F.L., Dickinson, D.M., and Bennett, M.D. Gender differences 

in outcomes in an HMO-based substance abuse treatment program. Journal of Addictive 

Diseases. 23(2):47–70, 2004. 

Greenan, D.E., and Tunnell, G. Couple Therapy With Gay Men. New York: Guilford Press, 2003. 

Greenfeld, L.A. Sex Offenses and Offenders: An Analysis of Data on Rape and Sexual Assault. Bureau 

of Justice Statistics, 1997. 

Greenfeld, L.A., and Henneberg, M.A. Victim and offender self-reports of alcohol involvement

in crime. Alcohol Research and Health 25(1):20–31, 2001. 

152 
 

 

 

 

Appendices 

Greenfeld, L.A., Rand, M.R., Craven, D., Klaus, P.A., Perkins, C.A., Ringel, C., Warchol, G.,

Maston, C., and Fox, J.A. Violence by Intimates: Analysis of Data on Crimes by Current or

Former Spouses, Boyfriends, and Girlfriends. Bureau of Justice Statistics Factbook. NCJ167237. Washington, DC: U.S. Department of Justice, 1998. 

Grella, C.E., Greenwell, L., Mays, V.M., and Cochran, S.D. Influence of gender, sexual 

orientation, and need on treatment utilization for substance use and mental disorders:

Findings from the California Quality of Life Survey. BMC Psychiatry 9:52, 2009a. 

Grella, C.E., and Joshi, V. Gender differences in drug treatment careers among clients in the 

national Drug Abuse Treatment Outcome Study. American Journal of Drug and Alcohol Abuse 

25(3):385–406, 1999. 

Grella, C.E., Karno, M.P., Warda, U.S., Niv, N., and Moore, A.A. Gender and comorbidity

among individuals with opioid use disorders in the NESARC study. Addictive Behaviors 

34(6–7):498–504, 2009b. 

Grieco, E.M. The Native Hawaiian and Other Pacific Islander Population: Census 2000 Brief.

Washington, DC: U.S. Census Bureau, 2001. 

Grieco, E.M., and Cassidy, R.C. Overview of Race and Hispanic Origin: Census 2000 Brief.

Washington, DC: U.S. Census Bureau, 2001. 

Grill, E., Weitkunat, R., and Crispin, A. Separation from children as a specific risk factor to

fathers’ health and lifestyles. Sozial- Und Praventivmedizin 46(4):272–278, 2001. 

Grossman, M. Individual Behaviors and Substance Use: The Role of Price. Working Paper 10948. 

Cambridge, MA: National Bureau of Economic Research, 2004. 

Gunter, T.D., Arndt, S., Wenman, G., Allen, J., Loveless, P., Sieleni, B., and Black, D.W.

Frequency of mental and addictive disorders among 320 men and women entering the Iowa

prison system: Use of the MINI-Plus. Journal of the American Academy of Psychiatry and the 

Law 36(1):27–34, 2008. 

Haack, M.R., and Adger, H., Jr., eds. Strategic Plan for Interdisciplinary Faculty Development: 

Arming the Nation’s Health Professional Workforce for a New Approach to Substance Use Disorders. 

Providence, RI: Association for Medical Education and Research in Substance Abuse, 2002. 

Haas, G.L., Glick, I.D., Clarkin, J.F., Spencer, J.H., and Lewis, A.B. Gender and schizophrenia

outcome: A clinical trial of an inpatient family intervention. Schizophrenia Bulletin 16(2):277– 

292, 1990. 

Halkitis, P.N., Mukherjee, P.P., and Palamar, J.J. Longitudinal modeling of methamphetamine 

use and sexual risk behaviors in gay and bisexual men. AIDS and Behavior 13(4):783–791, 

2009a. 

Halkitis, P.N., Palamar, J.J., and Mukherjee, P.P. Poly-club-drug use among gay and bisexual men:

A longitudinal analysis. Drug and Alcohol Dependence 89(2–3):153–160, 2007. 

153 
 

Addressing the Specific Behavioral Health Needs of Men 

Halkitis, P.N., Solomon, T.M., Moeller, R.W., Doig, S.A., Espinosa, L.S., Siconolfi, D., and

Homer, B.D. Methamphetamine use among gay, bisexual and non-identified men-who-havesex-with-men: An analysis of daily patterns. Journal of Health Psychology 14(2):222–231, 

2009b. 

Hall, A.S., and Kelly, K.R. Noncustodial fathers in groups: Maintaining the parenting bond. In:

Andronico, M.P., ed. Men in Groups: Insights, Interventions, and Psychoeducational Work (pp. 

243–256). Washington, DC: American Psychological Association, 1996. 

Hall, J.A., and Roter, D.L. Do patients talk differently to male and female physicians? A metaanalytic review. Patient Education and Counseling 48(3):217–224, 2002. 

Halpern, D.F. Sex differences in intelligence: Implications for education. American Psychologist 

52(10):1091–1102, 1997. 

Hardy, K. Plenary Address. Presented at the Dare to Act Post-Conference Institute: Men and 

Trauma, Renaissance Harborplace Hotel, Baltimore, MD: December 3, 2004. 

Hare, R.D. Manual for the Hare Psychopathy Checklist-Revised. Toronto: Multi-Health Systems, 

1991. 

Harrison, P.M., and Beck, A.J. Prisoners in 2002: Bureau of Justice Statistics Bulletin. Washington, 

DC: Bureau of Justice Statistics, 2003. 

Harrison, P.M., and Karberg, J.C. Prison and Jail Inmates at Midyear 2003: Bureau of Justice 

Statistics Bulletin (May). Washington, DC: Bureau of Justice Statistics, 2004. 

Hart, S.D., Kropp, P.R., Laws, D.R., Kalver, J., Logan, C., and Watt, K.A. Risk for Sexual Violence 

Protocol (RSVP): Structured Professional Guidelines for Assessing Risk of Sexual Violence. 

Vancouver: BC Institute Against Family Violence, 2003. 

Harwood, H., Fountain, D., Carothers, S., Gerstein, D., and Johnson, R. Gender differences in

the economic impacts of clients before, during and after substance abuse treatment. Drugs 

and Society 13(1–2):251–269, 1998. 

Harwood, H.J. Survey on behavioral health workplace. Frontlines: Linking Alcohol Services Research 

& Practice. Washington, DC: National Institute of Alcohol Abuse and Alcoholism, 2002. 

Hasin, D.S., Stinson, F.S., Ogburn, E., and Grant, B.F. Prevalence, correlates, disability, and

comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from 

the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General 

Psychiatry 64(7):830–842, 2007. 

Hassan, I., McCabe, R., and Priebe, S. Professional-patient communication in the treatment of

mental illness: A review. Communication and Medicine 4(2):141–152, 2007. 

Hastings, G., Anderson, S., Cooke, E., and Gordon, R. Alcohol marketing and young people’s 

drinking: A review of the research. Journal of Public Health Policy 26:296–311, 2005. 

Hazelden Foundation. Twelve Step Recovery is Spirituality at Its Best: Alive & Free. Center City, 

MN: Hazelden, 2003. 

154 
 

 

 

 

 

 

Appendices 

Heath, D.B. Cultural factors in the choice of drugs. In: Galanter, M., ed. Recent Developments in 

Alcoholism: Combined Alcohol and Other Drug Dependence, Vol. 8 (pp. 245–254). New York: 

Plenum Press, 1990. 

Heath, D.B. Drinking Occasions: Comparative Perspectives on Alcohol and Culture. Series on 

Alcohol in Society. Philadelphia: Brunner/Mazel, 2000. 

Heckman, T.G., Somlai, A.M., Peters, J., Walker, J., Otto-Salaj, L., Galdabini, C.A., and Kelly,

J.A. Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS 

Care 10(3):365–375, 1998. 

Hemmingsson, T., Lundberg, I., and Diderichsen, F. The roles of social class of origin, achieved

social class and intergenerational social mobility in explaining social-class inequalities in

alcoholism among young men. Social Science and Medicine 49(8):1051–1059, 1999. 

Hemmingsson, T., Lundberg, I., Diderichsen, F., and Allebeck, P. Explanations of social class 

differences in alcoholism among young men. Social Science and Medicine 47(10):1399–1405, 

1998. 

Hendershot, C.S., and George, W.H. Alcohol and sexuality research in the AIDS era: Trends in

publication activity, target populations and research design. AIDS and Behavior 11(2):217– 

226, 2007. 

Herbert, J.T., Hunt, B., and Dell, G. Counseling gay men and lesbians with alcohol problems.

Journal of Rehabilitation 60(2):52–57, 1994. 

Herbst, M.D., Batki, S.L., Manfredi, L.B., and Jones, T. Treatment outcomes for methadone 

clients receiving lump-sum payments at initiation of disability benefits. Psychiatric Services 

47(2):119–142, 1996. 

Herek, G.M. Thinking about AIDS and stigma: A psychologist’s perspective. Journal of Law and 

Medical Ethics 30(4):594–607, 2002. 

Heron, M., Hoyert, D.L., Murphy, S.L.X.J., Kochanik, K.D., and Tejada-Vera, B. Deaths: Final

data for 2006. National Vital Statistics Reports 57:14, 2009. 

Higgins, S.T., Budney, A.J., Bickel, W.K., and Badger, G.J. Participation of significant others in

outpatient behavioral treatment predicts greater cocaine abstinence. American Journal of Drug 

and Alcohol Abuse 20(1):47–56, 1994. 

Higuchi, S., Parrish, K.M., Dufour, M.C., Towle, L.H., and Harford, T.C. Relationship between

age and drinking patterns and drinking problems among Japanese, Japanese Americans, and

Caucasians. Alcoholism: Clinical and Experimental Research 18(2):305–310, 1994. 

Hiller, M.L., Knight, K., and Simpson, D.D. Prison-based substance abuse treatment, residential 

aftercare and recidivism. Addiction 94(6):833–842, 1999. 

Hilton, M.E. Demographic distribution of drinking problems in 1984. In: Clark, W.B., and

Hilton, M.E., eds. Alcohol in America: Drinking Practices and Problems (pp. 87–101). Albany, 

NY: State University of New York Press, 1991. 

155 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Hodgins, D.C., el Guebaly, N., and Addington, J. Treatment of substance abusers: Single or

mixed gender programs? Addiction 92(7):805–812, 1997. 

Hoffman, F. Cultural adaptations of Alcoholics Anonymous to serve Hispanic populations.

International Journal of Addictions 29(4):445–460, 1994. 

Hoffman, J.A., Mayo, D.W., Koman, J.J., and Caudill, B.D. Description and initial use of the

cocaine and sexuality questionnaire. Sexual Addiction & Compulsivity 1(4):293–305, 1994. 

Hoge, C.W., Auchterlonie, J.L., and Milliken, C.S. Mental health problems, use of mental health

services, and attrition from military service after returning from deployment to Iraq or

Afghanistan. Journal of the American Medical Association 295(9):1023–1032, 2006. 

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., and Koffman, R.L. Combat

duty in Iraq and Afghanistan: Mental health problems and barriers to care. New England 

Journal of Medicine 351(1):13–22, 2004. 

Hohman, M.M., and Galt, D.H. Latinas in treatment: Comparisons of residents in a culturally 

specific recovery home with residents in non-specific recovery homes. Journal of Ethnic & 

Cultural Diversity in Social Work 9(3–4):93–109, 2001. 

Holahan, C.J., Moos, R.H., Holahan, C.K., Cronkite, R.C., & Randall, P.K. Drinking to cope,

emotional distress and alcohol use and abuse: A ten-year model. Journal of Studies on Alcohol 

62:190–198, 2001. 

Holmes, W.C., and Slap, G.B. Sexual abuse of boys: Definition, prevalence, correlates, sequelae,

and management. Journal of American Medical Association 280(21):1855–1862, 1998. 

Hser, Y.I., Huang, D., Teruya, C., and Anglin, M.D. Gender comparisons of drug abuse 

treatment outcomes and predictors. Drug and Alcohol Dependence 72(3):255–264, 2003. 

Hughes, T.A., Wilson, D.J., and Beck, A.J. Trends in State Parole, 1990–2000. Bureau of Justice 

Statistics Special Report. Washington, DC: Bureau of Justice Statistics, 2001. 

Hughes, T.L., and Eliason, M. Substance use and abuse in lesbian, gay, bisexual and transgender

populations. Journal of Primary Prevention 22(3):263–298, 2002. 

Human Rights Watch. Targeting Blacks: Drug Law Enforcement and Race in the United States.

New York: Author, 2008. 

Humphreys, K., and Moos, R.H. Encouraging posttreatment self-help group involvement to

reduce demand for continuing care services: Two-year clinical and utilization outcomes.

Alcoholism: Clinical and Experimental Research 31(1):64–68, 2007. 

Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., Horvath, A.T., 

Kaskutas, L.A., Kirk, T., Kivlahan, D., Laudet, A., McCrady, B.S., McLellan, A.T.,

Morgenstern, J., Townsend, M., and Weiss, R. Self-help organizations for alcohol and drug

problems: Toward evidence-based practice and policy. Journal of Substance Abuse Treatment 

26(3):151–158, 2004. 

156 
 

 

 

 

 

Appendices 

Hunt, G.P., MacKenzie, K., and Joe-Laidler, K. Alcohol and masculinity: The case of ethnic

youth gangs. In: Wilson, T.M., ed. Drinking Cultures: Alcohol and Identity (pp. 225–254). 

Oxford: Berg, 2005. 

Hunt, K., Lewars, H., Emslie, C., and Batty, G.D. Decreased risk of death from coronary heart

disease amongst men with higher ‘femininity’ scores: a general population cohort study. 

International Journal of Epidemiology 36(3):612–620, 2007. 

Imber-Black, E. Family rituals—from research to the consulting room and back again: Comment

on the special section. Journal of Family Psychology 16(4):445–446, 2002. 

Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: 

National Academy Press, 1990. 

Isenhart, C. Masculine gender role stress in an inpatient sample of alcohol abusers. Psychology of 

Addictive Behaviors 7(3):177–184, 1993. 

Isenhart, C. Treating substance abuse in men. In: Brooks, G.R., and Good, G.E., eds. The New 

Handbook of Psychotherapy and Counseling With Men: A Comprehensive Guide to Settings,

Problems, and Treatment Approaches, Vols. 1 & 2 (pp. 246–262). San Francisco, CA: JosseyBass, 2001. 

Iverson, A., Nikolaou, V., Greenberg, N., Unwin, C., Hull, L., Hotopf, M., Dandeker, C., Ross, J.,

and Wessely, S.C. What happens to British veterans when they leave the armed forces?

European Journal of Public Health 15(2):175–184, 2005. 

Jacobson, I.G., Ryan, M.A.K., Hooper, T.I., Smith, T.C., Amoroso, P.J., Boyko, E.J., Gackstetter,

G.D., Wells, T.S., and Bell, N.S. Alcohol use and alcohol-related problems before and after

military combat deployment. Journal of the American Medical Association 300(6):663–675, 

2008. 

Jaffe, P.G., Lemon, N.K.D., and Poisson, S.E. Child Custody and Domestic Violence: A Call for 

Safety and Accountability. Thousand Oaks, CA: Sage Publications, 2003. 

Jakupcak, M. Masculine gender role stress and men’s fear of emotions as predictors of selfreported aggression and violence. Violence and Victims 18(5):533–541, 2003. 

Jarrett, N.C., Bellamy, C.D., and Adeyemi, S.A. Men’s health help-seeking and implications for 

practice. American Journal of Health Studies 22(2):88, 2007. 

Jeffries, J.M., Menghraj, S., and Hairston, C.F. Serving Incarcerated and Ex-Offender Fathers and 

Their Families: A Review of the Field. New York: Vera Institute of Justice, 2001. 

Johnson, A.K., and Cnaan, R.A. Social work practice with homeless persons: State of the art.

Research on Social Work Practice 5(3):340–382, 1995. 

Johnson, J.L., and Leff, M. Children of substance abusers: Overview of research findings.

Pediatrics 103(5):1085–1099, 1999. 

Johnson, M.E., Brems, C., Mills, M.E., and Fisher, D.G. Psychiatric symptomatology among

individuals in alcohol detoxification treatment. Addictive Behaviors 32(8):1745–1752, 2007. 

157 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Johnson, N.G. Women helping men: Strengths of and barriers to women therapists working with

men clients. In: Brooks, G.R., and Good, G.E. The New Handbook of Psychotherapy and 

Counseling With Men. San Francisco: Jossey-Bass, 2001. 

Johnson, P.B., and Glassman, M. The relationship between ethnicity, gender and alcohol 

consumption: A strategy for testing competing models. Addiction 93(4):583–588, 1998. 

Johnson, V.E. Intervention: How To Help Someone Who Doesn’t Want Help: A Step-by-Step Guide for 

Families and Friends of Chemically Dependent Persons. Minneapolis, MN: Johnson Institute 

Books, 1986. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G., and Schulenberg, J.E. Monitoring the Future:

National Survey Results on Drug Use, 1975-2003. Volume I: Secondary School Students. NIH 

Publication No. 04-5507. Bethesda, MD: National Institute on Drug Abuse, 2003. 

Joint Commission on Accreditation of Healthcare Organizations. Spiritual Assessment. Oakbrook 

Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2004. 

Jones, T.R., and Pratt, T.C. The prevalence of sexual violence in prison: The state of the

knowledge base and implications for evidence-based correctional policymaking. International 

Journal of Offender Therapy and Comparative Criminology 52(3):280–295, 2008. 

Jones-Webb, R.J., Hsiao, C.Y., and Hannan, P. Relationships between socioeconomic status and

drinking problems among black and white men. Alcoholism: Clinical and Experimental 

Research 19(3):623–627, 1995. 

Jonker, J., De Jong, C.A., de Weert-van Oene, G.H., and Gijs, L. Gender-role stereotypes and

interpersonal behavior: How addicted inpatients view their ideal male and female therapist.

Journal of Substance Abuse Treatment 19(3):307–312, 2000. 

Joyce, P.R., Sellman, D., Wells, E., and Frampton, C.M. Parental bonding in men with alcohol 

disorders: A relationship with conduct disorder. Australian and New Zealand Journal of 

Psychiatry 28(3):405–411, 1994. 

Kalichman, S.C., Johnson, J.R., Adair, V., Rompa, D., Multhauf, K., and Kelly, J.A. Sexual 

sensation seeking: Scale development and predicting AIDS-risk behavior among

homosexually active men. Journal of Personality Assessment 62(3):385–397, 1994. 

Kalichman, S.C., and Rompa, D. Sexual sensation seeking and sexual compulsivity scales:

Reliability, validity, and predicting HIV risk behavior. Journal of Personality Assessment 

65(3):586–601, 1995. 

Kanayama, G., Cohane, G.H., Weiss, R.D., and Pope, J. Past anabolic-androgenic steroid use 

among men admitted for substance abuse treatment: An underrecognized problem? Journal of 

Clinical Psychiatry 64(2):156–160, 2003. 

Kanayama, G., Hudson, J.I., and Pope, H.G., Jr. Long-term psychiatric and medical

consequences of anabolic-androgenic steroid abuse: A looming public health concern? Drug 

and Alcohol Dependence 98(1–2):1–12, 2008. 

158 
 

 

 

 

 

Appendices 

Kantor, G.K., and Asdigian, N.L. Gender differences in alcohol-related spousal aggression. In:

Wilsnack, R.W., and Wilsnack, S.C. Gender and Alcohol. New Brunswick, NJ: Publications 

Center, Rutgers Center of Alcohol Studies, 1997. 

Karberg, J.C., and James, D.J. Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002. 

Bureau of Justice Statistics: Special Report. NCJ209588 Washington, DC: U.S. Department

of Justice, 2005. 

Karno, M.P., and Longabaugh, R.L. What do we know? Process analysis and the search for a

better understanding of Project MATCH’s anger-by-treatment matching effect. Journal of 

Studies on Alcohol, 65:501–512, 2004. 

Kashner, T.M., Rosenheck, R., Campinell, A.B., Suris, A., Crandall, R., Garfield, N.J., Lapuc, P.,

Pyrcz, K., Soyka, T., and Wicker, A. Impact of work therapy on health status among

homeless, substance-dependent veterans: A randomized controlled trial. Archives of General 

Psychiatry 59(10):938–944, 2002. 

Kasprow, W.J., Rosenheck, R., Frisman, L., and DiLella, D. Residential treatment for dually 

diagnosed homeless veterans: A comparison of program types. American Journal on Addictions 

8(1):34–43, 1999. 

Kaufman, J., and Zigler, E. The intergenerational transmission of violence is overstated. In:

Gelles, R.J., and Loseke, D.R., eds. Current Controversies on Family Violence (pp. 167–196). 

Newbury Park, CA: Sage Publications, 1993. 

Kausch, O. Patterns of substance abuse among treatment-seeking pathological gamblers. Journal 

of Substance Abuse Treatment 25(4):263–270, 2003. 

Keen, S. Fire in the Belly: On Being a Man. New York: Bantam Books, 1991. 

Kelley, M.L., and Fals-Stewart, W. Couples- versus individual-based therapy for alcohol and

drug abuse: Effects on children’s psychosocial functioning. Journal of Consulting and Clinical 

Psychology 70(2):417–427, 2002. 

Keltner, D., and Harker, L. The forms and functions of the nonverbal signal of shame. In:

Gilbert, P., and Andrews, B., eds. Shame: Interpersonal Behavior, Psychopathology, and Culture

(pp. 78–98). London: Oxford University Press, 1998. 

Kessler, R.C. Sex differences in DSM-III-R psychiatric disorders in the United States: Results 

from the National Comorbidity Survey. Journal of the American Medical Women’s Association 

53(4):148–158, 1998. 

Kessler, R.C. Gender and mood disorders. In: Goldman, M., and Hatch, M., eds. Women and 

Health (pp. 997–1009). San Diego, CA: Academic Press, 2000a. 

Kessler, R.C. Posttraumatic stress disorder: the burden to the individual and to society. Journal of 

Clinical Psychiatry 61(Suppl. 5):4–12, 2000b. 

159 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Kessler, R.C. The global burden of anxiety and mood disorders: Putting the European Study of

the Epidemiology of Mental Disorders (ESEMeD) findings into perspective. Journal of 

Clinical Psychiatry 68:10–19, 2007. 

Kessler, R.C., Hwang, I., LaBrie, R., Petukhova, M., Sampson, N.A., Winters, K.C, and Shaffer, 

H.J. DSM-IV pathological gambling in the National Comorbidity Survey replication.


Psychological Medicine 38(9):1351–60, 2008.
 

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen,

H.U., and Kendler, K.S. Lifetime and 12-month prevalence of DSM-III-R psychiatric

disorders in the United States. Archives of General Psychiatry 51:8–19, 1994. 

Kessler, R.C., Nelson, C.B., McGonagle, K.A., Edlund, M.J., Frank, R.G., and Leaf, P.J. The 

epidemiology of co-occurring addictive and mental disorders: Implications for prevention and

service utilization. American Journal of Orthopsychiatry 66(1):17–31, 1996a. 

Kessler, R.C., Nelson, C.B., McGonagle, K.A., Liu, J., Swartz, M., and Blazer, D.G. Comorbidity 

of DSM-III-R major depressive disorder in the general population: Results from the U.S.

National Comorbidity Survey. British Journal of Psychiatry June (Suppl. 30):17–30, 1996b. 

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., and Nelson, C.B. Posttraumatic stress 

disorder in the National Comorbidity Survey. Archives of General Psychiatry 52(12):1048– 

1060, 1995. 

Kilmer, B., Caulkins, J.P., Liccardo Pacula, R., MacCoun, R.J., and Reuter, P.H. Altered State? 

Assessing How Marijuana Legalization in California Could Influence Marijuana Consumption

and Public Budgets. Santa Monica, CA: The RAND Corporation, 2010. 

Kilts, C.D., Gross, R.E., Ely, T.D., and Drexler, K.P.G. The neural correlates of cue-induced 

craving in cocaine-dependent women. American Journal of Psychiatry 161(2):233–241, 2004. 

Kimmel, M.S., and Messner, M.A. Men’s Lives, 8th ed. Boston: Allyn and Bacon, 2010. 

King, R.S. Disparity by Geography: The War on Drugs in America’s Cities. Washington, DC: The 

Sentencing Project, 2008. 

Kirby, K.C., Lamb, R.J., Iguchi, M.Y., Husband, S.D., and Platt, J.J. Situations occasioning

cocaine use and cocaine abstinence strategies. Addiction 90(9):1241–1252, 1995. 

Kirisci, L., Dunn, M.G., Mezzich, A.C., and Tarter, R.E. Impact of parental substance use 

disorder and child neglect severity on substance use involvement in male offspring.

Prevention Science 2(4):241–255, 2001. 

Kiselica, M.S. Parenting skills training with teenage fathers. In: Andronico, M.P., ed. Men in 

Groups: Insights, Interventions, and Psychoeducational Work (pp. 283–300). Washington, DC: 

American Psychological Association, 1996. 

Klein, H. Contemporary Italian American college student drinking patterns. In: Scelsa, J.,

LaGumina, S., and Tomasi, L., eds. Italian Americans in Transition (pp. 177–187). New York: 

American Italian Historical Association, 1990. 

160 
 

 

 

 

 

 

Appendices 

Kline, A. Pathways into drug user treatment: The influence of gender and racial/ethnic identity.

Substance Use and Misuse 31(3):323–342, 1996. 

Klitzman, R.L., Greenberg, J.D., Pollack, L.M., and Dolezal, C. MDMA (“ecstasy”) use, and its 

association with high risk behaviors, mental health, and other factors among gay/bisexual 

men in New York City. Drug and Alcohol Dependence 66(2):115–125, 2002. 

Klonoff-Cohen, H., Lam-Kruglick, P., and Gonzalez, C. Effects of maternal and parental alcohol 

consumption on the success rates of in vitro fertilization and gamete intrafallopian transfer.

Fertility and Sterility 79(2):330–339, 2003. 

Klonsky, D.E., Jane, J.S., Turkheimer, E., and Oltmanns, T.F. Gender role and personality 

disorders. Journal of Personality Disorders 16(5):464–476, 2002. 

Knupfer, G. The prevalence in various social groups of eight different drinking patterns, from 

abstaining to frequent drunkenness: Analysis of 10 U.S. surveys combined. British Journal of 

Addiction 84(11):1305–1318, 1989. 

Koenen, K.C., Lyons, M.J., Goldberg, J., Simpson, J.C., Williams, W.M., Toomey, R., Eisen,

S.A., True, W.R., Cloitre, M., Wolfe, J., and Tsuang, M.T. A high risk twin study of combatrelated PTSD comorbidity. Twin Research 6(3):218–226, 2003. 

Koenig, H.G. Religion and medicine II: Religion, mental health, and related behaviors.

International Journal of Psychiatry in Medicine 31(1):97–109, 2001a. 

Koenig, H.G. Religion and medicine IV: Religion, physical health, and clinical implications.

International Journal of Psychiatry in Medicine 31(3):321–336, 2001b. 

Kohn, C.S., Mertens, J.R., and Weisner, C.M. Coping among individuals seeking private

chemical dependence treatment: Gender differences and impact on length of stay in

treatment. Alcoholism: Clinical and Experimental Research 26(8):1228–1233, 2002. 

Koss, M.P., and Dinero, T.E. Predictors of sexual aggression among a national sample of male 

college students. Annals of the New York Academy of Science 528:133–147, 1988. 

Kraybill, K., and Zerger, S. Providing Treatment for Homeless People With Substance Use Disorders:

Case Studies of Six Programs. Nashville, TN: National Health Care for the Homeless Council, 

2003. 

Krestan, J., ed. Bridges to Recovery: Addiction, Family Therapy, and Multicultural Treatment. New 

York: The Free Press, 2000. 

Kropp, P.R., Hart, S.D., Webster, C.D., and Eaves, D. Manual for the Spousal Assault Risk 

Assessment Guide, 2nd ed. North Tonawanda, NY: Multi-Health Systems, 1995. 

Krugman, S. Male development and the transformation of shame. In: Levant, R.F., and Pollack,

W.S., eds. A New Psychology of Men (pp. 91–126). New York: Basic Books, 1995. 

Krugman, S. Men’s shame and trauma in therapy. In: Pollack, W.S., and Levant, R.F., eds. New 

Psychotherapy for Men (pp. 167–190). Somerset, NJ: John Wiley & Sons, 1998. 

161 
 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., Weiss,

D.S., and Grady, D.A. Trauma and the Vietnam War Generation: Report of Findings From the

National Vietnam Veterans Readjustment Study. Brunner/Mazel Psychosocial Stress Series No. 

18. New York: Brunner/Mazel, 1990. 

Kuntsche, S., Knibbe, R.A., and Gmel, G. Social roles and alcohol consumption: A study of 10 

industrialised countries. Social Science and Medicine (68):1263–1270, 2009. 

Kunz, J.L., and Graham, K. Life course changes in alcohol consumption in leisure activities of

men and women. Journal of Drug Issues 26(4):805–826, 1996. 

Lab, D.D., Feigenbaum, J.D., and De Silva, P. Mental health professionals’ attitudes and practices 

towards male childhood sexual abuse. Child Abuse & Neglect 24(3):391–409, 2000. 

Ladd, G.T., and Petry, N.M. A comparison of pathological gamblers with and without substance 

abuse treatment histories. Experimental and Clinical Psychopharmacology 11(3): 202–209, 2003. 

Ladd, G.T., and Petry, N.M. Gender differences among pathological gamblers seeking treatment.

Experimental and Clinical Psychopharmacology 10(3):302–309, 2002. 

LairRobinson, R. Men and gambling. In: Straussner, S.L.A., and Zelvin, E., eds. Gender and 

Addictions: Men and Women in Treatment (pp. 469–492). Northvale, NJ: Jason Aronson, 1997. 

Landau, J., Garrett, J., Shea, R.R., Stanton, M.D., Brinkman-Sull, D., and Baciewicz, G. Strength

in numbers: The ARISE method for mobilizing family and network to engage substance 

abusers in treatment. A relational intervention sequence for engagement. American Journal of 

Drug and Alcohol Abuse 26(3):379–398, 2000. 

Laudet, A.B., Morgen, K., and White, W.L. The role of social supports, spirituality, religiousness,

life meaning and affiliation with 12-Step fellowships in quality of life satisfaction among

individuals in recovery from alcohol and drug problems. Alcohol Treatment Quarterly 24(1– 

2):33–73, 2006. 

Lazare, A. Shame, humiliation, and stigma in the medical interview. In: Lansky, M.R., and

Morrison, A.P., eds. The Widening Scope of Shame (pp. 383–396). Hillsdale, NJ: Analytic Press, 

1997. 

Lazarus, R.S., and Folkman, S. Stress, Appraisal, and Coping. New York: Springer, 1984. 

Lazur, R.F. Men in the family: A family system’s approach to treating men. In: Pollack, W.S., and 

Levant, R.F., eds. New Psychotherapy for Men (pp. 127–144). Somerset, NJ: John Wiley & 

Sons, 1998. 

Lebow, J., Kelly, J.F., Knobloch-Fedders, L.M., and Moos, R. Relationship factors in treating

substance use disorders. In: Castonguay, L.G., and Beutler, L.E., eds. Principles of Therapeutic 

Change That Work (pp. 293–317). New York: Oxford University Press, 2005. 

Lee, A.J., Crombie, I.K., Smith, W.C., and Tunstall-Pedoe, H. Alcohol consumption and

unemployment among men: The Scottish Heart Health Study. British Journal of Addiction 

85(9):1165–1170, 1990. 

162 
 

 

Appendices 

Lee, L.C., and Zane, N. Addictive behaviors. In: Lee, L.C., and Zane, N.W.S., eds. Handbook of 

Asian American Psychology. Thousand Oaks, CA: Sage Publications, 1998. 

Lehman, W.E., and Bennett, J.B. Job risk and employee substance use: The influence of personal 

background and work environment factors. American Journal of Drug and Alcohol Abuse 

28(2):263–286, 2002. 

Lejuez, C.W., Simmons, B.L., Aklin, W.M., Daughters, S.B., and Dvir, S. Risk-taking propensity 

and risky sexual behavior of individuals in residential substance use treatment. Addictive 

Behaviors 29(8):1643–1647, 2004. 

Lemke, S., Schutte, K.K., Brennan, P.L., and Moos, R.H. Gender differences in social influences 

and stressors linked to increased drinking. Journal of Studies on Alcohol and Drugs 69(5):695– 

702, 2008. 

Lesser, J., Tello, J., Koniak-Griffin, D., Kappos, B., and Rhys, M. Young Latino fathers’ 

perceptions of paternal role and risk for HIV/AIDS. Hispanic Journal of Behavioral Sciences 

23(3):327–343, 2001. 

Levant, R.F. Toward the reconstruction of masculinity. In: Levant, R.F., and Pollack, W.S., eds. A 

New Psychology of Men (pp. 229–251). New York: Basic Books, 1995. 

Levant, R.F. The male code and parenting: A psychoeducational approach. In: Andronico, M.P.,

ed. Men in Groups: Insights, Interventions, and Psychoeducational Work (pp. 229–241). 

Washington, DC: American Psychological Association, 1996. 

Levant, R.F., Hall, R.J., Williams, C., and Hasan, N.T. Gender differences in alexithymia: A

meta-analysis. Psychology of Men & Masculinity 10:190–203, 2009. 

Levant, R.F., Hirsch, L.S., Celentano, E., Cozza, T.M., Hill, S., MacEachern, M., Marty, N., and

Schnedeker, J. The male role: An investigation of contemporary norms. Journal of Mental 

Health Counseling 14(3):325–337, 1992. 

Levant, R.F., Majors, R.G., and Kelley, M.L. Masculinity ideology among young African

American and European American women and men in different regions of the United States.

Cultural Diversity and Mental Health 4(3):227–236, 1998. 

Levant, R.F., and Philpot, C.L. Conceptualizing gender in marital and family therapy research:

The gender role strain paradigm. In: Liddle, H.A., Santisteban, D.A., Levant, R.F., and Bray,

J.H., eds. Family Psychology: Science-Based Interventions (pp. 301–329). Washington, DC: 

American Psychological Association, 2002. 

Levant, R.F., and Pollack, W.S., eds. A New Psychology of Men. New York: Basic Books, 1995. 

Levant, R.F., and Silverstein, L.B. Integrating gender and family systems theories: The 

“both/and” approach to treating a postmodern couple. In: McDaniel, S.H., Lusterman, D.D.,

and Philpot, C.L., eds. Casebook for Integrating Family Therapy: An Ecosystemic Approach (pp. 

245–252). Washington, DC: American Psychological Association, 2001. 

163 
 

 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Levin, Y., and Sanacora, G. Depression. In: Grant, J.E., and Potenza, M.N., eds. Textbook of Men’s 

Mental Health, 1st ed. (pp. 93–117). Washington, DC: American Psychiatric Publishing, Inc., 

2007. 

Lewis, H.B. Shame and Guilt in Neurosis. New York: International Universities Press, 1971. 

Lex, B.W. Gender and cultural influences on substance abuse. In: Eisler, R.M., and Hersen, M.,

eds. Handbook of Gender, Culture, and Health (pp. 255–297). Mahwah, NJ: Lawrence Erlbaum 

Associates, 2000. 

Li, J., Liu, H., Liu, H., Feng, T., and Cai, Y. Psychometric assessment of HIV/STI sexual risk 

scale among MSM: A Rasch model approach. BMC Public Health 11:763, 2011. 

Lichtenstein, B. Drugs, incarceration, and HIV/AIDS among African American men: A critical

literature review and call to action. American Journal of Men’s Health 3(3):252–264, 2009. 

Link, B.G., Struening, E.L., Rahav, M., Phelan, J.C., and Nuttbrock, L. On stigma and its 

consequences: Evidence from a longitudinal study on men and dual diagnosis of mental 

illness and substance abuse. Journal of Health and Social Behavior 38(2):177–190, 1997. 

Lisak, D. Homicide, violence, and male aggression. In: Brooks, G.R., and Good, G.E., eds. The 

New Handbook of Psychotherapy and Counseling With Men: A Comprehensive Guide to Settings, 

Problems, and Treatment Approaches, Vol. 1 (pp. 278–292). San Francisco: Jossey-Bass, 2001a. 

Lisak, D. Male survivors of trauma. In: Brooks, G.R., and Good, G.E., eds. The New Handbook of 

Psychotherapy and Counseling With Men: A Comprehensive Guide to Settings, Problems, and

Treatment Approaches, Vol. 1 (pp. 263–277). San Francisco: Jossey-Bass, 2001b. 

Liu, W.M. The social class-related experiences of men: Integrating theory and practice.

Professional Psychology: Research and Practice 33(4):355–360, 2002. 

Liu, W.M. The study of men and masculinity as an important multicultural competency 

consideration. Journal of Clinical Psychology 61(6):685–697, 2005. 

Liu, W.M., and Iwamoto, D.K. Asian American men’s gender role conflict: The role of Asian 

values, self-esteem, and psychological distress. Psychology of Men & Masculinity 7(3):153–164, 

2006. 

Liu, W.M., Rochlen, A., and Mohr, J.J. Real and ideal gender-role conflict: Exploring

psychological distress among men. Psychology of Men & Masculinity 6(2):137–148, 2005. 

Lo, C.C., and Stephens, R.C. Arrestees’ perceived needs for substance-specific treatment: 

Exploring urban-rural differences. American Journal of Drug and Alcohol Abuse 28(4):623–642, 

2002. 

Loneck, B., Garrett, J.A., and Banks, S.M. A comparison of the Johnson intervention with four

other methods of referral to outpatient treatment. American Journal of Drug and Alcohol Abuse 

22(2):233–246, 1996. 

Lopez, A.D. The Global Burden of Disease: 2020 Focus 5. Washington, DC: International Food 

Policy Research Institute, 2004. 

164 
 

 

 

 

 

 

 

 

 

 

Appendices 

Luczak, S.E., Elvine-Kreis, B., Shea, S.H., Carr, L.G., and Wall, T.L. Genetic risk for alcoholism 

relates to level of response to alcohol in Asian American men and women. Journal of Studies 

on Alcohol 63(1):74–82, 2002. 

Luthar, S.S., and Suchman, N.E. Developmentally informed parenting interventions: The 

relational psychotherapy mothers’ group. In: Cicchetti, D., and Toth, S.L., eds. Rochester 

Symposium on Developmental Psychopathology: Developmental Approaches to Prevention and

Intervention, Vol. 9 (pp. 271–309). Rochester, NY: University of Rochester Press, 1999. 

Luthar, S.S., and Suchman, N.E. Relational psychotherapy mothers’ group: A developmentally 

informed intervention for at-risk mothers. Development and Psychopathology 12(2):235–253, 

2000. 

Lyme, A., Powell, D.J., and Andrew, S. Men’s Healing: Toolbox for Life. West Palm Beach, FL: 

Hanley Hope Publishing, 2008. 

Lyons, M. Enabling or disabling? Students’ attitudes toward persons with disabilities. American 

Journal of Occupational Therapy 45(4):311–316, 1991. 

Ma, G.X., Shive, S., Tan, Y., and Toubbeh, J. Prevalence and predictors of tobacco use among

Asian Americans in the Delaware Valley region. American Journal of Public Health 

92(6):1013–1020, 2002. 

MacDonald, J. Disclosing shame. In: Gilbert, P., and Andrews, B., eds. Shame: Interpersonal 

Behavior, Psychopathology, and Culture (pp. 141–157). London: Oxford University Press, 1998. 

Magovcevic, M., and Addis, M.E. Linking gender-role conflict to nonnormative and self

stigmatizing perceptions of alcohol abuse and depression. Psychology of Men & Masculinity 

6(2):127–136, 2005. 

Mahalik, J.R., Good, G.E., and Englar-Carlson, M. Masculinity scripts, presenting concerns, and

help seeking: Implications for practice and training. Professional Psychology: Research and 

Practice 34(2):123–131, 2003a. 

Mahalik, J.R., Locke, B.D., Ludlow, L.H., Diemer, M.A., Scott, R.P.J., Gottfried, M., and

Freitas, G. Development of the conformity to masculine norms inventory. Psychology of Men 

and Masculinity 4(1):3–25, 2003b. 

Mahalik, J.R., Talmadge, W.T., Locke, B.D., and Scott, R.P. Using the conformity to masculine 

norms inventory to work with men in a clinical setting. Journal of Clinical Psychology 

61(6):661–674, 2005. 

Makino, M., Tsuboi, K., and Dennerstein, L. Prevalence of eating disorders: A comparison of

Western and non-Western countries. Medscape General Medicine 6(3):49, 2004. 

Mancebo, M.C., Grant, J.E., Pinto, A., Eisen, J.L., and Rasmussen, S.A. Substance use disorders 

in an obsessive compulsive disorder clinical sample. Journal of Anxiety Disorders 23(4):429– 

435, 2009. 

165 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Mannelli, P., and Pae, C.U. Medical comorbidity and alcohol dependence. Current Psychiatry 

Reports 9(3):217–224, 2007. 

Mansfield, A.K., Addis, M.E., and Courtenay, W. Measurement of men’s help seeking: 

Development and evaluation of the barriers to help-seeking scale. Psychology of Men & 

Masculinity 6(2):95–108, 2005. 

Marini, I.D. Issues of males with physical disabilities in rehabilitation settings. In: Brooks, G.R.,

and Good, G.E., eds. The New Handbook of Psychotherapy and Counseling With Men: A 

Comprehensive Guide to Settings, Problems, and Treatment Approaches, Vols. 1 & 2 (pp. 185– 

205). San Francisco: Jossey-Bass, 2001. 

Marlatt, G.A. Relapse prevention: Theoretical rationale and overview of the model. In: Marlatt,

G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies in the Treatment of 

Addictive Behaviors (pp. 3–70). New York: Guilford Press, 1985. 

Marlatt, G.A. Taxonomy of high-risk situations for alcohol relapse: Evolution and development

of a cognitive-behavioral model. Addiction 91(Suppl):S37–S49, 1996. 

Marlin, E. Genograms: The New Tool for Exploring the Personality, Career, and Love Patterns You 

Inherit. Chicago: Contemporary Books, 1989. 

Marsella, A.J. Urbanization, mental health, and social deviancy: A review of issues and research.

American Psychologist 53(6):624–634, 1998. 

Marsh, J.C., Cao, D., and D’Aunno, T. Gender differences in the impact of comprehensive 

services in substance abuse treatment. Journal of Substance Abuse Treatment 27(4):289–300, 

2004. 

Martens, M.P., Dams-O’Connor, K., and Beck, N.C. A systematic review of college studentathlete drinking: Prevalence rates, sport-related factors, and interventions. Journal of Substance 

Abuse Treatment 31(3):305–316, 2006. 

Massoglia, M. Incarceration, health, and racial disparities in health. Law & Society Review 

42(2):275–306, 2008. 

Masten, A.S., Faden, V.B., Zucker, R.A., and Spear, L.P. Underage drinking: A developmental 

framework. Pediatrics 121:S235–S251, 2008. 

Mathews, F. The Invisible Boy: Revisioning the Victimization of Male Children and Teens. Ottawa, 

Canada: Public Health Agency of Canada, 1996. 

May, P.A., and Gossage, P. New data on the epidemiology of adult drinking and substance use 

among American Indians of the Northern States: Male and female data on prevalence,

patterns, and consequences. American Indian and Alaska Native Mental Health Research 

10(2):1–26, 2001. 

Maynard, C., Cox, G.B., Krupski, A., and Stark, K. Utilization of services for mentally ill 

chemically abusing patients discharged from residential treatment. The Journal of Behavioral 

Health Services and Research 26(2):219–228, 1999. 

166 
 

 

 

 

 

 

 

Appendices 

McCabe, S.E., Hughes, T.L., Bostwick, W.B., West, B.T., and Boyd, C.J. Sexual orientation,

substance use behaviors and substance dependence in the United States. Addiction 

104(8):1333–1345, 2009. 

McCaul, M.E., Svikis, D.S., and Moore, R.D. Predictors of outpatient treatment retention:

Patient versus substance use characteristics. Drug and Alcohol Dependence 62(1):9–17, 2001. 

McClelland, D.C., Davis, W.N., Kalin, R., and Wanner, E. The Drinking Man: Alcohol and 

Human Motivation. New York: The Free Press, 1972. 

McCormick, R.A., and Smith, M. Aggression and hostility in substance abusers: The 

relationship to abuse patterns, coping style, and relapse triggers. Addictive Behaviors 

20(5):555–562, 1995. 

McCrady, B.S., Epstein, E.E., and Kahler, C.W. Alcoholics Anonymous and relapse prevention

as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month 

outcomes. Journal of Consulting and Clinical Psychology 72(5):870–878, 2004. 

McCurdy, K., and Daro, D. Current Trends in Child Abuse Reporting and Fatalities: The Results of the

1993 Annual Fifty State Survey. Chicago: National Committee to Prevent Child Abuse, 1994. 

McElroy, S.L., Soutullo, C.A., Taylor, P., Jr., Nelson, E.B., Beckman, D.A., Brusman, L.A.,

Ombaba, J.M., Strakowski, S.M., and Keck, P.E., Jr. Psychiatric features of 36 men convicted

of sexual offenses. Journal of Clinical Psychiatry 60(6):414–420, 1999. 

McFall, M.E., Fontana, A., Raskind, M.A., and Rosenheck, R.A. Analysis of violent behavior in

Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. Journal of 

Traumatic Stress 12(3):501–517, 1999. 

McGoldrick, M. You Can Go Home Again: Reconnecting With Your Family. New York: W.W. 

Norton & Company, 1995. 

McGoldrick, M., ed. Re-Visioning Family Therapy: Race, Culture, and Gender in Clinical Practice. 

New York: Guilford Press, 1998. 

McGoldrick, M., Gerson, R., and Petry, S.S. Genograms: Assessment and Intervention, 3rd ed. New 

York: W.W. Norton & Company, 2008. 

McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds. Ethnicity and Family Therapy, 3rd ed. 

New York: Guilford Press, 2005. 

McKay, J.R., Lynch, K.G., Shepard, D.S., Morgenstern, J., Forman, R.F., and Pettinati, H.M. Do

patient characteristics and initial progress in treatment moderate the effectiveness of telephonebased continuing care for substance use disorders? Addiction 100(2):216–226, 2005. 

McKay, J.R., Rutherford, M.J., Alterman, A.I., Cacciola, J.S., and Kaplan, M.R. An examination

of the cocaine relapse process. Drug and Alcohol Dependence 38(1):35–43, 1995. 

McKay, J.R., Rutherford, M.J., Cacciola, J.S., Kabasakalian-McKay, R., and Alterman, A.I. 

Gender differences in the relapse experiences of cocaine patients. Journal of Nervous and 

Mental Disease 184(10):616–622, 1996. 

167 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

McKinnon, J. The Black Population: 2000. Census 2000 Brief. Washington, DC: U.S. Census 

Bureau, 2001. 

McKinnon, J. The Black Population in the United States: 2002: Current Population Reports. 

Washington, DC: U.S. Census Bureau, 2003. 

McLellan, A.T., Hagan, T.A., Levine, M., Meyers, K., Gould, F., Bencivengo, M., Durell, J., and

Jaffe, J. Does clinical case management improve outpatient addiction treatment? Drug and 

Alcohol Dependence 55(1–2):91–103, 1999. 

McLellan, A.T., Lewis, D.C., O’Brien, C.P., and Kleber, H.D. Drug dependence, a chronic

medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the 

American Medical Association (284):1689–1695, 2000. 

McMahon, T.J. Drug dependence, psychological representations of fathering, and reproductive 

strategy. In: Dewey, W.L., and Harris, L.S., eds. Problems of Drug Dependence, 2002 (pp. 47– 

48). Proceedings of the 64th Annual Scientific Meeting, The College on Problems of Drug

Dependence, Inc. NIDA Research Monograph 183. NIH Publication No. 03-5339.

Bethesda, MD: National Institute on Drug Abuse, 2003. 

McMahon, T.J., and Giannini, F.D. Fathers Too! A Psychosocial Intervention for Drug-Abusing 

Fathers. Unpublished treatment manual. New Haven, CT: Yale University School of

Medicine, 2002. 

McMahon, T.J., and Giannini, F.D. Substance-abusing fathers in family court: Moving from

popular stereotypes to therapeutic jurisprudence. Family Court Review 41(3):337–353, 2003. 

McMahon, T.J., and Rounsaville, B.J. Substance abuse and fathering: Adding poppa to the 

research agenda. Addiction 97(9):1109–1115, 2002. 

McMahon, T.J., Winkel, J.D., Luthar, S.S., and Rounsaville, B.J. Looking for poppa: Parenting

status of men versus women seeking drug abuse treatment. American Journal of Drug and 

Alcohol Abuse 31(1):79–91, 2005. 

McMillin, S. A warning from SOAR: Stigma kills. Addiction Letter 11(5):3, 1995. 

McNeely, R.L., Cook, P.W., and Torres, J.B. Is domestic violence a gender issue, or a human

issue? In: See, L.A.L., ed. Violence as Seen Through a Prism of Color (pp. 227–251). 

Binghamton, NY: Haworth Social Work Practice Press, 2001. 

McRae, A.L., Hedden, S.L., Malcolm, R.J., Carter, R.E., and Brady, K.T. Characteristics of

cocaine- and marijuana-dependent subjects presenting for medication treatment trials.

Addictive Behaviors 32(7):1433–1440, 2007. 

Menninger, J.A. Assessment and treatment of alcoholism and substance-related disorders in the 

elderly. Bulletin of the Menninger Clinic 66(2):166–183, 2002. 

Mensinger, J.L., Lynch, K.G., TenHave, T.R., and McKay, J.R. Mediators of telephone-based

continuing care for alcohol and cocaine dependence. Journal of Consulting and Clinical 

Psychology 75(5):775–784, 2007. 

168 
 

 

 

 

 

 

Appendices 

Mertens, J.R., and Weisner, C.M. Predictors of substance abuse treatment retention among

women and men in an HMO. Alcoholism: Clinical and Experimental Research 24(10):1525– 

1533, 2000. 

Messina, N., Burdon, W., Hagopian, G., and Prendergast, M. Predictors of prison-based

treatment outcomes: A comparison of men and women participants. American Journal of Drug 

and Alcohol Abuse 32(1):7–28, 2006. 

Messina, N., Wish, E., and Nemes, S. Predictors of treatment outcomes in men and women

admitted to a therapeutic community. American Journal of Drug and Alcohol Abuse 26(2):207– 

227, 2000. 

Meyer, I.H. Minority stress and mental health in gay men. Journal of Health and Social Behavior 

36(1):38–56, 1995. 

Meyers, R.J., Dominguez, T.P., and Smith, J.E. Community reinforcement training with

concerned others. In: Van Hasselt, V.B., and Hersen, M., eds. Sourcebook of Psychological 

Treatment Manuals for Adult Disorders (pp. 257–294). New York: Plenum Press, 1996. 

Meyers, R.J., Miller, W.R., and Smith, J.E. Community reinforcement and family training

(CRAFT). In: Meyers, R.J., and Miller, W.R., eds. A Community Reinforcement Approach to 

Addiction Treatment (pp. 147–160). International Research Monographs in the Addictions.

New York: Cambridge University Press, 2001. 

Miller, B.A. Women’s alcohol use and their violent victimization. In: Howard, J.M., Martin, S.E.,

Mail, P.D., Hilton, M.E., and Taylor, E.D., eds. Women and Alcohol: Issues for Prevention 

Research (pp. 239–260). NIAAA Research Monograph No. 32. Bethesda, MD: National

Institute on Alcohol Abuse and Alcoholism, 1996. 

Miller, B.A., Downs, W.R., and Gondoli, D.M. Spousal violence among alcoholic women as 

compared to a random household sample of women. Journal of Studies on Alcoholism 

50(6):533–540, 1989. 

Miller, J.B. The Development of Women’s Sense of Self. Work in Progress No. 12. Wellesley, MA:

Stone Center for Developmental Services and Studies, 1984. 

Miller, N.S. Generalized vulnerability to drug and alcohol addiction. In: Miller, N.S., ed. Principles 

and Practice of Addictions in Psychiatry (pp. 18–25). Philadelphia: W.B. Saunders Co., 1997. 

Miller, N.S., and Flaherty, J.A. Effectiveness of coerced addiction treatment (alternative 

consequences): A review of the clinical research. Journal of Substance Abuse Treatment 18(1):9– 

16, 2000. 

Miller, W.R., Andrews, N.R., Wilbourne, P., and Bennett, M.E. A wealth of alternatives: Effective 

treatments for alcohol problems. In: Miller, W.R., and Heather, N., eds. Treating Addictive 

Behaviors: Processes of Change, 2nd ed. (pp. 203–216). New York: Plenum Press, 1998. 

Miller, W.R., Benefield, R.G., and Tonigan, J.S. Enhancing motivation for change in problem

drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical 

Psychology 61(3):455–461, 1993. 

169 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Miller, W.R., Meyers, R.J., and Tonigan, J.S. Engaging the unmotivated in treatment for alcohol 

problems: A comparison of three strategies for intervention through family members. Journal 

of Consulting and Clinical Psychology 67(5):688–697, 1999. 

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People for Change, 2nd ed. 

New York: Guilford Press, 2002. 

Miller, W.R., and Thoresen, C.E. Spirituality and health. In: Miller, W.R., ed. Integrating 

Spirituality Into Treatment: Resources for Practitioners (pp. 3–18). Washington, DC: American 

Psychological Association, 1999. 

Miller, W.R., Westerberg, V.S., Harris, R.J., and Tonigan, J.S. What predicts relapse? Prospective 

testing of antecedent models. Addiction 91(Suppl.):S155–S172, 1996. 

Millery, M.P., and Kleinman, B.P. Gender Differences in Psychiatric Profiles in a Detoxification

Sample of Drug Abusers: Antisocial Men and Traumatized Women. Poster presented at the 

College for Problems in Drug Dependence ( June). Scottsdale, AZ: 2001. 

Minino, A.M., Arias, E., Kochanek, K.D., Murphy, S.L., and Smith, B.L. Deaths: Final Data for 

2000. National Vital Statistics Reports: Vol. 50, No. 15. Hyattsville, MD: National Center for

Health Statistics, 2002. 

Monk, D., and Ricciardelli, L.A. Three dimensions of the male gender role as correlates of

alcohol and cannabis involvement in young Australian men. Psychology of Men & Masculinity 

4(1):57–69, 2003. 

Moos, R.H. Active ingredients of substance use-focused self-help groups. Addiction 103(3):387– 

396, 2008. 

Moos, R.H., and Moos, B.S. Participation in treatment and Alcoholics Anonymous: A 16-year

follow-up of initially untreated individuals. Journal of Clinical Psychology 62(6):735–750, 2006. 

Moos, R.H., Moos, B.S., and Timko, C. Gender, treatment and self-help in remission from 

alcohol use disorders. Clinical Medicine Research 4(3):163–174, 2006. 

Moriarty, P.J., Lieber, D., Bennett, A., White, L., Parrella, M., Harvey, P.D., and Davis, K.L. 

Gender differences in poor outcome patients with lifelong schizophrenia. Schizophrenia 

Bulletin 27(1):103–113, 2001. 

Moss, H.B., Mezzich, A., Yao, J.K., Gavaler, J., and Martin, C.S. Aggressivity among sons of

substance-abusing fathers: Association with psychiatric disorder in the father and son,

paternal personality, pubertal development, and socioeconomic status. American Journal of 

Drug and Alcohol Abuse 21(2):195–208, 1995a. 

Moss, H.B., Vanyukov, M., Majumder, P.P., Kirisci, L., and Tarter, R.E. Prepubertal sons of

substance abusers: Influences of parental and familial substance abuse on behavioral

disposition, IQ, and school achievement. Addictive Behaviors 20(3):345–358, 1995b. 

Muehlenhard, C.L., and Linton, M.A. Date rape and sexual aggression in dating situations:

Incidence and risk factors. Journal of Counseling Psychology 34(2):186–196, 1987. 

170 
 

 

 

 

Appendices 

Müller, S., Piontek, D., Pabst, A., Baumeister, S.E., and Kraus, L. Changes in alcohol 

consumption and beverage preference among adolescents after the introduction of the 

alcopops tax in Germany. Addiction 105(7):1205–1213, 2010. 

Mulvey, K.P., Hubbard, S., and Hayashi, S. A national study of the substance abuse treatment

workforce. Journal of Substance Abuse Treatment 24:51–57, 2003. 

Nadler, A., Maler, S., and Friedman, A. Effects of helper’s sex, subjects’ androgyny, and selfevaluation on males’ and females’ willingness to seek and receive help. Sex Roles 10(5–6):327– 

339, 1984. 

Najavits, L.M., Schmitz, M., Gotthardt, S., and Weiss, R.D. Seeking safety plus exposure 

therapy: An outcome study on dual diagnosis men. Journal of Psychoactive Drugs 37(4):425– 

435, 2005. 

Nasser, E.H., Walders, N., and Jenkins, J.H. The experience of schizophrenia: What’s gender got

to do with it? A critical review of the current status of research on schizophrenia.

Schizophrenia Bulletin 28(2):351–362, 2002. 

National Center for Health Statistics. Table 27. Life Expectancy at Birth, at 65 Years of Age, and at

75 Years of Age, by Race and Sex: United States, Selected Years 1900-2005. Health, United States,

2007: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: National 

Center for Health Statistics, 2007. 

National Center for PTSD and Walter Reed Army Medical Center. Iraq War Clinician Guide,

2nd ed. Washington, DC: U.S. Department of Veterans Affairs, 2004. 

National Institute for Occupational Safety and Health. Worker Health Chartbook, 2004. 

Cincinnati, OH: Department of Health and Human Services, 2004. 

National Institute of Justice. 2000 Arrestee Drug Abuse Monitoring: Annual Report. Washington, 

DC: U.S. Department of Justice, 2003. 

National Institute of Mental Health. In Harm’s Way: Suicide in America. NIH Publication No. 03­

4594. Bethesda, MD: National Institute of Mental Health, 2001. 

National Institute of Mental Health. Men and Depression. NIH Publication No. 03-4972. 

Bethesda, MD: National Institute of Mental Health, 2003. 

National Institute on Alcohol Abuse and Alcoholism. Alcohol and the Workplace. Alcohol Alert 

No. 44 ( July). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, 1999. 

National Institute on Alcohol Abuse and Alcoholism. The Physicians’ Guide to Helping Patients 

With Alcohol Problems. NIH Publication No. 95-3769. Rockville, MD: National Institute on

Alcohol Abuse and Alcoholism, 1995. 

National Institute on Alcohol Abuse and Alcoholism. Screening for Alcohol Problems: An Update. 

Alcohol Alert No. 56. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism,

2002. 

171 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

National Institute on Alcohol Abuse and Alcoholism. Module 10C: Older Adults and Alcohol 

Problems. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, 2005. 

National Institute on Drug Abuse. Assessing Drug Abuse Among Adolescents and Adults: 

Standardized Instruments. Clinical Report Series. NIH Publication No. 94-3757. Rockville,

MD: National Institute on Drug Abuse, 1994. 

National Institute on Drug Abuse. Visual technique helps drug abuse treatment patients map

road to recovery. NIDA Notes 11(2), 1996. 

National Institute on Drug Abuse. NIDA Community Drug Alert Bulletin: Methamphetamine. 

Rockville, MD: National Institute on Drug Abuse, 1998. 

National Institute on Drug Abuse. Drug Abuse and Addiction Research: 25 Years of Discovery to

Advance the Health of the Public: The Sixth Triennial Report to Congress From the Secretary of

Health and Human Services. Bethesda, MD: National Institutes of Health, 1999. 

National Institute on Drug Abuse. Anabolic Steroid Abuse. National Institute on Drug Abuse 

Research Report Series. Bethesda, MD: National Institute on Drug Abuse, 2000. 

National Institute on Drug Abuse. Group Therapy Research, Bethesda Marriott April 29-30, 2003.

Bethesda, MD: National Institute on Drug Abuse, 2003. 

Neff, J.A., Prihoda, T.J., and Hoppe, S.K. “Machismo,” self-esteem, education and high maximum 

drinking among Anglo, Black and Mexican American male drinkers. Journal of Studies on 

Alcohol 52(5):458–463, 1991. 

Nemoto, T., Aoki, B., Huang, K., Morris, A., Nguyen, H., and Wong, W. Drug use behaviors 

among Asian drug users in San Francisco. Addictive Behaviors 24(6):823–838, 1999. 

Nemoto, T., Operario, D., and Soma, T. Risk behaviors of Filipino methamphetamine users in

San Francisco: Implications for prevention and treatment of drug use and HIV. Public Health 

Reports 117(Suppl. 1):S30–S38, 2002. 

Nesic, J., and Duka, T. Gender specific effects of a mild stressor on alcohol cue reactivity in heavy 

social drinkers. Pharmacology, Biochemistry and Behavior 83(2):239–248, 2006. 

Neve, R.J., Lemmens, P.H., and Drop, M.J. Older and younger male alcoholics in outpatient

treatment. Addictive Behaviors 24(5):661–672, 1999. 

Nielsen, A.L. Examining drinking patterns and problems among Hispanic groups: Results from a

national survey. Journal of Studies on Alcohol 61(2):301–310, 2000. 

Niv, N., and Hser, Y.I. Women-only and mixed-gender drug abuse treatment programs: Service 

needs, utilization and outcomes. Drug and Alcohol Dependence 87(2–3):194–201, 2007. 

Niv, N., Wong, E.C., and Hser, Y.I. Asian Americans in community-based substance abuse 

treatment: Service needs, utilization, and outcomes. Journal of Substance Abuse Treatment 

33(3):313–319, 2007. 

172 
 

 

 

 

Appendices 

Nock, MK., and Kessler, R.C. Prevalence of and risk factors for suicide attempts versus suicide 

gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology 

115(3):616–623, 2006. 

Nonn, T. Hitting bottom: Homelessness, poverty, and masculinity. In: Arrighi, B., ed.

Understanding Inequality: The Intersection of Race/Ethnicity, Class, and Gender, 2nd ed. (pp. 

281–288). Lanham, MD: Rowman & Littlefield Publishers, Inc., 2007. 

North, C.S., Eyrich, K.M., Pollio, D.E., and Spitznagel, E.L. Are rates of psychiatric disorders in

the homeless population changing? American Journal of Public Health 94(1):103–108, 2004. 

Nudell, D.M., Monoski, M.M., and Lipschultz, L.I. Common medications and drugs: How they 

affect male fertility. Urologic Clinics of North America 29(4):965–973, 2002. 

Nye, C.L., Zucker, R.A., and Fitzgerald, H.E. Early intervention in the path to alcohol problems 

through conduct problems: Treatment involvement and child behavior change. Journal of 

Consulting and Clinical Psychology 63(5):831–840, 1995. 

O’Dwyer, P. The Irish and substance abuse. In: Straussner, S.L.A., ed. Ethnocultural Factors in 

Substance Abuse Treatment (pp. 199–215). New York: Guilford Press, 2001. 

O’Farrell, T.J., Choquette, K.A., and Cutter, H.S. Couples relapse prevention sessions after

behavioral marital therapy for male alcoholics: Outcomes during the three years after starting

treatment. Journal of Studies on Alcohol 59(4):357–370, 1998. 

O’Farrell, T.J., and Fals-Stewart, W. Treatment models and methods: Family models. In:

McCrady, B.S., and Epstein, E.E., eds. Addictions: A Comprehensive Guidebook (pp. 287–305). 

New York: Oxford University Press, 1999. 

O’Farrell, T.J., Fals-Stewart, W., Murphy, C.M., Stephan, S.H., and Murphy, M. Partner violence 

before and after couples-based alcoholism treatment for male alcoholic patients: The role of

treatment involvement and abstinence. Journal of Consulting and Clinical Psychology 

72(2):202–217, 2004. 

Office of Applied Studies. How Men and Women Enter Substance Abuse Treatment. The DASIS 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2001. 

Office of Applied Studies. Substance Use, Dependence or Abuse Among Full-Time Workers. The 

NHSDA Report. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2002. 

Office of Applied Studies. Veterans in Substance Abuse Treatment: 1995–2000. The DASIS Report.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2003. 

Office of Applied Studies. Admissions With Co-Occurring Disorders: 1995 and 2001. The DASIS 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration,

2004a. 

173 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Office of Applied Studies. 2003 National Survey on Drug Use and Health: Detailed tables.

Results From the 2003 National Survey on Drug Use and Health: National Findings. HHS 

Publication No. (SMA) 04-3964. NSDUH Series H-25. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 2004b. 

Office of Applied Studies. Alcohol Use and Alcohol-Related Risk Behaviors Among Veterans. The 

NSDUH Report. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2005. 

Office of Applied Studies. Facilities Offering Special Treatment Programs or Groups: 2005. The 

DASIS Report. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2007a. 

Office of Applied Studies. Substance Use and Substance Use Disorders Among American Indians and 

Alaska Natives. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2007b. 

Oggins, J., Guydish, J., and Delucchi, K. Gender differences in income after substance abuse 

treatment. Journal of Substance Abuse Treatment 20(3):215–224, 2001. 

Ogunwole, S.U. We the People: American Indians and Alaska Natives in the United States.

Washington, DC: U.S. Census Bureau 2006. 

Ohannessian, C.M., and Hesselbrock, V.M. The influence of perceived social support on the 

relationship between family history of alcoholism and drinking behaviors. Addiction 

88(12):1651–1658, 1993. 

Ojeda, L., Rosales, R., and Good, G.E. Socioeconomic status and cultural predictors of male role 

attitudes among Mexican American men: ¿Son Más Machos? Psychology of Men & 

Masculinity 9(3):133–138, 2008. 

O’Neil, J.M., Good, G.E., and Holmes, S. Fifteen years of theory and research on men’s gender

role conflict: New paradigms for empirical research. In: Levant, R.F., and Pollack, W.S., eds.

A New Psychology of Men (pp. 164–206). New York: Basic Books, 1995. 

O’Neil, J.M., Helms, B.J., Gable, R.K., David, L., and Wrightsman, L.S. Gender-role conflict

scale: College men’s fear of femininity. Sex Roles 14(5–6):335–350, 1986. 

Operario, D., Smith, C.D., Arnold, E., and Kegeles, S. Sexual risk and substance use behaviors 

among African American men who have sex with men and women. AIDS and Behavior. July 

2, 2009. 

Orloff, E. Can marriage survive addiction? Counselor 2(3):26–30, 2001. 

Orwin, R.G., Francisco, L., and Bernichon, T. Effectiveness of Women’s Substance Abuse Treatment 

Programs: A Meta-Analysis. Fairfax, VA: Caliber Associates, National Evaluation Data 

Services, 2001. 

174 
 

 

 

 

 

 

 

 

Appendices 

Ouimette, P.C., Ahrens, C., Moos, R.H., and Finney, J.W. During treatment changes in substance 

abuse patients with posttraumatic stress disorder: The influence of specific interventions and

program environments. Journal of Substance Abuse Treatment 15(6):555–564, 1998. 

Ouimette, P.C., Kimerling, R., Shaw, J., and Moos, R.H. Physical and sexual abuse among women

and men with substance use disorders. Alcoholism Treatment Quarterly 18(3):7–17, 2000. 

Overholser, J.C., Freiheit, S.R., and DiFilippo, J.M. Emotional distress and substance abuse as 

risk factors for suicide attempts. Canadian Journal of Psychiatry 42(4):402–408, 1997. 

Padilla, A.M., and Salgado de Snyder, V.N. Hispanics: What the culturally informed evaluator needs

to know. In: Orlandi, M.A., Weston, R., and Epstein, L.G., eds. Cultural Competence for

Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working With

Ethnic/Racial Communities (pp. 117–146). OSAP Cultural Competence Series I. HHS

Publication No. (ADM) 92-1884. Rockville, MD: Office for Substance Abuse Prevention, 1992. 

Page, R.C., and Berkow, D.N. Group work as facilitation of spiritual development for drug and

alcohol abusers. Journal for Specialists in Group Work 23(3):285–297, 1998. 

Paris, J. Gender differences in personality traits and disorders. Current Psychiatry Reports 6(1):71– 

74, 2004. 

Park, M.J., Mulye, T.P., Adams, S.H., Brindis, C.D., and Irwin, J. The health status of young

adults in the United States. Journal of Adolescent Health (39):305–317, 2006. 

Parke, R.D., and Brott, A.A. Throwaway Dads: The Myths and Barriers That Keep Men From 

Being the Fathers They Want To Be. Boston: Houghton Mifflin, 1999. 

Parrott, D.J., and Giancola, P.R. A further examination of the relation between trait anger and

alcohol-related aggression: The role of anger control. Alcoholism: Clinical and Experimental 

Research 28(6):855–864, 2004. 

Parrott, D.J., and Zeichner, A. Effects of alcohol and trait anger on physical aggression in men.

Journal of Studies on Alcohol 63(2):196–204, 2002. 

Pederson, E.L., and Vogel, D.L. Male gender role conflict and willingness to seek counseling:

Testing a mediation model on college-aged men. Journal of Counseling Psychology 54(4):373– 

384, 2007. 

Peralta, R. College alcohol use and the embodiment of hegemonic masculinity among European

American men. Sex Roles 56(11):741–756, 2007. 

Perron, B.E., Mowbray, O.P., Glass, J.E., Delva, J., Vaughn, M.G., and Howard, M.O.

Differences in service utilization and barriers among Blacks, Hispanics, and Whites with

drug use disorders. Substance Abuse Treatment, Prevention, and Policy 4:3, 2009 

Peters, M.A., and Phelps, L. Body image dissatisfaction and distortion, steroid use, and sex

differences in college age bodybuilders. Psychology in the Schools 38(3):283–289, 2001. 

Peterson, Z.D., Janssen, E., and Heiman, J.R. The association between sexual aggression and

HIV risk behavior in heterosexual men. Journal of Interpersonal Violence 25(3):538-556, 2009. 

175 
 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Petry, N.M, and Bohn, M.J. Fishbowls and candy bars: Using low-cost incentives to increase 

treatment retention. NIDA Science & Practice Perspectives 2(1):55–61, 2003. 

Peugh, J., and Belenko, S. Examining the substance abuse patterns and treatment needs of

incarcerated sex offenders. Sexual Abuse: A Journal of Research and Treatment 13(3):179–195, 

2001. 

Philpot, C.L. Family therapy for men. In: Brooks, G.R., and Good, G.E., eds. The New Handbook 

of Psychotherapy and Counseling With Men: A Comprehensive Guide to Settings, Problems, and

Treatment Approaches, Vols. 1 & 2 (pp. 622–636). San Francisco, CA: Jossey-Bass, 2001. 

Philpot, C.L., and Brooks, G.R. Intergender communication and gender-sensitive family therapy.

In: Mikesell, R.H., Lusterman, D.D., and McDaniel, S., eds. Integrating Family Therapy: 

Handbook of Family Psychology and Systems Theory (pp. 303–325). Washington, DC: American 

Psychological Association, 1995. 

Philpot, C.L., Brooks, G.R., Lusterman, D.D., and Nutt, R.L. Bridging Separate Gender Worlds:

Why Men and Women Clash and How Therapists Can Bring Them Together. Washington, DC: 

American Psychological Association, 1997. 

Pinto, A., Mancebo, M.C., Eisen, J.L., Pagano, M.E., and Rasmussen, S.A. The Brown

Longitudinal Obsessive Compulsive Study: Clinical features and symptoms of the sample at

intake. Journal of Clinical Psychiatry 67(5):703–711, 2006. 

Platt, J.J. Vocational rehabilitation of drug abusers. Psychological Bulletin 117(3):416–433, 1995. 

Pleck, J.H. The Myth of Masculinity. Cambridge, MA: MIT Press, 1981. 

Pleck, J.H. The gender role strain paradigm: An update. In: Levant, R.F., and Pollack, W.S., eds. 

A New Psychology of Men (pp. 11–32). New York: Basic Books, 1995. 

Pollack, W.S. Engendered psychotherapy: Listening to the male and female voice. Voices: The Art 

and Source of Psychotherapy 30(3):43–47, 1994. 

Pollack, W.S. Deconstructing dis-identification: Rethinking psychoanalytic concepts of male

development. Psychoanalysis & Psychotherapy 12(1):30–45, 1995. 

Pollack, W.S. Mourning, melancholia, and masculinity. In: Pollack, W.S., and Levant, R.F., eds.

New Psychotherapy for Men (pp. 147–166). Somerset, NJ: John Wiley & Sons, 1998a. 

Pollack, W.S. Real Boys: Rescuing Our Sons From the Myths of Boyhood. New York: Random House, 

1998b. 

Pollack, W.S. The trauma of Oedipus: Toward a new psychoanalytic psychotherapy for men. In:

Pollack, W.S., and Levant, R.F., eds. New Psychotherapy for Men (pp. 13–34). Somerset, NJ: 

John Wiley & Sons, 1998c. 

Pollack, W.S. Real Boys’ Voices. New York: Penguin, 2000. 

176 
 

 

 

 

 

 

 

 

 

Appendices 

Pollack, W.S. “Masked men”: New psychoanalytically oriented treatment models for adult and

young adult men. In: Brooks, G.R., and Good, G.E., eds. The New Handbook of Psychotherapy

and Counseling With Men: A Comprehensive Guide to Settings, Problems, and Treatment

Approaches, Vol. 2 (pp. 527–543). San Francisco: Jossey-Bass, 2001. 

Pollack, W.S. Gender issues: Modern models of young male resilient mental health. In: Young 

Adult Mental Health (pp. 96–109). New York: Oxford University Press, 2010. 

Pollack, W.S., and Levant, R.F. Introduction: Treating men in the 21st century. In: Pollack, W.S.,

and Levant, R.F., eds. New Psychotherapy for Men (pp. 1–10). Somerset, NJ: John Wiley & 

Sons, 1998. 

Potts, M.K., Burnham, M.A., and Wells, K.B. Gender differences in depression detection: A

comparison of clinician diagnosis and standardized assessment. Psychological Assessment 

3(4):609–615, 1991. 

Powell, D.J. Playing Life’s Second Half: A Man’s Guide for Turning Success Into Significance. San 

Francisco: New Harbinger Publications, 2003. 

Powell, D.J., and Brodsky, A. Clinical Supervision in Alcohol and Drug Abuse Counseling: Principles, 

Models, Methods. San Francisco: Jossey-Bass, 1998. 

Powers, M.B., Vedel, E., and Emmelkamp, P.M.G. Behavioral couples therapy (BCT) for alcohol 

and drug use disorders: A meta-analysis. Clinical Psychology Review 28(6):952–962, 2008. 

Prescott, C.A. Sex differences in the genetic risk for alcoholism. Alcohol Health and Research World 

26(4):264–73, 2002. 

Pridal, C.G. Male gender role issues in the treatment of sexual dysfunction. In: The New 

Handbook of Psychotherapy and Counseling With Men: A Comprehensive Guide to Settings,

Problems, and Treatment Approaches, Vols. 1 & 2 (pp. 309–334). San Francisco: Jossey-Bass, 

2001. 

Pridemore, W.A. Vodka and violence: Alcohol consumption and homicide rates in Russia.

American Journal of Public Health 92(12):1921–1930, 2002. 

Prochaska, J.O., and DiClemente, C.C. The stages of change. In: The transtheoretical approach: 

crossing traditional boundaries of therapy (pp. 21–32). Homewood, IL: Dow Jones-Irwin, 1984. 

Public Broadcasting Service. Faith in America: Facts and Stats. Arlington, VA: Public 

Broadcasting Service, 2002. 

Pujazon-Zazik, M., and Park, M.J. Marijuana: Use among young males and health outcomes.

American Journal of Men’s Health 3(3):265–274, 2009. 

Purcell, D.W., Parsons, J.T., Halkitis, P.N., Mizuno, Y., and Woods, W.J. Substance use and

sexual transmission risk behavior of HIV-positive men who have sex with men. Journal of 

Substance Abuse 13(1–2):185–200, 2001. 

Putnam, F.W. Ten-year research update review: Child sexual abuse. Journal of the American 

Academy of Child & Adolescent Psychiatry 42(3):269–278, 2003. 

177 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Quigley, B.M., and Leonard, K.E. Alcohol and the continuation of early marital aggression.

Alcoholism: Clinical and Experimental Research 24(7):1003–1010, 2000. 

Quintero, G.A., and Estrada, A. Cultural models of masculinity and drug use: “Machismo,”

heroin, and street survival on the U.S.-Mexico border. Contemporary Drug Problems 

25(1):147–168, 1998. 

Rabinowitz, J., and Marjefsky, S. Predictors of being expelled from and dropping out of alcohol 

treatment. Psychiatric Services 49(2):187–189, 1998. 

Rahav, M., Nuttbrock, L., Rivera, J.J., and Link, B.G. HIV infection risks among homeless,

mentally ill, chemical misusing men. Substance Use and Misuse 33(6):1407–1426, 1998. 

Ramirez, R.R., and de la Cruz, G.P. The Hispanic Population in the United States: March 2002.

Current Population Reports. Washington, DC: U.S. Census Bureau, 2003. 

Rand, M.R. Violence-Related Injuries Treated in Hospital Emergency Departments. Bureau of Justice 

Statistics Special Report. Washington, DC: Bureau of Justice Statistics, 1997. 

Ratner, P.A., Johnson, J.L., Shoveller, J.A., Chan, K., Martindale, S.L., Schilder, A.J., Botnick,

M.R., and Hogg, R.S. Non-consensual sex experienced by men who have sex with men: Prevalence and association with mental health. Patient Education and Counseling 49(1):67–74, 2003. 

Rawson, R.A., Washton, A., Domier, C.P., and Reiber, C. Drugs and sexual effects: Role of drug

type and gender. Journal of Substance Abuse Treatment 22(2):103–108, 2002. 

Raymond, N.C., Coleman, E., Ohlerking, F., Christenson, G.A., and Miner, M. Psychiatric 

comorbidity in pedophilic sex offenders. American Journal of Psychiatry 156(5):786–788, 1999. 

Real, T. I Don’t Want To Talk About It: Overcoming the Secret Legacy of Male Depression. New York: 

Scribner, 1997. 

Reardon, S.F., and Buka, S.L. Differences in onset and persistence of substance abuse and dependence among Whites, Blacks, and Hispanics. Public Health Reports 117(Suppl. 1):S51–S59, 2002. 

Reid, J., Macchetto, P., and Foster, S. No Safe Haven: Children of Substance-Abusing Parents. New 

York: National Center on Addiction and Substance Abuse at Columbia University, 1999. 

Reilly, P.M., and Shopshire, M.S. Anger management group treatment for cocaine dependence:

Preliminary outcomes. American Journal of Drug and Alcohol Abuse 26(2):161–177, 2000. 

Reilly, P.M., and Shopshire, M.S. Anger Management for Substance Abuse and Mental Health

Clients: A Cognitive Behavioral Therapy Manual. HHS Publication No. (SMA) 02-3661.

Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health

Services Administration, 2002. 

Reilly, P.M., Shopshire, M.S., Durazzo, T.C., and Campbell, T.A. Anger Management for Substance 

Abuse and Mental Health Clients: Participant Workbook. HHS Publication No. (SMA) 02­

3662. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental 

Health Services Administration, 2002. 

178 
 

 

 

Appendices 

Rempel, G.R., Neufeld, A., and Kushner, K.E. Interactive use of genograms and ecomaps in

family caregiving research. Journal of Family Nursing 13(4):403–419, 2007. 

Retzinger, S.M. Shame in the therapeutic relationship. In: Gilbert, P., and Andrews, B., eds.

Shame: Interpersonal Behavior, Psychopathology, and Culture (pp. 206–222). London: Oxford 

University Press, 1998. 

Rhoades, E.R. The health status of American Indian and Alaska native males. American Journal 

of Public Health (93):774–778, 2003. 

Rich, J.A., and Grey, C.M. Pathways to recurrent trauma among young Black men: Traumatic

stress, substance use, and the “code of the street.” American Journal of Public Health 95(5):816– 

824, 2005. 

Richardson, A. and Budd, T. Young adults, alcohol, crime and disorder. Criminal Behaviour and 

Mental Health (13):5–17, 2003 

Ries, R.K., Fiellin, D.A., Miller, S.C., and Saitz, R. Principles of Addiction Medicine, 4th ed. 

Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009. 

Ries, R.K., Dyck, D.G., Short, R., Srebnik, D., Fisher, A., and Comtois, K.A. Outcomes of

managing disability benefits among patients with substance dependence and severe mental 

illness. Psychiatric Services (55):445–447, 2004. 

Rietmeijer, C.A., Wolitski, R.J., Fishbein, M., Corby, N.H., and Cohn, D.L. Sex hustling,

injection drug use, and non-gay identification by men who have sex with men: Associations 

with high-risk sexual behaviors and condom use. Sexually Transmitted Diseases 26(2):353–360, 

1998. 

Ritsher, J.B., Moos, R.H., and Finney, J.W. Relationship of treatment orientation and continuing

care to remission among substance abuse patients. Psychiatric Services 53(5):595–601, 2002. 

Robertson, E., and Donnermeyer, J.F. Patterns of drug use among nonmetropolitan and rural 

adults. Substance Use and Misuse 33(10):2109–2129, 1998. 

Robertson, J.E. Rape among incarcerated men: Sex, coercion and STDs. AIDS Patient Care and 

STDs 17(8):423–430, 2003. 

Robertson, J.M., and Fitzgerald, L.F. Overcoming the masculine mystique: Preferences for

alternative forms of assistance among men who avoid counseling. Journal of Counseling 

Psychology 39(2):240–246, 1992. 

Robinson, B. Religious Beliefs of Americans. 2003. http://www.religioustolerance.org/chr_poll4.htm 

[Accessed February 25, 2013]. 

Robinson, J., Sareen, J., Cox, B.J., and Bolton, J. Self-medication of anxiety disorders with alcohol 

and drugs: Results from a nationally representative sample. Journal of Anxiety Disorders 

23(1):38–45, 2009. 

Rodriguez-Andrew, S. Alcohol use and abuse among Latinos: Issues and examples of culturally 

competent services. Alcoholism Treatment Quarterly 16(1–2):55–70, 1998. 

179 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Roehrich, L., and Kinder, B.N. Alcohol expectancies and male sexuality: Review and implications 

for sex therapy. Journal of Sex & Marital Therapy 17(1):45–54, 1991. 

Rondinelli, A.J., Ouellet, L.J., Strathdee, S.A., Latka, M.H., Hudson, S.M., Hagan, H., and

Garfein, R.S. Young adult injection drug users in the United States continue to practice HIV 

risk behaviors. Drug and Alcohol Dependence 104(1–2):167–174, 2009. 

Room, R., Graham, K., Rehm, J., Jernigan, D., and Monteiro, M. Drinking and its burden in a 

global perspective: Policy considerations and options. European Addiction Research 9(4):165– 

175, 2003. 

Rosen, C.S., Ouimette, P.C., Sheikh, J.I., Gregg, J.A., and Moos, R.H. Physical and sexual abuse 

history and addiction treatment outcomes. Journal of Studies on Alcohol 63(6):683–687, 2002a. 

Rosen, M.I., Desai, R., Bailey, M., Davidson, L., and Rosenheck, R. Consumer experience with

payeeship provided by a community mental health center. Psychiatric Rehabilitation Journal 

25(2):190–195, 2001. 

Rosen, M.I., Rosenheck, R.A., Shaner, A., Eckman, T., Gamache, G., and Krebs, C. Veterans 

who may need a payee to prevent misuse of funds for drugs. Psychiatric Services 53(8):995– 

1000, 2002b. 

Rosenheck, R. Disability payments and chemical dependence: Conflicting values and uncertain

effects. Psychiatric Services 48(6):789–791, 1997. 

Roszell, D.K., McFall, M.E., and Malas, K.L. Frequency of symptoms and concurrent psychiatric

disorder in Vietnam veterans with chronic PTSD. Hospital and Community Psychiatry 

42(3):293–296, 1991. 

Roter, D., Lipkin, M., Jr., and Korsgaard, A. Sex differences in patients’ and physicians’ 

communication during primary care medical visits. Medical Care 29(11):1083–1093, 1991. 

Rubin, A., Stout, R.L., and Longabaugh, R. Gender differences in relapse situations. Addiction 

91(Suppl.):S111–S120, 1996. 

Ruzek, J. Concurrent posttraumatic stress disorder and substance use disorder among veterans:

Evidence and treatment issues. In: Ouimette, P., and Brown, P.J., eds. Trauma and Substance 

Abuse: Causes, Consequences, and Treatment of Comorbid Disorders (pp. 191–207). Washington, 

DC: American Psychological Association, 2003. 

Rybak, C.J., and Brown, B.M. Assessment of internalized shame: Validity and reliability of the

Internalized Shame Scale. Alcoholism Treatment Quarterly 14(1):71–83, 1996. 

Rychtarik, R.G., Connors, G.J., Whitney, R.B., McGillicuddy, N.B., Fitterling, J.M., and Wirtz,

P.W. Treatment settings for persons with alcoholism: Evidence for matching clients to

inpatient versus outpatient care. Journal of Consulting and Clinical Psychology 68(2):277–289, 

2000. 

Saez, P.A., Casado, A., and Wade, J.C. Factors influencing masculinity ideology among Latino 

men. The Journal of Men’s Studies 17(2):116–128, 2009. 

180 
 

Appendices 

Saitz, R. Medical and surgical complications of addictions. In: Ries, R.K., Fiellin, D.A., Miller,

S.C., and Saitz, R., eds. Principles of Addiction Medicine, 4th ed. (pp. 945–968). Philadelphia:

Wolters Kluwer/Lippincott Williams & Wilkins, 2009. 

Sandman, D., Simantov, E., and An, C. Out of Touch: American Men and the Health Care System: 

Commonwealth Fund Men’s and Women’s Health Survey Findings. New York: The 

Commonwealth Fund, 2000. 

Sandoz, J. Alcoholism recovery: Myth, philosophy, and the 12 Steps. Counselor May/June:36–38, 

2000. 

Satre, D.D., and Areán P.A. Effects of gender, ethnicity, and medical illness on drinking cessation

in older primary care patients. Journal of Aging and Health 17(1):70–84, 2005. 

Satre, D.D. and Knight, B.G. Alcohol expectancies and their relationship to alcohol use: Age and

sex differences. Aging & Mental Health 5:73–83, 2001. 

Satre, D.D., Mertens, J.R., Arean, P.A., and Weisner, C. Five-year alcohol and drug treatment

outcomes of older adults versus middle-aged and younger adults in a managed care program.

Addiction 99(10):1286–1297, 2004a. 

Satre, D.D., Mertens, J.R., and Weisner, C. Gender differences in treatment outcomes for alcohol 

dependence among older adults. Journal of Studies on Alcohol 65(5):638–642, 2004b. 

Saul, J.E., Schillo, B.A., Evered, S., Luxenberg, M.G., Kavanaugh, A., Cobb, N., and An, L.C. 

Impact of a statewide Internet-based tobacco cessation intervention. Journal of Medical 

Internet Research 9(3):e28, 2007. 

Scheff, T.J. The shame-rage spiral: A case study of an interminable quarrel. In: Lewis, H.B., ed.

The Role of Shame in Symptom Formation (pp. 109–149). Hillsdale, NJ: Lawrence Erlbaum 

Associates, 1987. 

Scher, M. Male therapist, male client: Reflections on critical dynamics. In: Brooks, G.R., and

Good, G.E., The New Handbook of Psychotherapy and Counseling With Men: A Comprehensive 

Guide to Settings, Problems, and Treatment Approaches, Vol. 2 (pp. 308–320). San Francisco: 

Jossey-Bass, 2005. 

Scherrer, J.F., Slutske, W.S., Xian, H., Waterman, B., Shah, K.R., Volberg, R., and Eisen, S.A.

Factors associated with pathological gambling at 10-year follow-up in a national sample of

middle-aged men. Addiction 102(6):970–978, 2007. 

Schrimsher, G.W., Parker, J.D., and Burke, R.S. Relation between cognitive testing performance 

and pattern of substance use in males at treatment entry. Clinical Neuropsychologist 21(3):498– 

510, 2007. 

Schuckit, M.A. Primary men alcoholics with histories of suicide attempts. Journal of Studies on 

Alcohol 47(1):78–81, 1986. 

181 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Schuckit, M.A., and Smith, T.L. A comparison of correlates of DSM-IV alcohol abuse or

dependence among more than 400 sons of alcoholics and controls. Alcoholism: Clinical and 

Experimental Research 25(1):1–8, 2001. 

Schumacher, J.A., Fals-Stewart, W., and Leonard, K.E. Domestic violence treatment referrals for

men seeking alcohol treatment. Journal of Substance Abuse Treatment 24(3):279–283, 2003. 

Schwab, A.J., and DiNitto, D.M. Factors related to the successful vocational rehabilitation of

substance abusers. Journal of Applied Rehabilitation Counseling 24(3):11–20, 1993. 

Schwartz, M.F., and Southern, S. Compulsive cybersex: The new tea room. In: Cooper, A., ed.

Cybersex: The Dark Side of the Force: A Special Issue of the Journal of Sexual Addiction and 

Compulsion (pp. 127–144). Philadelphia: Brunner-Routledge, 2000. 

Schwartzman, J. Normality from a cross-cultural perspective. In: Walsh, F., ed. Normal Family 

Processes (pp. 383–398). New York: Guilford Press, 1982. 

Sedlak, A.J., and Broadhurst, D.D. The Third National Incidence Study of Child Abuse and Neglect.

National Center on Child Abuse and Neglect. Washington, DC: U.S. Government Printing

Office, 1996. 

Semple, S.J., Zians, J., Grant, I., and Patterson, T.L. Methamphetamine use, impulsivity, and

sexual risk behavior among HIV-positive men who have sex with men. Journal of Addictive 

Diseases 25(4):105–114, 2006. 

Shay, J.J., and Maltas, C.P. Reluctant men in couple therapy: Corralling the Marlboro man. In:

Pollack, W.S., and Levant, R.F., eds. New Psychotherapy for Men (pp. 97–126). Somerset, NJ: 

John Wiley & Sons, 1998. 

Shelton, S., and Liljequist, L. Characteristics and behaviors associated with body image in male

domestic violence offenders. Eating Behaviors 3(3):217–227, 2002. 

Shernoff, M. Returning with AIDS: Supporting rural emigrants. Focus 11(4):1–4, 1996. 

Shoptaw, S. Methamphetamine use in urban gay and bisexual populations. Topics in HIV 

Medicine 14(2):84–87, 2006. 

Siegrist, J., and Rodel, A. Work stress and health risk behavior. Scandinavian Journal of Work 

Environment and Health 32(6):473–481, 2006. 

Silverstein, L., Auerbach, C., and Levant, R. Contemporary fathers reconstructing masculinity:

Clinical implications of gender role strain. Professional Psychology: Research and Practice 

33(4):361–369, 2002. 

Simoni-Wastila, L., and Yang, H.K. Psychoactive drug abuse in older adults. American Journal of 

Geriatric Pharmacotherapy (AJGP) 4(4):380–394, 2006. 

Simons, L., and Giorgio, T. Characteristics of substance among men and women entering a drug

treatment program: An exploration of sex differences. Addictive Disorders & Their Treatment 

7(1):15–23, 2008. 

182 
 

 

 

 

Appendices 

Singer, J.A. Message in a Bottle: Stories of Men and Addiction. New York: The Free Press, 1997. 

Singer, M. Why do Puerto-Rican injection drug users inject so often? Journal of Anthropology and 

Medicine 6(1):31–58, 1999. 

Sinha, R., Easton, C., and Kemp, K. Substance abuse treatment characteristics of probationreferred young adults in a community-based outpatient program. American Journal of Drug 

and Alcohol Abuse 29(3):585–597, 2003. 

Skinner, W.F. The prevalence and demographic predictors of illicit and licit drug use among

lesbians and gay men. American Journal of Public Health 84(8):1307–1310, 1994. 

Skinner, W.F., and Otis, M.D. Drug and alcohol use among lesbian and gay people in a Southern

U.S. sample: Epidemiological, comparative, and methodological findings from the Trilogy 

Project. Journal of Homosexuality 30(3):59–92, 1996. 

Smiler, A.P. Thirty years after the discovery of gender: Psychological concepts and measures of

masculinity. Sex Roles 50(1–2):15–26, 2004. 

Smith, G.S., Branas, C.C., and Miller, T.R. Fatal nontraffic injuries involving alcohol: A

metaanalysis. Annals of Emergency Medicine 33(6):659–668, 1999. 

Smith, K.M., and Romanelli, F. Recreational use and misuse of phosphodiesterase 5 inhibitors.

Journal of the American Pharmaceutical Association 45(1):63–72, 2005. 

Smith, T.C., Wingard, D.L., Ryan, M.A., Kritz-Silverstein, D., Slymen, D.J., and Sallis, J.F. Prior

assault and posttraumatic stress disorder after combat deployment. Epidemiology 19(3):505– 

512, 2008. 

Snowden, L.R., and Hines, A.M. Acculturation, alcohol consumption, and AIDS-related risky 

sexual behavior among African American men. Journal of Community Psychology 26(4):345– 

359, 1998. 

Snyder, H.N. Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident,

and Offender Characteristics. Washington, DC: Bureau of Justice Statistics, U.S. Department 

of Justice, 2000. 

Sobell, L.C., and Sobell, M.B. Timeline followback: A technique for assessing self-reported

ethanol consumption. In: Allen, J., and Litten, R.Z., eds. Measuring Alcohol Consumption: 

Psychosocial and Biological Methods (pp. 41–72). Totowa, NJ: Humana Press, 1992. 

Sogyal, R. The Tibetan Book of Living and Dying. Gaffney, P., and Harvey, A., eds. San Francisco: 

Harper San Francisco, 1992. 

Soldz, S., and Vaillant, G.E. A 50-year longitudinal study of defense use among inner city men:

A validation of the DSM-IV defense axis. Journal of Nervous and Mental Disease 186(2):104– 

111, 1998. 

Solomon, Z., and Mikulincer, M. Combat stress reactions, posttraumatic stress disorder, and

social adjustment: A study of Israeli veterans. Journal of Nervous and Mental 

Disease 175(5):277–285, 1987. 

183 
 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Soyka, M., and Schmidt, P. Outpatient alcoholism treatment—24-month outcome and

predictors of outcome. Substance Abuse Treatment, Prevention, and Policy 4(1):15, 2009. 

Spielberger, C.D. State-Trait Anger Expression Inventory–2. Lutz, FL: Psychological Assessment 

Resources, Inc., 1999. 

Stall, R., Paul, J.P., Greenwood, G., Pollack, L.M., Bein, E., Crosby, G.M., Mills, T.C., Binson, 

D., Coates, T.J., and Catania, J.A. Alcohol use, drug use and alcohol-related problems among

men who have sex with men: The Urban Men’s Health Study. Addiction 96(11):1589–1601, 

2001. 

Stein, B.D., Kogan, J.N., and Sorbero, M. Substance abuse detoxification and residential 

treatment among Medicaid-enrolled adults: Rates and duration of subsequent treatment.

Drug and Alcohol Dependence 104(1–2):100–106, 2009. 

Steinberg, M.L., Epstein, E.E., McCrady, B.S., and Hirsch, L.S. Sources of motivation in a

couples outpatient alcoholism treatment program. American Journal on Drug and Alcohol Abuse 

23(2):191–205, 1997. 

Sterling, R.C., Gottheil, E., Glassman, S.D., Weinstein, S.P., Serota, R.D., and Lundy, A.

Correlates of employment: A cohort study. American Journal of Drug and Alcohol Abuse 

27(1):137–146, 2001. 

Stewart, S.H., and Kushner, M.G. Recent research on the comorbidity of alcoholism and

pathological gambling. Alcoholism, Clinical and Experimental Research 27(2): 285–291, 2003. 

Stimpson, N.J., Thomas, H.V., Weightman, A.L., Dunstan, F., and Lewis, G. Psychiatric disorder

in veterans of the Persian Gulf War of 1991: Systematic review. British Journal of Psychiatry 

183:391–403, 2003. 

Stout, R., Del Boca, F.K., Carbonari, J., Rychtarik, R., Litt, M.D., and Cooney, N.L. Primary

treatment outcomes and matching effects: Outpatient arm. In: Babor, T.F., and Del Boca,

F.K., eds. Treatment Matching in Alcoholism (pp. 105–134). Cambridge, United Kingdom: 

Cambridge University Press, 2003. 

Strasburger, L.H., Gutheil, T.G., and Brodsky, A. On wearing two hats: Role conflict in serving

as both psychotherapist and expert witness. American Journal of Psychiatry 154: 448–456, 

1997. 

Straus, M.A. The controversy over domestic violence by women: A methodological, theoretical,

and sociology of science analysis. In: Arriaga, X.B., and Oskamp, S., eds. Violence in Intimate 

Relationships (pp. 17–44). Thousand Oaks, CA: Sage, 1999. 

Straus, M.A., Hamby, S.L., Boney-McCoy, S., and Sugarman, D.B. The Revised Conflict Tactics

Scale (CTS2): Development and preliminary psychometric data. Journal of Family Issues 

17(3):283–316, 1996. 

Strawbridge, W.J., Shema, S.J., Cohen, R.D., and Kaplan, G.A. Religiosity buffers effects of some 

stressors on depression but exacerbates others. Journals of Gerontology: Series B: Psychological 

Sciences and Social Sciences 53(3):S118–S126, 1998. 

184 
Appendices 

Strecher, V.J., Shiffman, S., and West, R. Randomized controlled trial of a web-based computertailored smoking cessation program as a supplement to nicotine patch therapy. Addiction 

100(5):682–688, 2005. 

Streifel, C. Gender, alcohol use, and crime. In: Wilsnack, R.W., and Wilsnack, S.C., eds. Gender 

and Alcohol: Individual and Social Perspectives (pp. 395–412). New Brunswick, NJ: Rutgers 

Center of Alcohol Studies, 1997. 

Strobbe, S., Brower, K.J., and Galen, L.W. Gender and outpatient detoxification from alcohol.

Journal of Addictions Nursing 14(1):19–25, 2003. 

Strock, M. Depression. NIH Publication No. 04-3561. Bethesda, MD: National Institute of

Mental Health, 2004. 

Strowig, A.B. Relapse determinants reported by men treated for alcohol addiction: The 

prominence of depressed mood. Journal of Substance Abuse Treatment 19(4):469–474, 2000. 

Struckman-Johnson, C.J., and Struckman-Johnson, D.L. Sexual coercion rates in seven

Midwestern prison facilities for men. Prison Journal 80(4):379–390, 2000. 

Struckman-Johnson, C.J., Struckman-Johnson, D.L., Rucker, L., Bumby, K., and Donaldson, S. 

Sexual coercion reported by men and women in prison. Journal of Sex Research 33(1):67–76, 

1996. 

Stuart, G.L. Improving violence intervention outcomes by integrating alcohol treatment. Journal 

of Interpersonal Violence 20(4):388–393, 2005. 

Substance Abuse and Mental Health Services Administration. Get Connected! Linking Older

Americans With Medication, Alcohol, and Mental Health Resources. HHS Publication No. 

(SMA) 03-3824. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse 

and Mental Health Services Administration, 2003. 

Substance Abuse and Mental Health Services Administration. The Confidentiality of Alcohol and

Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and

Substance Abuse Programs. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2004. 

Substance Abuse and Mental Health Services Administration. Results From the 2004 National 

Survey on Drug Use and Health: National Findings. HHS Publication No. (SMA) 05-4062. 

Rockville, MD: Office of Applied Studies, 2005. 

Substance Abuse and Mental Health Services Administration. Results From the 2007 National 

Survey on Drug Use and Health: National Findings. NSDUH Series H-34, HHS Publication

No. (SMA) 08-4343. Rockville, MD: Office of Applied Studies, 2008. 

Substance Abuse and Mental Health Services Administration. Results From the 2008 National 

Survey on Drug Use and Health: National Findings. NSDUH Series H-36. HHS Publication 

No. (SMA) 09-4434. Rockville, MD: Office of Applied Studies, 2009. 

185 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Substance Abuse and Mental Health Services Administration. Addressing Viral Hepatitis in People 

With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 53. HHS

Publication No. (SMA) 11-4656. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2011a. 

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults 

With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP)

Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 2011b. 

Substance Abuse and Mental Health Services Administration. Behavioral Health Services for 

People Who Are Homeless. Treatment Improvement Protocol (TIP) Series 55. HHS

Publication No. (SMA) 13-4734. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2013. 

Substance Abuse and Mental Health Services Administration. Behavioral Health Services for 

American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series.

Rockville, MD: Substance Abuse and Mental Health Services Administration, planned a. 

Substance Abuse and Mental Health Services Administration. Building Health, Wellness, and 

Quality of Life for Sustained Recovery. Treatment Improvement Protocol (TIP) Series.

Rockville, MD: Substance Abuse and Mental Health Services Administration, planned b. 

Substance Abuse and Mental Health Services Administration. Improving Cultural Competence. 

Treatment Improvement Protocol (TIP) Series. Rockville, MD: Substance Abuse and

Mental Health Services Administration, planned c. 

Substance Abuse and Mental Health Services Administration. Managing Anxiety Symptoms in 

Behavioral Health Services. Treatment Improvement Protocol (TIP) Series. Rockville, MD:

Substance Abuse and Mental Health Services Administration, planned d. 

Substance Abuse and Mental Health Services Administration. Recovery in Behavioral Health 

Services. Treatment Improvement Protocol (TIP) Series. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, planned e. 

Substance Abuse and Mental Health Services Administration. Reintegration-Related Behavioral 

Health Issues in Veterans and Military Families. Treatment Improvement Protocol (TIP)

Series. Rockville, MD: Substance Abuse and Mental Health Services Administration,

planned f. 

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in 

Behavioral Health Services. Treatment Improvement Protocol (TIP) Series. Rockville, MD:

Substance Abuse and Mental Health Services Administration, planned g. 

Substance Abuse and Mental Health Services Administration. Using Telephone- and Web-Based 

Technologies in Behavioral Health Settings. Treatment Improvement Protocol (TIP) Series.

Rockville, MD: Substance Abuse and Mental Health Services Administration, planned h. 

186 
 

 

 

Appendices 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results 

From the 2003 National Survey on Drug Use and Health: National Findings. NSDUH Series 

H-25, HHS Publication No. (SMA) 04-3964. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2004a. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

Treatment Episode Data Set (TEDS): 1992–2002. National Admissions to Substance Abuse

Treatment Services. DASIS Series: S-23. HHS Publication No. (SMA) 04-3965, Rockville,

MD: Substance Abuse and Mental Heath Services Administration, 2004b. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Male 

Admissions With Co-Occurring Psychiatric and Substance Use Disorders: 2005. The DASIS 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration,

December 13, 2007a. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Gender 

Differences in Alcohol Use and Alcohol Dependence or Abuse: 2004 and 2005. The NSDUH 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, April 

2, 2007b. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Male 

Admissions With Co-Occurring Psychiatric and Substance Use Disorders: 2005. The DASIS 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration,

December 13, 2007c. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The 

National Survey of Substance Abuse Treatment Services (N-SSATS): 2006. HHS Publication 

No. (SMA) 07-4296. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2007d. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug

Abuse Warning Network, 2006: National Estimates of Drug-Related Emergency Department

Visits. In. DAWN Series D-30, HHS Publication No.(SMA) 08-4339, Rockville, MD:

Substance Abuse and Mental Health Services Administration, 2008a. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

Treatment Episode Data Set (TEDS) Highlights: 2006. National Admissions to Substance Abuse 

Treatment Services. DASIS Series: S-40. HHS Publication No. (SMA) 08-4313. Rockville,

MD: Substance Abuse and Mental Health Services Administration, 2008b. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The 

TEDS Report: Predictors of Substance Abuse Treatment Completion or Transfer to Further

Treatment by Service Type. The TEDS Report. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2009a. 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The 

TEDS Report: Treatment Outcomes Among Clients Discharged From Outpatient Substance Abuse

Treatment. The TEDS Report. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2009b. 

187 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Substance Abuse and Mental Health Services Administration, Office of Applied Studies.The 

TEDS Report: Trends in Methamphetamine Admissions to Treatment: 1997–2007. The TEDS 

Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009c. 

Suddaby, K., and Landau, J. Positive and negative timelines: A technique for restorying. Family 

Process 37(3):287–298, 1998. 

Sue, D.W., and Sue, D. Counseling the Culturally Diverse: Theory and Practice, 5th ed. Hoboken, 

N.J: John Wiley, 2008. 

Swartz, J.A., and Lurigio, A.J. Psychiatric illness and comorbidity among adult male jail detainees 

in drug treatment. Psychiatric Services 50(12):1628–1630, 1999. 

Tafrate, R.C., Kassinove, H., and Dundin, L. Anger episodes in high and low trait anger

community adults. Journal of Clinical Psychology 58(12):1573–1590, 2002. 

Taft, C.T., Kaloupek, D.G., Schumm, J.A., Marshall, A.D., Panuzio, J., King, D.W., and Keane,

T.M. Posttraumatic stress disorder symptoms, physiological reactivity, alcohol problems, and

aggression among military veterans. Journal of Abnormal Psychology 116(3):498–507, 2007. 

Takeuchi, D.T., Sue, S., and Yeh, M. Return rates and outcomes from ethnicity-specific mental 

health programs in Los Angeles. American Journal of Public Health 85(5):638–643, 1995. 

Takeuchi, D.T., Zane, N., Hong, S., Chae, D.H., Gong, F., Gee, G.C., Walton, E., Sue, S., and

Alegria, M. Immigration-related factors and mental disorders among Asian Americans.

American Journal of Public Health 97(1):84–90, 2007. 

Tangney, J.P., and Dearing, R.L. Shame and Guilt. New York: Guilford Press, 2002. 

Taylor, B. “Coming out” as a life transition: Homosexual identity formation and its implications 

for health care practice. Journal of Advanced Nursing 30(2):520–525, 1999. 

Temple, M.T., Fillmore, K.M., Hartka, E., Johnstone, B., Leino, E.V., and Motoyoshi, M. A

meta-analysis of change in marital and employment status as predictors of alcohol 

consumption on a typical occasion. British Journal of Addiction 86(10):1269–1281, 1991. 

Thom, B. Risk-Taking Behaviour in Men: Substance Use and Gender. London: Health 

Development Agency, 2003. 

Thomas, E.J., and Ager, R.D. Unilateral family therapy with spouses of uncooperative alcohol 

abusers. In: O’Farrell, T.G., ed. Treating Alcohol Problems: Marital and Family Interventions

(pp. 3–33). New York: Guilford Press, 1993. 

Thompkins, C.D., and Rando, R.A. Gender role conflict and shame in college men. Psychology of 

Men and Masculinity 4(1):79–81, 2003. 

Thompson, E.H., and Pleck, J.H. The structure of male role norms. American Behavioral Scientist 

29(5):531–543, 1986. 

188 
 

 

 

Appendices 

Thompson, E.H., and Pleck, J.H. Masculinity ideologies: A review of research instrumentation

on men and masculinities. In: Levant, R.F., and Pollack, W.S., eds. A New Psychology of Men 

(pp. 129–163). New York: Basic Books, 1995. 

Thompson, R.A., Nored, L.S., and Cheeseman, D.K. The Prison Rape Elimination Act (PREA):

An evaluation of policy compliance with illustrative excerpts. Criminal Justice Policy Review 

19(4):414–437, 2008. 

Thompson, V.L.S., Talley, M., Caito, N., and Kreuter, M. African American men’s perceptions of 

factors influencing health information-seeking. American Journal of Men’s Health 3(1):6–15, 

2009. 

Tiet, Q.Q., Ilgen, M.A., Byrnes, H.F., Harris, A.H., and Finney, J.W. Treatment setting and

baseline substance use severity interact to predict patients’ outcomes. Addiction 102(3):432– 

440, 2007. 

Timko, C., and DeBenedetti, A. A randomized controlled trial of intensive referral to 12-Step 

self-help groups: One-year outcomes. Drug and Alcohol Dependence 90(2–3):270–279, 2007. 

Timko, C., Finney, J.W., and Moos, R.H. The 8-year course of alcohol abuse: Gender differences 

in social context and coping. Alcoholism, Clinical and Experimental Research 29(4):612–621, 

2005. 

Timko, C., Moos, B.S., and Moos, R.H. Gender differences in 16-year trends in assault- and

police-related problems due to drinking. Addictive Behaviors 34(9):744–750, 2009. 

Timms, D. Gender, social mobility and psychiatric diagnoses. Social Science and Medicine 

46(9):1235–1247, 1998. 

Tivis, L.J., Parsons, O.A., and Nixon, S.J. Anger in an inpatient treatment sample of chronic

alcoholics. Alcoholism: Clinical and Experimental Research 22(4):902–907, 1998. 

Tjaden, P., and Thoennes, N. Extent, Nature, and Consequences of Intimate Partner Violence:

Findings From the National Violence Against Women Survey. Rockville, MD: National Institute 

of Justice, 2000. 

Tonigan, J.S. Project Match treatment participation and outcome by self-reported ethnicity.

Alcoholism, Clinical and Experimental Research 27(8):1340–1344, 2003. 

Torres, J.B. Masculinity and gender roles among Puerto Rican men: Machismo on the U.S.

mainland. American Journal of Orthopsychiatry 68(1):16–26, 1998. 

Torres, J.B., Solberg, V.S., and Carlstrom, A.H. The myth of sameness among Latino men and

their machismo. American Journal of Orthopsychiatry 72(2):163–181, 2002. 

Towle, S. Steve’s Story: No Access to Treatment. The NAADD Report. San Mateo, CA: National

Association for Alcohol, Drugs, and Disability, 2002. 

189 
 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Tracy, S.W., Trafton, J.A., and Humphreys, K. The Department of Veterans Affairs Substance Abuse 

Treatment System: Results of the 2003 Drug and Alcohol Program Survey. Palo Alto, CA:

Program Evaluation and Resource Center and Health Services Research & Development

Service Center for Health Care Evaluation, Veterans Affairs Health Care System, 2004. 

Treise, D., Wolburg, J.M., and Otnes, C.C. Understanding the “social gifts” of drinking rituals:

An alternative framework for PSA developers. Journal of Advertising 28:17–31, 1999. 

Trenton, A.J., and Currier, G.W. Behavioural manifestations of anabolic steroid use. CNS Drugs 

19(7):571–595, 2005. 

Trocmé, N., MacLaurin, B., Fallon, B., Daciuk, J., Billingsley, D., Tourigny, M., Mayer, M., 

Wright, J., Barter, K., Burford, G., Hornick, J., Sullivan, R., and McKenzie, B. Canadian 

Incidence Study of Reported Child Abuse and Neglect: Final Report. Ottawa, Ontario: Minister of 

Public Works and Government Services Canada, 2001. 

Tu, G.C., and Israel, Y. Alcohol consumption by Orientals in North America is predicted largely 

by a single gene. Behavior Genetics 25(1):59–65, 1995. 

United Nations Economic Commission for Europe. Crime and Violence—Perpetrators and Types of 

Crime–Gender Issues. Geneva, Switzerland: United Nations Economic Commission for 

Europe, 2004. 

U.S. Census Bureau. Hispanic and Asian Americans Increasing Faster Than Overall Population. 

Washington, DC: U.S. Census Bureau News, 2004. 

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. 

Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and

Mental Health Services Administration, Center for Mental Health Services, National 

Institutes of Health, National Institute of Mental Health, 1999. 

U.S. Department of Health and Human Services. The Surgeon General’s Call to Action To Prevent 

and Reduce Underage Drinking. Rockville, MD: U.S. Department of Health and Human

Services, Office of the Surgeon General, 2007. 

U.S. Department of Health and Human Services, Administration for Children and Families.

Child Maltreatment, 2007. Washington, DC: U.S. Government Printing Office, 2009. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services

Administration, Office of Applied Studies. National Household Survey on Drug Abuse, 1998

[computer file]. ICPSR02934-V3. Ann Arbor, MI: Inter-University Consortium for Political 

and Social Research, 2000. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. National Survey on Drug Use and Health, 2006

[computer file]. ICPSR21240-V3. Ann Arbor, MI: Inter-University Consortium for Political 

and Social Research, 2007. 

190 
 

 

 

Appendices 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. National Survey on Drug Use and Health, 2007

[computer file]. ICPSR23782-V1. Ann Arbor, MI: Inter-University Consortium for Political

and Social Research, 2008a. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS), 2006

[computer file]. ICPSR21540-V2. Ann Arbor, MI: Inter-University Consortium for Political 

and Social Research, 2008b. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS), 2007

[computer file]. ICPSR24280. Ann Arbor, MI: Inter-University Consortium for Political and

Social Research, 2009a. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. National Survey on Drug Use and Health, 2008

[computer file]. ICPSR26701-V1. Ann Arbor, MI: Inter-University Consortium for Political 

and Social Research, 2009b. 

U.S. Department of Justice. Criminal Victimization in the United States, 2006: Statistical Tables. 

National Crime Victimization Survey. Washington, DC: U.S. Department of Justice, 2008. 

U.S. Public Health Service. The Surgeon General’s Call to Action To Prevent Suicide. Washington, 

DC: U.S. Public Health Service, 1999. 

Vaillant, G.E. A long-term follow-up of male alcohol abuse. Archives of General Psychiatry 

53(3):243–249, 1996. 

Vaillant, G.E. Alcoholics Anonymous: Cult or cure? Australian and New Zealand Journal of 

Psychiatry 39(6):431–436, 2005. 

Vaillant, G.E., and Hiller-Sturmhofel, S. The natural history of alcoholism. Alcohol Health and 

Research World 20(3):152–161, 1996. 

Van, T.H., and Koblin, B.A. HIV, alcohol, and noninjection drug use. Current Opinion in HIV 

and AIDS 4(4):314–318, 2009. 

Vandello, J.A., Bosson, J.K., Cohen, D., Burnaford, R.M., and Weaver, J.R. Precarious manhood.

Journal of Personality and Social Psychology 95(6):1325–1339, 2008. 

van Etten, M.L., Neumark, Y.D., and Anthony, J.C. Male-female differences in the earliest stages

of drug involvement. Addiction 94(9):1413–1419, 1999. 

van Oers, J.A.M., Bongers, I.M.B., Van de Goor, L.A.M., and Garretsen, H.F.L. Alcohol 

consumption, alcohol-related problems, problem drinking, and socioeconomic status. Alcohol 

and Alcoholism 34(1):78–88, 1999. 

van Wormer, K. The male-specific group in alcoholism treatment. Small Group Behavior 

20(2):228–242, 1989. 

191 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Vega, W.A., Alderete, E., Kolody, B., and Aguilar-Gaxiola, S. Illicit drug use among Mexicans

and Mexican Americans in California: The effects of gender and acculturation. Addiction 

93(12):1839–1850, 1998. 

Vega, W.A., Gil, A.G., and Zimmerman, R.S. Patterns of drug use among Cuban American, 

African American, and White non-Hispanic boys. American Journal of Public Health 

83(2):257–259, 1993. 

Vesga-Lopez, O., Schneier, F.R., Wang, S., Heimberg, R.G., Liu, S.M., Hasin, D.S., and Blanco,

C. Gender differences in generalized anxiety disorder: Results from the National 

Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical 

Psychiatry 69(10):1606–1616, 2008. 

Veterans Health Administration. VHA Program Guide 1103.1: Substance Abuse Treatment.

Standards for a Continuum of Care. Washington, DC: Department of Veterans Affairs,

Veterans Health Administration, 1996. 

Vogel, D.L., Wade, N.G., and Haake, S. Measuring the self-stigma associated with seeking

psychological help. Journal of Counseling Psychology 53(3):325–337, 2006. 

von Sydow, K., Lieb, R., Pfister, H., Hofler, M., Sonntag, H., and Wittchen, H.U. The natural

course of cannabis use, abuse and dependence over four years: A longitudinal community 

study of adolescents and young adults. Drug and Alcohol Dependence 64(3):347–361, 2001. 

von Sydow, K., Lieb, R., Pfister, H., Hofler, M., and Wittchen, H.U. Use, abuse and dependence

of ecstasy and related drugs in adolescents and young adults: A transient phenomenon?

Results from a longitudinal community study. Drug and Alcohol Dependence 66(2):147–159, 

2002. 

Wade, J.C. Substance abuse: Implications for counseling African American men. Journal of 

Mental Health Counseling 16(4):415–433, 1994. 

Wade, J.C. Traditional masculinity and African American men’s health-related attitudes and 

behaviors. American Journal of Men’s Health 3(2):165–172, 2009. 

Wagenaar, A.C., Toomey, T.L. Alcohol policy: Gaps between legislative action and current

research. Contemporary Drug Problems 27(4):681–733, 2000. 

Waldron, I. Gender differences in mortality—causes and variation in different societies. In:

Conrad, P., ed. The Sociology of Health and Illness: Critical Perspectives, 7th ed. New York: 

Worth-St. Martin’s Press, 2005. 

Walfish, S., Massey, R., and Krone, A. Anxiety and anger among abusers of different substances.

Drug and Alcohol Dependence 25(3):253–256, 1990. 

Walitzer, K.S., and Dearing, R.L. Gender differences in alcohol and substance use relapse.

Clinical Psychology Review 26(2):128–148, 2006. 

192 
 

 

 

 

 

Appendices 

Walton, M.A., Blow, F.C., and Booth, B.M. Diversity in relapse prevention needs: Gender and

race comparisons among substance abuse treatment patients. American Journal of Drug and 

Alcohol Abuse 27(2):225–240, 2001. 

Warner, B.D., and Leukefeld, C.G. Rural-urban differences in substance use and treatment

utilization among prisoners. American Journal of Drug and Alcohol Abuse 27(2):265–280, 2001. 

Washton, A.M. Cocaine, Methamphetamine, and Compulsive Sexuality. Microsoft PowerPoint 

presentation, 2009. 

Watt, T.T. The race/ethnic age crossover effect in drug use and heavy drinking. Journal of 

Ethnicity in Substance Abuse 7(1):93–114, 2008. 

Webster, C.D., Douglas, K.S., Eaves, D., and Hart, S.D. Assessing risk of violence to others. In:

Webster, C.D., and Jackson, M.A., eds. Impulsivity: Theory, Assessment, and Treatment (pp. 

251–277). New York: Guilford Press, 1997. 

Webster, J.M., Pimentel, J.H., and Clark, D.B. Characteristics of DUI offenders convicted in wet,

dry, and moist counties. Accident Analysis and Prevention 40:976–982, 2008. 

Weidel, J.J., Provencio-Vasquez, E., and Grossman, J. Sex and drugs: High-risk behaviors at

circuit parties. American Journal of Men’s Health 2(4):344–352, 2008. 

Weinberg, M.S., and Williams, C.J. Male Homosexuals: Their Problems and Adaptations. New York: 

Oxford University Press, 1974. 

Weingartner, K., Robison, J., Fogel, D., and Gruman, C. Depression and substance use in a

middle-aged and older Puerto Rican population. Journal of Cross-Cultural Gerontology 

17(2):173–193, 2002. 

Weinsheimer, R.L., Schermer, C.R., Malcoe, L.H., Balduf, L.M., and Bloomfield, L.A. Severe 

intimate partner violence and alcohol use among female trauma patients. Journal of Trauma 

58(1):22–29, 2005. 

Weinstein, S.P., Gottheil, E., and Sterling, R.C. Randomized comparison of intensive outpatient

vs. individual therapy for cocaine abusers. Journal of Addictive Diseases 16(2):41–56, 1997. 

Weinstock, J., Barry, D., and Petry, N.M. Exercise-related activities are associated with positive 

outcome in contingency management treatment for substance use disorders. Addictive 

Behaviors 33(8):1072–1075, 2008. 

Weinstock, L.S. Gender differences in the presentation and management of social anxiety 

disorder. Journal of Clinical Psychiatry 60(Supplement 9):9–13, 1999. 

Weisner, C., Matzger, H., and Kaskutas, L.A. How important is treatment? One-year outcomes 

of treated and untreated alcohol-dependent individuals. Addiction 98(7):901–911, 2003. 

Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., and Lu, Y. Integrating primary medical 

care with addiction treatment: A randomized controlled trial. Journal of the American Medical 

Association 286(14):1715–1723, 2001. 

193 
 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

Weiss, R.D., Griffin, M.L., Gallop, R.J., Najavits, L.M., Frank, A., Crits-Christoph, P., Thase,

M.E., Blaine, J., Gastfriend, D.R., Daley, D., and Luborsky, L. The effect of 12-Step self-help

group attendance and participation on drug use outcomes among cocaine-dependent patients.

Drug and Alcohol Dependence 77(2):177–184, 2005. 

Weiss, R.D., Jaffee, W.B., de Menil, V.P., and Cogley, C.B. Group therapy for substance use 

disorders: What do we know? Harvard Review of Psychiatry 12(6):339–350, 2004. 

Weiss, R.D., Martinez-Raga, J., Griffin, M.L., Greenfield, S.F., and Hufford, C. Gender

differences in cocaine dependent patients: A 6-month follow-up study. Drug and Alcohol 

Dependence 44(1):35–40, 1997. 

Wells, K., Klap, R., Koike, A., and Sherbourne, C. Ethnic disparities in unmet need for

alcoholism, drug abuse, and mental health care. American Journal of Psychiatry 158(12):2027– 

2032, 2001. 

Welte, J.W., Barnes, G.M., Wieczorek, W.F., Tidwell, M.C., and Parker, J.C. Risk factors for

pathological gambling. Addictive Behaviors 29(2):323–325, 2004. 

West, L.A. Negotiating masculinities in American drinking subcultures. The Journal of Men’s 

Studies 9(3):371–392, 2001. 

Wexler, D.B. Men in Therapy: New Approaches for Effective Treatment. New York: W.W. Norton & 

Company, 2009. 

Wilcox, D.M. Alcoholic Thinking. Westport, CT: Praeger, 1998. 

Wilcox, H.C., Conner, K.R., and Caine, E.D. Association of alcohol and drug use disorders and

completed suicide: An empirical review of cohort studies. Drug and Alcohol Dependence 

76(Suppl. 1):S11–S19, 2004. 

Williams, R.J., and Ricciardelli, L.A. Gender congruence in confirmatory and compensatory 

drinking. Journal of Psychology 133(3):323–331, 1999. 

Wilson, S.R., Brown, N.L., Mejia, C., and Lavori, P. Effects of interviewer characteristics on

reported sexual behavior of California Latino couples. Hispanic Journal of Behavioral Sciences 

4(1):38–62, 2002. 

Windle, M., Windle, R.C., Scheidt, D.M., and Miller, G.B. Physical and sexual abuse and

associated mental disorders among alcoholic inpatients. American Journal of Psychiatry 

152(9):1322–1328, 1995. 

Winkelman, M. Complementary therapy for addiction: “Drumming out drugs.” American Journal 

of Public Health 93(4):647–651, 2003. 

Winkler, D., Pjrek, E., Heiden, A., Wiesegger, G., Klein, N., Konstantinidis, A., and Kasper, S.

Gender differences in the psychopathology of depressed inpatients. European Archives of 

Psychiatry and Clinical Neuroscience 254(4):209–214, 2004. 

194 
 

 

 

Appendices 

Wolfe, J., Martinez, R., and Scott, W.A. Baseball and beer: An analysis of alcohol consumption

patterns among male spectators at major-league sporting events. Annals of Emergency 

Medicine 31(5):629–632, 1998. 

Wolin, S.J., and Bennett, L.A. Family rituals. Family Process 23(3):401–420, 1984. 

Wong, F.Y., Huang, Z.J., Thompson, E.E., De Leon, J.M., Shah, M.S., Park, R.J., and Do, T.D. 

Substance use among a sample of foreign- and U.S.-born Southeast Asians in an urban 

setting. Journal of Ethnicity in Substance Abuse 6(1):45–66, 2007. 

Wong, Y.J., Pituch, K.A., and Rochlen, A.B. Men’s restrictive emotionality: An investigation of

associations with other emotion-related constructs, anxiety, and underlying dimensions.

Psychology of Men & Masculinity 7(2):113–126, 2006. 

World Health Organization. The World Health Report: 2004. Changing History. Geneva, 

Switzerland: World Health Organization, 2004. 

Wu, L.T., Kouzis, A.C., and Leaf, P.J. Influence of comorbid alcohol and psychiatric disorders on

utilization of mental health services in the National Comorbidity Survey. American Journal of 

Psychiatry 156(8):1230–1236, 1999. 

Yalom, I.D. Existential Psychotherapy. New York: Basic Books, 1980. 

Yeom, H.S., and Shepard, D.S. Cost-effectiveness of a mixed-gender aftercare program for

substance abuse: Decomposing measured and unmeasured gender differences. Journal of 

Mental Health Policy and Economics 10(4):207–21, 2007. 

Zemishlany, Z., Aizenberg, D., and Weizman, A. Subjective effects of MDMA (“ecstasy”) on 

human sexual function. European Psychiatry 16(2):127–130, 2001. 

Zemore, S.E. Re-examining whether and why acculturation relates to drinking outcomes in a

rigorous, national survey of Latinos. Alcoholism, Clinical and Experimental Research 

29(12):2144–2153, 2005. 

Zemore, S.E. An overview of spirituality in AA (and recovery). In: Galanter, M., and Kaskutas,

L.A., eds. Recent Developments in Alcoholism: Research on Alcoholics Anonymous and Spirituality

in Addiction Recovery, Vol. 18 (pp. 111–123). New York: Springer Science and Business 

Media, 2008. 

Zerger, S. Substance Abuse Treatment: What Works for Homeless People? A Review of the Literature. 

Nashville, TN: National Health Care for the Homeless Council, 2002. 

Zhang, Z., Huang, L.X., and Brittingham, A.M. Worker Drug Use and Workplace Policies and

Programs: Results From the 1994 and 1997 National Household Survey on Drug Abuse. Analytic

Series: A-11. Rockville, MD: Substance Abuse and Mental Health Services Administration,

1999. 

Zickler, P. Nicotine’s multiple effects on the brain’s reward system drive addiction. NIDA Notes 

17(6):1–6, 2003. 

195 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Zielinski, D.S. Child maltreatment and adult socioeconomic well-being. Child Abuse and Neglect 

33(10):666–678, 2009. 

Zilberman, M.L., Tavares, H., Andrade, A.G., and el-Guebaly, N. The impact of an outpatient

program for women with substance use-related disorders on retention. Substance Use and 

Misuse 38(14):2109–2124, 2003. 

Zlotnick, C., Clarke, J.G., Friedmann, P.D., Roberts, M.B., Sacks, S., and Melnick, G. Gender

differences in comorbid disorders among offenders in prison substance abuse treatment 

programs. Behavioral Sciences & the Law 26(4):403–412, 2008. 

Zuckerman, M. Sensation Seeking: Beyond the Optimal Level of Arousal. Hillsdale, NJ: Lawrence 

Erlbaum Associates, 1979. 

Zuckerman, M. Sensation seeking: A comparative approach to a human trait. Behavioral and 

Brain Sciences 7(3):413–471, 1984. 

Zuckerman, M. Behavioral Expressions and Biosocial Bases of Sensation Seeking. New York: 

Cambridge University Press, 1994. 

Zywiak, W.H., Stout, R.L., Longabaugh, R., Dyck, I., Connors, G.J., and Maisto, S.A. Relapseonset factors in Project MATCH: The Relapse Questionnaire. Journal of Substance Abuse 

Treatment 31(4):341–345, 2006a. 

Zywiak, W.H., Stout, R.L., Trefry, W.B., Glasser, I., Connors, G.J., Maisto, S.A., and Westerberg,

V.S. Alcohol relapse repetition, gender, and predictive validity. Journal of Substance Abuse 

Treatment 30(4):349–353, 2006b. 

196 
Appendices 

Appendix B—Glossary 

Acculturation—the socialization process through which people in minority groups adopt certain

elements from the majority culture. 

Assessment—a comprehensive evaluation of a client’s indepth status and needs. 

Chromosome—a microscopic, rodlike structure in the cell’s nucleus that carries genetic material. 

Co-occurring disorders—co-occurring substance use (abuse or dependence) and mental disorders. In the context of this TIP, clients said to have co-occurring disorders have one or more 

mental disorders as well as one or more disorders relating to the use of alcohol and/or drugs. 

Countertransference—the feelings, reactions, biases, and images from the past that the clinician

may project onto the client. 

Culture—the conceptual system that structures the way we view the world. Culture incorporates 

a particular set of beliefs, norms, and values that influence our ideas about the nature of relationships, the way we live our lives, and the way we organize our world. 

Cyber—a prefix relating to computers or computer networks. 

Employee assistance programs—programs that provide professional consultation services for

employees who are experiencing personal issues that might be negatively affecting their work 

performance. 

Ethnicity—shared values and beliefs, social identity, mutual belongingness, and standards of behavior that define a group of people. 

Gender—category to which an individual is assigned, by self or others, on the basis of sex. 

Gender identity—the subjective, continuous, and persistent sense of oneself as male or female. 

Gender role conflict—a psychological state in which a person’s beliefs about himself or herself or 

his or her behaviors conflict with socialized gender roles, resulting in negative consequences.

Gender conflict occurs when rigid, sexist, or restrictive gender roles result in personal restrictions,

devaluation, or violation of others or self. 

Gender role stress—may arise from excessive commitment to and reliance on certain culturally 

approved masculine or feminine schemes that limit the range of coping strategies a person is able 

197 
 

Addressing the Specific Behavioral Health Needs of Men 

to use in any particular situation. Masculine gender role stress may also arise from the belief that

one is not living up to culturally sanctioned gender role behavior. Men may experience stress if

they feel that they have acted in an unmanly or feminine fashion. Many men are doubly stressed

by experiencing fear or by feeling that they have not appeared successful or tough enough in situations requiring masculine appearances of strength and invincibility. 

Gene—a specific sequence of DNA that encodes for a specific trait, characteristic, or protein in

an organism. 

Genetic transmission—inherited characteristics passed from parents to children. 

Heterosexism—an attitude or belief that heterosexual behavior is the norm. 

Intersystemic—occurring between systems. 

Intrasystemic—occurring within systems. 

Maladaptive—marked by faulty or inadequate adaptation. 

Male—of, relating to, or designating the sex that has organs to produce spermatozoa for fertilizing ova. 

Mandate—a command, order, or direction—written or oral—which courts are authorized to give 

and people are bound to obey. 

Marginalization—removal of someone’s importance and power. 

Masculine role socialization—the process whereby men learn how they (as men) are expected to

act, feel, and think. As part of this learning process, they experience negative consequences (e.g.,

public humiliation, anger from peers) when they fail to meet those expectations. 

Masculine—relating to or marked by the characteristics of the male sex or gender. 

Masculinity ideologies—a body of socially constructed ideas and beliefs about what it means to

be a man. The ideologies attempt to measure the degree to which an individual endorses these 

cultural norms regarding the male gender role. 

Nonrelational sex—the tendency to experience sex primarily as lust without any requirements for 

relational intimacy or emotional attachment. 

Posttraumatic stress disorder (PTSD)—an illness whose essential feature is the development of

characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury or other

threat to one’s physical integrity; it can also result from witnessing an event that involves death,

injury, or a threat to the physical integrity of another person or learning about the unexpected or

violent death, serious harm, or threat of death or injury experienced by a family member or other

close friend or relative. 

Psychoactive—possessing the ability to alter mood, feelings, behavior, cognitive processes, or

mental states; usually applied to pharmacologic agents. 

198 
 

 

 

Appendices 

Psychotherapy—treatment of emotional, behavioral, personality, and mental disorders based primarily on verbal or nonverbal communication and interventions with the patient, in contrast to

treatments that use chemical and physical measures. 

Race—a social construct to describe people with shared physical characteristics. 

Racism—an attitude or belief that people with certain characteristics are better than others. 

Religion—any specific system of belief about one or more deities, often involving rituals, a code 

of ethics, and a philosophy of life. 

Screening—a process to determine whether a client warrants further evaluation for a particular

diagnosis (e.g., substance use disorders, mental disorders, HIV/AIDS). A screening process can

be designed so that it can be conducted with little additional training by counselors. Positive

screenings are followed by comprehensive assessments. 

Sex—the biological differences between women and men. 

Sociocultural—of or involving both social and cultural factors. 

Spirituality—the state or quality of being dedicated to a deity, a religion, or spiritual things or

values, especially as contrasted with material or temporal ones. 

Stigma—a negative association attached to some activity or condition; a cause of shame or embarrassment. 

Substance—can refer to a drug of abuse, a medication, or a toxin. 

Substance abuse—a maladaptive pattern of substance use manifested through recurrent and significant adverse consequences related to the repeated use of substances. Sometimes used interchangeably with the term substance dependence. 

Substance dependence—a maladaptive pattern of substance use leading to clinically significant

impairment or distress, as manifested by a need for increasing amounts of the substance to

achieve intoxication, markedly diminished effect of the substance with continued use, the need to

continue to take the substance in order to avoid withdrawal symptoms, and other serious behavioral effects, occurring at any time in the same 12-month period. 

Substance use disorders—a class of substance-related disorders that includes both substance 

abuse and substance dependence. 

Transference—the feelings, reactions, biases, and images from the past that the client may project

onto the clinician. 

199 

Appendices 

Appendix C—Resource Panel 

John C. Bailey

Special Expert

Office of Policy, Planning, and Budget

Office of the Administrator 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Frank Canizales, M.S.W.

Management Analyst

Alcohol Program 

Division of Clinical and Preventive Services 

Indian Health Service 

Rockville, MD 

Redonna K. Chandler, Ph.D.

Health Scientist Administrator 

Services Research Branch 

Division of Epidemiology, Services, and

Prevention Research 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

Christine Cichetti 

Drug Policy Advisor

U.S. Department of Health and Human

Services 

Washington, DC 

H. Westley Clark, M.D., J.D., M.P.H., 

CAS, FASAM

Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Edwin M. Craft, Dr.P.H. 

Program Analyst

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Christina Currier 

Public Health Analyst

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief 

Services Research Branch 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

201 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Kirk E. James, M.D. 

Special Expert

Systems Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Andrea Kopstein, Ph.D., M.P.H.

Branch Chief 

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Cece McNamara, Ph.D.

Health Scientist Administrator 

Behavioral Treatment Development Branch

Division of Treatment Research 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

Julie A. Sabol 

Web Marketing Specialist

Customer Loyalty Practice 

ORC Macro 

Calverton, MD 

Michael D. Shankle, M.P.H. 

Research Specialist

Pennsylvania Prevention Project

Graduate School of Public Health 

Department of Infectious Diseases and

Microbiology

University of Pittsburgh

Pittsburgh, PA 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, DC 

Karl D. White, Ed.D. 

Public Health Analyst

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

202 
 

 

 

 

 

 

 

Appendices 

Appendix D—Field Reviewers 

Gary L. Baker, LCSW

Director, Social Services

Office of Addictive Disorders 

Pines Treatment Center 

Shreveport, LA 

Mona R. Bomgaars

Member 

Commission on Public Health 

American Academy of Family Physicians 

Honolulu, HI 

Patricia T. Bowman 

Probation Counselor 

Fairfax Alcohol Safety Action Program

Fairfax, VA 

Frank Canizales, M.S.W.

Management Analyst

Alcohol Program 

Division of Clinical and Preventive Services 

Indian Health Service 

Rockville, MD 

Jerome F.X. Carroll, Ph.D. 

Consultant in Private Practice 

Chair 

Columbia University Drugs and Society

Seminar 

Brooklyn, NY 

Redonna K. Chandler, Ph.D.

Health Scientist Administrator 

Services Research Branch 

Division of Epidemiology, Services, and

Prevention Research 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

R. T. Codd, III

Director/Owner 

Cognitive–Behavioral Therapy Center of

Western North Carolina 

Certified Member of the Academy of

Cognitive Therapy

Asheville, NC 

Marc S. Condojani

Clinical Training Coordinator

Alcohol and Drug Abuse Division

Colorado Department of Human Services 

Denver, CO 

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief 

Services Research Branch 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, MD 

Thomas L. Geraty, M.S.W., Ph.D., 

LICSW 

Jamaica Plain, MA 

203 
 

 

Addressing the Specific Behavioral Health Needs of Men 

Wendy K. Hausotter

Project Manager 

Northwest Frontier Addiction Technology

Transfer Center 

Salem, OR 

Heather Healy, LCSW-C, CCDC, CEAP

Association of Flight Attendants

Washington, DC 

Maya D. Hennessey

Women’s Specialist

Supervisor, Quality Assurance, Technical 

Assistance and Training

Office of Special Programs 

Division of Substance Abuse 

Illinois Department of Human Services and

Substance Abuse 

Chicago, IL 

Michael W. Herring

Licensed Clinical Social Worker 

Wayne Psychiatric Associates, P.A.

Goldsboro, NC 

Kenneth J. Hoffman, M.D., M.P.H. 

Medical Director 

Military Health System Population Health

Programs 

TRICARE Management Activity

Falls Church, VA 

Norman G. Hoffmann 

President 

Evince Clinical Assessments 

Clinical Associate Professor of Community 

Health 

Brown University 

Smithfield, RI 

David M. Kaplan, Ph.D.

Associate Executive Director 

Professional Affairs 

American Counseling Association

Alexandria, VA 

Michael Warren Kirby, Jr., M.A., Ph.D. 

Chief Executive Officer 

Arapahoe House, Inc.

Thornton, CO 

Jan Ligon, Ph.D., LCSW

Associate Professor 

School of Social Work 

Georgia State University 

Atlanta, GA 

Alan Lyme

Program Manager 

Center for Men’s Recovery 

Hanley-Hazelden Center

West Palm Beach, FL 

Irmo Marini, Ph.D., CRC, CLCP, FVE

Professor/Graduate Program Coordinator

Rehabilitative Services Program

College of Health Sciences and Human

Services 

University of Texas–Pan American

Edinburg, TX 

Thomas J. McMahon, Ph.D.

Assistant Professor 

Yale University School of Medicine 

West Haven, CT 

Cece McNamara, Ph.D.

Health Scientist Administrator 

Behavioral Treatment Development Branch

Division of Treatment Research 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, MD 

Karen H. Mooney

Women’s Treatment Coordinator 

Alcohol and Drug Abuse Division

Colorado Department of Human Services 

Denver, CO 

Dennis Morrow 

Executive Director 

JANUS Youth Programs 

Portland, OR 

204 
 

Appendices 

Robert L. Neri 

Vice President/Chief Clinical Officer

WestCare Foundation, Inc.

St. Petersburg, FL 

William (Bill) Francis Northey, Jr., Ph.D.

Research Specialist

American Association for Marriage and

Family Therapy 

Alexandria, VA 

Charles Parker 

Project Specialist

James R. Thompson Center

Division of Alcoholism and Substance 

Abuse 

Illinois Department of Human Services 

Chicago, IL 

Thomas A. Peltz, M.Ed. 

Therapist/Licensed Mental Health Counselor

Certified Addiction Specialist

Private Practice 

Beverly Farms, MD 

Melissa V. Rael 

Senior Program Management Officer 

Co-Occurring and Homeless Branch

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Pat Regan

Social Work Supervisor

Louisiana Department of Health and

Hospitals 

Monroe, LA 

John A. Rich, M.D., M.P.H. 

Medical Director/Associate Professor

Boston Public Health Commission 

Boston University School of Medicine 

Boston, MA 

Julie A. Sabol 

Web Marketing Specialist

Customer Loyalty Practice 

ORC Macro 

Calverton, MD 

Michael D. Shankle, M.P.H. 

Research Specialist

Pennsylvania Prevention Project

Graduate School of Public Health 

Department of Infectious Diseases and

Microbiology

University of Pittsburgh

Pittsburgh, PA 

Mark R. Shields 

Program Specialist II

Division of Alcohol and Drug Abuse 

Missouri Department of Mental Health

Jefferson City, MO 

Mickey J. W. Smith, M.S.W. 

Senior Policy Associate

Behavioral Health Program

Policy and Practice Unit

Division of Professional Development and

Advocacy

National Association of Social Workers 

Washington, DC 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, DC 

Melvin H. Wilson, M.B.A., LCSW-C 

High Intensity Drug Trafficking Area

Coordinator 

Maryland Division of Parole and Probation

Baltimore, MD 

205 
 

Addressing the Specific Behavioral Health Needs of Men 

Appendix E—Acknowledgments 

Numerous people contributed to the development of this Treatment Improvement Protocol 

(TIP); see pages v–viii and Appendices C and D. Rose M. Urban, M.S.W., J.D., LCSW, LCAS,

served as the Knowledge Application Program (KAP) Executive Project Co-Director. Sheldon

Weinberg, Ph.D., served as the KAP Senior Researcher/Applied Psychologist. Other KAP

personnel included Claudia Blackburn, Psy.D., Expert Content Director; Bruce Carruth, Ph.D.,

former Expert Content Director; Jessica L. Culotta, M.A., Managing Project Co-Director and

former Managing Editor; Susan Kimner, former Managing Project Co-Director; Elizabeth 

Marsh Cupino, former Managing Project Co-Director; Raquel Witkin, M.S., former Deputy 

Project Manager; Jonathan Max Gilbert, Ph.D., Editor/Writer; Deborah Steinbach, M.A.,

former Editor/Writer; James M. Girsch, Ph.D., former Editor/Writer; Jason P. Merritt, former

Editor/Writer; Virgie D. Paul, M.L.S., Librarian; Elizabeth Plevyak, former Associate Editor;

Lee Ann Knapp, Quality Assurance Editor; Michelle Myers, former Quality Assurance Editor;

Angela Fiastro, Junior Editor; and Ilana Boivie, Sonja Easley, and Joseph Killiany. 

206 
 

 

 

 

 

Index 

Index 

A 

Addiction Severity Index, 118

Addiction Technology Transfer Centers 

(ATTCs), 11, 40

Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment (TIP 50), 18, 82 

administrators, 11

African Americans, 96, 96–97. See also culture 

and ethnicity

age-related issues, xviii, 86–89. See also older 

men; young men

aggression and concepts of masculinity, 5–6

AIDS, 18, 23, 45, 54, 57, 61, 63, 82, 84, 93

Alaska Natives and American Indians, 96, 97– 

98. See also culture and ethnicity

Albany-Rochester Sequence for Engagement

(ARISE), xix, 110

Albuquerque Health Care for the Homeless,

94 

alcohol abuse. See substance abuse 

Alcohol and Drug Abuse Institute, University 

of Washington, 16

Alcohol and Other Drug Screening of

Hospitalized Trauma Patients (TIP 16), 16 

Alcoholics Anonymous (AA). See 12-Step 

groups

Alcohol Policy Information System, 124

Alcohol Team, Centers for Disease Control 

and Prevention, 122

alexithymia, 5

American Indians and Alaska Natives, 96, 97– 

98. See also culture and ethnicity 

American Society of Addiction Medicine

(ASAM), 116

anabolic steroids, 54

anger management, 42, 43, 48, 52, 113

Anger Management for Substance Abuse and

Mental Health Clients: A Cognitive 


Behavioral Therapy Manual, 48


Anger Management for Substance Abuse and

Mental Health Clients: Participant Workbook,

48 

antisocial personality disorder (ASPD), 76, 77,

79–81, 80 

anxiety disorders, 69–75

American Society of Addiction Medicine, 116

Asians, Hawaiian Natives, and Pacific

Islanders, 96, 98. See also culture and 

ethnicity

assessment. See screening and assessment

Association for Medical Education and 

Research in Substance Abuse (AMERSA), 

40 

availability of drugs, 123–124 

B 

Battered Men Web site, 51

behavioral couples therapy, 51, 108

Behavioral Health Services for American Indians 

and Alaska Natives (planned TIP), 97

behavioral health workers and counselors, 11

countertransference techniques, 35–37

female counselors, 33, 36, 37–38, 40

gender bias and stereotyping, avoidance 

of, 31–33, 33 

207 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

gender of, 26, 31–40, 52, 107


male counselors, 33, 35, 36–37, 39–40


motivation to change, enhancing, 112


screening and assessment by, 14, 15


transference, 33–37


transition into mutual-help groups, 119,


121
 

Betty Ford Center, 39


binge drinking, 4, 8–9, 86, 88, 97, 98, 122, 123


bipolar disorder, 77–78


bisexual men. See gay and bisexual men


Brannon Masculinity Scale, 4, 20


Brief Interventions and Brief Therapies for


Substance Abuse (TIP 34), 31
 

bulimia, 79
 

C 

career-related issues. See employment and 

career-related issues
 

Casa Los Arboles, 94


case studies
 

childhood sexual abuse, client with 

history of (George), 59


emotional restraint ( Jack), 41


male counselor/male client interaction


(clinical team), 36–37


posttraumatic stress disorder (Tim), 70–


71
 

sexualized transference (Hank and


Jennifer), 34–35


shame (Harry), 46


Center for Social Work Research, University 


of Texas–Austin, 16, 17


Center for Substance Abuse Prevention, 62
 

Center for Substance Abuse Treatment
 

(CSAT)


fact sheet on mutual-help groups, 119


TIPs. See Treatment Improvement


Protocols 

Centers for Disease Control and Prevention 

(CDC)


Alcohol Team, 122


HIV/AIDS Surveillance Report, 84
 

National Center for Injury Prevention 


and Control, 82
 

child abuse in client’s current family. See 

domestic violence and child abuse
 

child custody, xvii, 53, 60


child support, 63


Child Support Enforcement Program, 63


childhood abuse and neglect (of client)


personal assessment of, 15, 19, 21–22


sexual abuse, 57–59


Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36),
 

19, 21, 22, 49, 59


as treatment issue, xvi–xvii, 57–59, 59
 

Childhood Trauma Interview, 22


children of substance abusers. See families and
 

significant others


co-occurring mental disorders. See mental 


disorders, co-occurring


co-occurring physical health problems. See 


physical health problems, co-occurring


cocaine, 9, 10, 12, 31, 32, 48, 53, 54, 55, 69, 96,


97, 100, 102, 106, 108, 113, 117


Cocaine Anonymous. See 12-Step groups


coerced treatment, 112–113


cognitive–behavioral therapy, 27, 32, 42, 47,


48, 56, 74, 85
 

combat stress reaction (CSR), 73–74


community influences, 122–124


Community Reinforcement and Family 


Training (CRAFT), xix, 111

competition and success, masculine 

importance of, 5


confidentiality laws and exceptions, 49


Confidentiality of Alcohol and Drug Abuse 


Patient Records laws, 49


Conformity to Masculine Norms Inventory,


20–21
 

Continuity of Offender Treatment for Substance 

Use Disorders From Institution to Community

(TIP 30), 15, 94


“Counseling Alcohol and Drug Dependent


Men” training program (Distance Learning


Center for Addiction Studies), 11


counselors. See behavioral health workers and 

counselors 

countertransference techniques, 35–37 

208 
 

 

 

 

 

 

 

 

 

 

 

 

Index 

couples. See families and significant others


crack cocaine, 10, 53, 97


criminal justice system, xviii, 94–95


gender-aware personal assessment and, 18


HIV/AIDS in, 57


mental disorders, co-occurring, 95


professionals associated with, 11


rape and sexual abuse in, 57


Substance Abuse Treatment for Adults in the
 

Criminal Justice System (TIP 44), 15,
 

47–48, 94


therapeutic communities in, 94, 117


violence and criminal behavior, 46–48


culture and ethnicity, xviii, 95–100


African Americans, 96, 96–97
 

American Indians and Alaska Natives, 96,


97–98 

Asians, Hawaiian Natives, and Pacific

Islanders, 96, 98
 

depression, rates of, 77


discrimination and concepts of


masculinity, 8


gender of counselor, 26, 39


Hispanic/Latino Americans, 96, 99–100
 

Improving Cultural Competence (planned
 

TIP), 15, 26, 95–96


primary substance of abuse by 


cultural/ethnic group, 96
 

screening and assessment affected by, 14,


15, 26


shame, 26, 44–45


suicidality, 81, 82, 97
 

White Americans, 96, 98–99
 

young men, 86, 87


cybersex, 56
 

D 

Defense Centers of Excellence Outreach 

Center, 92
 

depression, 18–19, 75–77, 76
 

detoxification, 19, 101–102


Detoxification and Substance Abuse Treatment 

(TIP 45), 102
 

Diagnostic and Statistical Manual of Mental 


Disorders, 4th Edition, Text Revision


(DSM-IV-TR), xiv, 2–3, 73, 74, 76, 78, 79
 

Differential Emotions Scale, 25
 

disabilities, mental. See mental disabilities 

disabilities, physical, 84


disruptive behavior in group settings due to


shame, 46
 

Distance Learning Center for Addiction


Studies, 11


domestic violence and child abuse
 

assessing current physical or sexual 


violence in client’s family, 22–23


family and couples therapy, 108


gay male couples, 50


men as victims of domestic abuse, 22, 49–


50, 51


parenting responsibility as treatment


issue, 63


Substance Abuse Treatment and Domestic 

Violence (TIP 25), 22, 49


as treatment issue, 48–49


treatment of, 50–51


Double Trouble in Recovery, 122


drug abuse. See substance abuse 

Drug Abuse Treatment Outcome Study 


(DATOS), 60, 105, 106, 108


Dual Diagnosis Anonymous and Dual 


Disorders Anonymous, 122


dysthymia, 75–77, 76
 

E 

eating disorders, 79


ecstasy (3,4­

methylenedioxymethamphetamine or


MDMA), 53, 55


education and educators, 11, 40


EMERGE, 22


emotional restraint
 

aggression, fearlessness, and


invulnerability, 5–6


masculinity, association with, 5


mental disorders, co-occurring, 40


as treatment issue, xvi, 40–44, 41, 43
 

209 
 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

employment and career-related issues, xviii,


90–91
 

employee assistance programs, 123


gender-aware personal assessment of, 17


Integrating Substance Abuse Treatment and


Vocational Services (TIP 38), 17, 91


masculinity, concepts of, 5, 7


socioeconomic status and risk of
 

substance abuse, 90
 

unemployment, xviii, 91


engagement of male clients, 29–31, 30
 

Enhancing Motivation for Change in Substance 


Abuse Treatment (TIP 35), 29, 31, 111, 112
 

ethnic groups. See culture and ethnicity


Experiential Shame Scale, 25
 

F 

faith-based organizations and programs, 11


families and significant others. See also
 

domestic violence and child abuse
 

child custody, xvii, 53, 60


child support, 63


child welfare and family court


proceedings, 63–64


interventions by, xix, 109–111


male-specific personal assessment of


family history, 21–22


parenting responsibilities, xvii, 60–63, 61,


62
 

reproductive responsibility, 63


Substance Abuse Treatment and Family


Therapy (TIP 39), 21, 31, 51, 109


support from, 64–65


treatment issues associated with, xvii, 59–


65, 61, 62


treatment methods involving, xix, 107–


111, 110
 

fearlessness and concepts of masculinity, 5–6


financial training and money management,


114–115
 

Focus on Families, 62
 

G 

gambling, pathological, 78–79


GATE, 82, 83
 

gay and bisexual men, xviii, 89–90


domestic violence, 50


eating disorders, 79


homophobia, heterosexism, and concepts 


of masculinity, 6–7, 55


A Provider’s Introduction to Substance Abuse
 

Treatment for Lesbian, Gay, Bisexual,


and Transgender Individuals (CSAT
 

2001), 55, 89


risk of substance abuse by, 89


sex trade workers, 56


sexual abuse of, 57


sexual identity of, 23, 54–55


sildenafil (Viagra), abuse of, 55


gender-aware personal assessment, 14, 15, 17–


20
 

gender bias and stereotyping, 31–33, 33
 

gender of behavioral health counselors, 26, 31–


40, 52, 107


gender role conflict, 8


Gender Role Conflict Scale, 20


Gender Role Stress Scale, 20


gender-specific group therapy, 103–104


gender-specific treatment settings, 115


gender versus sex, 2


generalized anxiety disorder (GAD), 69, 75


geographic region, 100


Georgetown University National Center for 


Cultural Competence, 26


Get Connected! Linking Older Adults With


Medication, Alcohol, and Mental Health


Resources toolkit (SAMHSA, 2003), 88


group therapy, xviii–xix, 103–106, 105
 

A Guide to Substance Abuse Services for Primary


Care Clinicians (TIP 24), 14, 16
 

H 

Habitat for Humanity, 43


Hawaiian Natives, 96, 98. See also culture and
 

ethnicity


Hazelden Clinic, 39


health care, men less likely to seek, 6, 68


healthcare providers, xiv, 11. See also behavioral
 

health workers and counselors
 

210 
 

 

 

 

 

 

Index 

Health Insurance Portability and


Accountability Act (HIPAA), 49


health issues. See mental disorders, cooccurring; physical health problems, cooccurring

Health Resources and Services 

Administration (HRSA), 40


hepatitis, 18, 82


heterosexism and homophobia, 6–7, 55


Hispanic/Latino Americans, 96, 99–100. See 


also culture and ethnicity


Historical-Clinical Risk Management


instrument, 22


HIV/AIDS, 18, 23, 45, 54, 57, 61, 63, 82, 84,
 

93
 

homelessness, xviii, 17, 45, 92–94, 93
 

homophobia and heterosexism, 6–7, 55


homosexuality. See gay and bisexual men
 

I
 

ideologies of masculinity, 3–4


Improving Cultural Competence (planned TIP),
 

15, 26, 95–96


incarceration. See criminal justice system


independence, as masculine trait, 7


individual therapy, 106–7


inpatient treatment, 115–18


Institute of Medicine, 14


Integrating Substance Abuse Treatment and

Vocational Services (TIP 38), 17, 91


Internalized Shame Scale, 25
 

Internet and sexuality, 56


interviewing, motivational, 112


invulnerability and concepts of masculinity, 5–6
 

J 

jail. See criminal justice system

Jewish Alcoholics, Chemically Dependent

Persons, and Significant Others, 122


Johnson Institute intervention, 109–110, 111


Just Detention Web site, 57
 

L 

Latino Americans, 96, 99–100. See also culture 

and ethnicity 

LifeRing Secular Recovery, 122


loss and rejection, coping with, 43–44
 

M 

Male Role Norms Inventory, 20


Male Role Norms Scale, 20


Managing Chronic Pain in Adults With or in


Recovery From Substance Use Disorders (TIP 


54), 18


Managing Depressive Symptoms in Substance 


Abuse Clients During Early Recovery (TIP 


48), 18–19, 75, 77


mandated treatment, 112–113


manic depression (bipolar disorder), 77–78


marijuana, 8, 10, 34, 48, 54, 89, 90, 96, 98, 102,
 

123
 

marketing of drugs, 123–24


masculinity, concepts of, xv, 1–11


aggression, fearlessness, and

invulnerability, 5–6


community influences on, 123


competition and success, 5


defining, 2


emotional restraint, 5


greater risk of substance abuse for men


and, xiv, 8–10, 10
 

health care, men less likely to seek, 6


heterosexism and homophobia, 6–7, 55


ideologies and stereotypical 


characteristics, 3–4


independence and self-sufficiency, 7


personal assessment of, 20–21


rituals and rites of passage, 4–5, 9


sex versus gender, 2


sexual accomplishment, 6–7


socialization of males and, 8


specialized services for men, need for, 10–


11
 

value of, 7–8


Matching Alcoholism Treatments to Client


Heterogeneity Project, 42


MDMA (3,4-methylenedioxymethamphetamine or ecstasy), 53, 55


medical care, men less likely to seek, 6, 68
 

211 
 

 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

medical care providers, xiv, 11. See also
 

behavioral health workers and counselors
 

medical issues. See mental disorders, cooccurring; physical health problems, cooccurring

Medication-Assisted Treatment for Opioid


Addiction in Opioid Treatment Programs


(TIP 43), 16


Meghan’s Laws, 49


Men’s behavioral health needs, xiii–xix, 1–11


adult men over age 18, focus on, xiv


defining sex versus gender, 2


masculinity concepts and, xv, 1–11. See 


also masculinity, concepts of


screening and assessment of, xv–xvi, 13–


26. See also screening and assessment


in specific populations, xvii–xviii, 67–100.


See also specific populations of men


substance abuse and. See substance abuse
 

treatment issues, xvi–xvii, 27–66. See also
 

treatment issues
 

treatment methods, xviii–xix, 101–124.


See also treatment methods
 

Men’s Trauma Recovery and Empowerment


Model (M-TREM), 71, 72
 

mental disabilities
 

Substance Use Disorder Treatment for
 

People With Physical and Cognitive


Disabilities (TIP 29), 18, 84, 85


traumatic brain injury, 85


mental disorders, co-occurring, xvii–xviii, 67–

82
 

anxiety disorders, 69–75


criminal justice system and, 95


Diagnostic and Statistical Manual of


Mental Disorders, 4th Edition, Text 


Revision, xiv, 2–3, 73, 74, 76, 78, 79
 

eating disorders, 79


emotional restraint, 40


functional limitations due to, 18


gender-aware personal assessment, 18–19


Managing Depressive Symptoms in 


Substance Abuse Clients During Early


Recovery (TIP 48), 18–19, 75, 77


men less likely to seek treatment for, 68
 

mood disorders, 75–78, 76
 

mutual-help groups, 122


pathological gambling, 78–79


personality disorders, 76, 77, 79–81, 80
 

risk of substance abuse and, 67–68


schizophrenia, 78


screening and assessment, 68, 68–69
 

shame associated with, 68


Substance Abuse Treatment for Persons With
 

Co-Occurring Disorders (TIP 42), 16,
 

68, 79, 82, 117


suicidality, xviii, 18, 75, 81–82, 82, 83, 97
 

methamphetamines, 9, 10, 48, 50, 53, 87, 89,
 

96, 97, 98, 100


Military OneSource, 74


mixed-gender group therapy, 104


mixed-gender treatment settings, 115


modalities of treatment, 102–103. See also
 

treatment methods 

money management and financial training,

114–115
 

mood disorders, 75–78, 76
 

motivation to change


enhancement techniques, 111–113

Enhancing Motivation for Change in


Substance Abuse Treatment (TIP 35), 29,
 

31, 111, 112


gender-aware personal assessment of, 19


interviewing, motivational, 112


male treatment-seeking behaviors, 28–30


mutual-help groups, 111, 118–122, 119. See 

also 12-Step groups 

N 

Narcotics Anonymous (NA). See 12-Step 


groups


National Association for Children of
 

Alcoholics, 107


National Center for Cultural Competence,


Georgetown University, 26


National Center for Injury Prevention and


Control, CDC, 82


National Center for PTSD, 74


National Center on Substance Abuse and
 

Child Welfare toolkit (SAMHSA), 62
 

212 
 

 

 

 

 

 

 

 

Index 

National Comorbidity Study, 80


National Epidemiologic Survey on Alcohol 


and Related Conditions (NESARC), 69,


80, 89


National Institute on Alcohol Abuse and
 

Alcoholism (NIAAA), 16, 17, 88, 93, 124
 

National Institute on Drug Abuse (NIDA), 


17, 105
 

National Survey of Drug Use and Health


(NSDUH), SAMHSA, 8, 10, 88, 90–91,


95, 97


National Survey of Homeless Assistance 


Providers and Clients, 92


National Treatment Improvement Evaluation


Study, 106


National Treatment Improvement Evaluation


Study (SAMHSA, 2001), 39


National Violence Against Women Survey 


(2000), 49, 50


Native Americans, 96, 97–98. See also culture 

and ethnicity

network therapy, 108–109

“New to VA” Web site, 92
 

node-link maps, 31, 32
 

nonrelational sex, 6


nurturing, male need to learn, 43
 

O 

Oakland Men’s Project, 47


obsessive–compulsive personality disorder


(OCPD), 80


obsessive–compulsive disorder (OCD), 69,


75–76
 

older men (65 and up), xviii, 77, 87–89, 115


online sexual activity, 56


opioids, 9, 10, 16, 48, 54, 96, 102, 109


outpatient treatment, 115–118 

P 

Pacific Islanders, 96, 98. See also culture and
 

ethnicity


parenting responsibilities, xvii, 60–63, 61, 62. 


See also families and significant others


partners and significant others. See families ad 

significant others 

Partners for Recovery Web site, SAMHSA,

123
 

pathological gambling, 78–79


personal assessment


gender-aware, 14, 15, 17–20


male-specific, 19, 20–26


personal relationships, 65–65


personality disorders, 76, 77, 79–81, 80
 

physical health problems, co-occurring, xviii,


82–84 

Addressing Viral Hepatitis in People 


With Substance Use Disorders (TIP


53), 82


disabilities, men with, 84


functional limitations due to, 18


gender-aware personal assessment, 18


hepatitis, 18, 82


HIV/AIDS, 18, 23, 45, 54, 57, 61, 63, 82,


84, 93


mutual-help groups, 122


Substance Use Disorder Treatment for
 

People With Physical and Cognitive

Disabilities (TIP 29), 18, 84, 85


suicidality and, 82


traumatic brain injury, 85


pornography, 56


posttraumatic stress disorder (PTSD), 19, 59,


70–73, 72
 

pricing of drugs, 123–124


primary care providers, 11, 14, 18


prison. See criminal justice system


Prison Rape Elimination Act of 2003, 57


problem assessment, 14–15, 16–17, 20


“Project Mainstream,” 40


prostitution, 56–57


A Provider’s Introduction to Substance Abuse
 

Treatment for Lesbian, Gay, Bisexual, and


Transgender Individuals (CSAT, 2001), 55,
 

89
 

psychiatric problems. See mental disorders, co-


occurring


psychiatrists and psychologists, 11
 

R 

racial groups. See culture and ethnicity 

213 
 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

rape and sexual abuse of adult men, 57, 70


readiness for treatment, evaluating, 20


Real Warriors, 92
 

records, confidentiality of, 49


Recovery in Behavioral Health Services (planned
 

TIP), 19, 114, 118–119


Recovery-Oriented Systems of Care (ROSC)


initiative, SAMHSA, 123


recovery support, 19, 113–114, 118–119, 123,


124
 

recruiting male behavioral health counselors,


39–40 

rejection and loss, coping with, 43–44

relapse and relapse prevention, xix, 113–114

community influences, 123


domestic violence and, 49


gender-aware personal assessment, 19


personal relationships and, 65–65


recovery support, 19, 113–114, 118–119,


123, 124


residual effects of substance abuse, living


with, 124


religion. See spirituality and religion


reproductive responsibility, 63


reproductive system, effects of substance abuse 


on, 53–54


research on men and substance abuse, 11


residential programs, 116–117


residual effects of substance abuse, living with,


124
 

resistance to treatment, 27–28, 29


Revised Conflict Tactics Scale, 22


Risk for Sexual Violence Protocol, 22


risk-taking or sensation-seeking, 5–6, 23, 24
 

rituals and rites of passage, 4–5, 9, 44, 86
 

S 

“Safe at Home” Instrument, 22


schizophrenia, 78


Screening and Assessing Adolescents for Substance 


Use Disorders (TIP 31), xiv


screening and assessment, xv–xvi, 13–26


comprehensive three-step process, 14–15


cultural issues affecting, 14, 15


defined and differentiated, 13–14
 

gender-aware personal assessment, 14, 15,


17–20
 

male-specific personal assessment, 19, 20–


26
 

male versus female responses to, 14


mental disorders, co-occurring, 68, 68–69
 

persons conducting, 14, 15


problem assessment, 14–15, 16–17, 20


purpose of, 13


readiness for treatment, 20


screening procedures, 14, 15–16


settings for, 16


suicidality, 82, 83
 

time frame and order of procedure, 19–20


Secular Organizations for Sobriety (SOS),

121, 122


Seeking Safety model, 73


Self-Management and Recovery Training


(SMART Recovery), 121, 122


self-sufficiency, as masculine trait, 7


settings for treatment, 115–118


sex trade workers, 56–57


sex versus gender, 2


Sexual Compulsivity Scale, 23


Sexual Risk Scale, 23


Sexual Sensation Seeking Scale, 23


Sexual Violence Risk-20 instrument, 22


sexuality


assessing current physical or sexual 

violence in client’s family, 22–23

childhood sexual abuse, clients with

histories of, 57–59


Internet and pornography, 56


male reproductive system, effects of


substance abuse on, 53–54


male-specific personal assessment of, 23


masculinity concepts and sexual 


accomplishment, 6–7


nonrelational sex, 6


problems with sexual performance and


sexual dysfunction, 55


rape and sexual abuse of adult men, 57, 70


reproductive responsibility and, 63


risky behavior, men more likely to engage 


in, 6
 

214 
 

 

 

 

 

 

Index 

sexual identity, 23, 54–55


stress and anxiety associated with, 23


substance abuse and compulsive sexual 


behavior, 52–53


transference, sexualized, 34–35


as treatment issue, xvii, 52–59


violence and, xvi, 6, 51–52


shame
 

case study (Harry), 46


disruptive behavior in group settings due 


to, 46
 

male-specific personal assessment, 23–26,


25
 

mental disorders, co-occurring, 68


sexual identity and, 54


stigma versus, 45


as treatment issue, xvi, 44–46


significant others. See families and significant
 

others
 

sildenafil (Viagra), abuse of, 55


Simple Screening Instruments for Outreach for


Alcohol and Other Drug Abuse and Infectious 


Diseases (TIP 11), 16


single-gender group therapy, 103–104


social phobia, 69, 74


social workers, 11. See also behavioral health 


workers and counselors
 

socialization of males, 8


socioeconomic status (SES), 79, 90, 97
 

specialized services for men, need for, 10–11


specific populations of men, xvii–xviii, 67–100.


See also criminal justice system; culture and

ethnicity; employment and career-related

issues; gay and bisexual men; mental 

disorders, co-occurring; physical health

problems, co-occurring; trauma histories,

men with; veterans

age-related issues, xviii, 86–89


geographic region, 100


men who are homeless, xviii, 17, 45, 92–


94, 93
 

older men, xviii, 77, 87–89, 115


systems-related needs and issues, xviii,


92–95
 

young men, xviii, 8, 86–87
 

spirituality and religion


defining and distinguishing, 65
 

faith-based organizations and programs, 


11
 

gender-aware personal assessment, 19


as treatment issue, xvii, 65, 65–66
 

in 12-Step groups, xvii, 65, 120, 121


Spirituality Competency Resource Center, 19


sponsorship and 12-Step groups, 120–121


Spousal Assault Risk Assessment Guide, 22


stages of change model, 22


state anger, 42


State Shame and Guilt Scale, 25
 

State-Trait Anger Expression Inventory-2, 22


stigma versus shame, 45


Strategic Planning Initiative (SAMHSA,


2003), 40


substance abuse
 

co-occurring disorders. See mental 

disorders, co-occurring; physical health

problems, co-occurring

defined, xiv, 2–3


differences between male and female 


substance abusers, 8–10, 10
 

male reproductive system, effects on, 53–


54
 

masculinity and, xv. See also masculinity,
 

concepts of


men at greater risk for, xiii–xiv, xiv–xv, 8–


10, 10
 

prevention programs, 11


residual effects, living with, 124


rituals and rites of passage associated with


alcohol, 4–5, 9, 86


screening and assessment of, xv–xvi, 13–


26. See also screening and assessment

sexual compulsivity and, 52–53

specialized services for men, need for, 10–

11
 

in specific populations, xvii–xviii, 67–100.


See also specific populations of men


training for male-specific treatment, 11


treatment issues, xvi–xvii, 27–66. See also
 

treatment issues 

215 
 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

treatment methods, xviii–xix, 101–24. See 


also treatment methods
 

treatment providers, 11


Substance Abuse: Administrative Issues in
 

Intensive Outpatient Treatment (TIP 46), 115


Substance Abuse Among Older Adults (TIP 26),
 

88
 

Substance Abuse and Mental Health Services 


Administration (SAMHSA)


Addressing Viral Hepatitis in People With


Substance Use Disorders (TIP 53), 82


anger management curriculum, 42, 43


Addiction Technology Transfer Centers,


11, 40


Behavioral Health Services for American
 

Indians and Alaska Natives (planned
 

TIP), 97


Get Connected! Linking Older Adults With


Medication, Alcohol, and Mental Health


Resources toolkit (2003), 88


interagency portal, 122


mission of, xi


National Center on Substance Abuse and
 

Child Welfare toolkit, 62


National Treatment Improvement


Evaluation Study (2001), 39


National Survey of Drug Use and Health,


8, 10, 88, 90–91, 95, 97


Partners for Recovery Web site, 123


Recovery-Oriented Systems of Care 


initiative, 123


Strategic Planning Initiative (2003), 40


Supportive Education for Children of


Addicted Parents toolkit, 62


Treatment Episode Data Set, 2006, 10,


91, 92, 95, 99


Substance Abuse: Clinical Issues in Intensive
 

Outpatient Treatment (TIP 47), 16, 115


Substance Abuse Treatment: Addressing the


Specific Needs of Women (TIP 51), xiii, 1


Substance Abuse Treatment and Domestic
 

Violence (TIP 25), 22, 49


Substance Abuse Treatment and Family Therapy


(TIP 39), 21, 31, 51, 109
 

Substance Abuse Treatment for Adults in the
 

Criminal Justice System (TIP 44), 15, 47–48,
 

94
 

Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36), 19,
 

21, 22, 49, 59


Substance Abuse Treatment for Persons With Co-


Occurring Disorders (TIP 42), 16, 68, 79, 82,
 

117
 

Substance Abuse Treatment for Persons With
 

HIV/AIDS (TIP 37), 23, 82, 84


Substance Abuse Treatment: Group Therapy


(TIP 41), 103


Substance Use Disorder Treatment for People


With Physical and Cognitive Disabilities


(TIP 29), 18, 84, 85
 

success and competition, masculine 


importance of, 5


suicidality, xviii, 18, 75, 81–82, 82, 83, 97
 

Supportive Education for Children of Addicted 

Parents toolkit (SAMHSA), 62
 

systems-related needs and issues, xviii, 92–95
 

T 

Target Cities Treatment Enhancement


Project, Los Angeles, 103


Test of Self-Conscious Affect-3, 25
 

therapeutic communities (TCs), 81, 87, 94,


116–17
 

Time Out! For Men, 104, 105
 

training in treatment of substance abuse in


men, 11


trait anger, 42


transference, 33–37

transition into mutual-help groups, 119, 121
 

trauma histories, men with, 16, 19. See also
 

childhood abuse and neglect


Alcohol and Other Drug Screening of


Hospitalized Trauma Patients (TIP 16),
 

16
 

Childhood Trauma Interview, 22


combat stress reaction, 73–74


Men’s Trauma Recovery and


Empowerment Model, 71, 72
 

216 
 

 

 

 

 

 

 

Index 

posttraumatic stress disorder, 19, 59, 70–


73, 72
 

Trauma-Informed Care in Behavioral Health
 

Services (planned TIP), 19, 71, 73


traumatic brain injury (TBI), 85
 

Treatment Episode Data Set (TEDS),


SAMHSA, 10, 91, 92, 95, 99


Treatment Improvement Protocols (TIPs)


Addressing Suicidal Thoughts and Behaviors 


in Substance Abuse Treatment (TIP 50),
 

18, 82


Alcohol and Other Drug Screening of


Hospitalized Trauma Patients (TIP 16),
 

16
 

Behavioral Health Services for People Who


Are Homeless (TIP 55), 17


Brief Interventions and Brief Therapies for


Substance Abuse (TIP 34), 31


Continuity of Offender Treatment for


Substance Use Disorders From Institution
 

to Community (TIP 30), 15, 94
 

defined, ix, xi


Detoxification and Substance Abuse
 

Treatment (TIP 45), 102


Enhancing Motivation for Change in


Substance Abuse Treatment (TIP 35), 29,
 

31, 111, 112


A Guide to Substance Abuse Services for
 

Primary Care Clinicians (TIP 24), 14,
 

16
 

Improving Cultural Competence (planned
 

TIP), 15, 26, 95–96


Integrating Substance Abuse Treatment and


Vocational Services (TIP 38), 17, 91


Managing Chronic Pain in Adults With or


in Recovery From Substance Use


Disorders (TIP 54), 18


Managing Depressive Symptoms in 


Substance Abuse Clients During Early


Recovery (TIP 48), 18–19, 75, 77


Medication-Assisted Treatment for Opioid


Addiction in Opioid Treatment Programs


(TIP 43), 16


Recovery in Behavioral Health Services


(planned TIP), 19, 114, 118–119
 

Screening and Assessing Adolescents for


Substance Use Disorders (TIP 31), xiv


Simple Screening Instruments for Outreach


for Alcohol and Other Drug Abuse and


Infectious Diseases (TIP 11), 16


Substance Abuse: Administrative Issues in
 

Intensive Outpatient Treatment (TIP 


46), 115


Substance Abuse Among Older Adults (TIP 


26), 88


Substance Abuse: Clinical Issues in Intensive
 

Outpatient Treatment (TIP 47), 16, 115


Substance Abuse Treatment: Addressing the


Specific Needs of Women (TIP 51), xiii, 1


Substance Abuse Treatment and Domestic
 

Violence (TIP 25), 22, 49


Substance Abuse Treatment and Family


Therapy (TIP 39), 21, 31, 51, 109


Substance Abuse Treatment for Adults in the
 

Criminal Justice System (TIP 44), 15,
 

47–48, 94


Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36),
 

19, 21, 22, 49, 59


Substance Abuse Treatment for Persons With
 

Co-Occurring Disorders (TIP 42), 16,
 

68, 79, 82, 117


Substance Abuse Treatment for Persons With
 

HIV/AIDS (TIP 37), 23, 82, 84


Substance Abuse Treatment: Group Therapy


(TIP 41), 103


Substance Use Disorder Treatment for People


With Physical and Cognitive Disabilities


(TIP 29), 18, 84, 85
 

Trauma-Informed Care in Behavioral
 

Health Services (planned TIP), 19, 71,
 

73
 

Treatment of Adolescents With Substance
 

Use Disorders (TIP 32), xiv


treatment issues, xvi–xvii, 27–66


anger management, 42, 43, 48, 52


childhood abuse and neglect, clients with


histories of, xvi–xvii, 57–59, 59
 

countertransference techniques, 35–37
 

217 
 

 

 

 

 

 

 

 

 

 

 

 

Addressing the Specific Behavioral Health Needs of Men 

discomfort with treatment and treatment 

providers, 27–30, 29
 

emotional restraint, xvi, 40–44, 41, 43


engagement of male clients, 29–31, 30
 

family issues, xvii, 59–65, 61, 62


gender bias and stereotyping, 31–33, 33
 

gender of behavioral health workers and


counselors, 26, 31–40, 52


male treatment-seeking behaviors, 28–30


nurturing and avoidance of violence,


learning, 43


readiness for treatment, evaluating, 20


rejection and loss, coping with, 43–44


resistance to treatment, 27–28, 29


sexual issues and problems, xvii, 52–59


sexuality and violence, xvi


shame, xvi, 44–46


spirituality and religion, xvii, 65, 65–66
 

transference, 33–37


violence, men with histories of, xvi–xvii,


46–52
 

visual representation, male response to,


30, 31
 

treatment methods, xviii–xix, 101–124. See also
 

relapse and relapse prevention

coercion, 112–113

community influences and, 122–124

detoxification, 19, 101–102

family and couples therapy, xix, 107–111,

110
 

family interventions, xix, 109–111


group therapy, xviii–xix, 103–106, 105
 

individual therapy, 106–7


inpatient, 115–118


modalities, 102–103


money management and financial


training, 114–115


motivation to change, enhancing, 111–


113
 

mutual-help groups, 111, 118–122, 119. 


See also 12-Step groups


posttraumatic stress disorder, 71–73, 72
 

recovery support, 19, 113–114, 118–119


residual effects of substance abuse, living


with, 124
 

settings, 115–118


therapeutic communities, 81, 87, 94, 116–


117
 

training for male-specific treatment, 11


Treatment of Adolescents With Substance Use
 

Disorders (TIP 32), xiv


treatment providers, 11. See also behavioral
 

health workers and counselors
 

12-Step groups, 119–121


anger management and, 42


behavioral health workers and counselors 


and transition into, 119, 121
 

nurturing and avoidance of violence, 43


rituals and rites of passage, 4–5, 44


shame, as treatment issue, 46
 

social phobia and, 74


spiritual element of, xvii, 65, 120, 121


sponsorship, 120–121
 

U 

unemployment, xviii, 91. See also employment
 

and career-related issues
 

unilateral family therapy (UFT), 111


University of Texas–Austin Center for Social 


Work Research, 16, 17


University of Washington Alcohol and Drug


Abuse Institute, 16


U.S. Department of Veterans Affairs (VA),


xviii, 71, 74, 91, 92
 

V
 

veterans, xviii, 91–92


combat stress reaction, 73–74


homelessness and, 92


posttraumatic stress disorder, 70–71


traumatic brain injury, 85
 

U.S. Department of Veterans Affairs and,

xviii, 71, 74, 91, 92
 

Viagra (sildenafil), abuse of, 55


violence. See also childhood abuse and neglect;


domestic violence and child abuse
 

aggression, fearlessness, and


invulnerability as masculine traits, 5–6


anger management, 42, 43, 48, 52, 113
 

criminal behavior, 46–48
 

218 
 

 

Index 

emotional restraint and, 5

men as victims of, xvi–xvii, 22, 46–47, 49–

50, 51 57, 70

nurturing and avoidance of violence,

learning, 43

rape and sexual abuse of adult men, 57, 70

rejection and loss, coping with, 43–44

sexual violence, xvi, 6, 51–52

treatment issues for men with histories of,

xvi–xvii, 46–52


in treatment situations, 52


young men and, 86


viral hepatitis, 82 

visual representation, male response to, 30, 31 

W 

White Americans, 96, 98–99. See also culture 

and ethnicity

wives, partners, and significant others. See 

families and significant others

work-related issues. See employment and 

career-related issues 

Y 

young men, xviii, 8, 86–87 

219 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CSAT TIPs and Publications Based on TIPs 

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that

brings together clinicians, researchers, program managers, policymakers, and other Federal and nonFederal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under

CSAT’s Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol 

and drug abuse treatment service system. 

What Is a Quick Guide? 

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information. 

What Are KAP Keys? 

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is 

fastened together with a key ring and can be kept within a treatment provider’s reach and consulted frequently.The Keys allow you, the busy clinician or program administrator, to locate information easily and

to use this information to enhance treatment services. 

Ordering Information 

Publications may be ordered for free at http://store.samhsa.gov. To order over the phone, please call

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Most publications can also be downloaded 

at http://kap.samhsa.gov. 

TIP 1	 State Methadone Treatment Guidelines— TIP 9 Assessment and Treatment of Patients With 

Replaced by TIP 43 Coexisting Mental Illness and Alcohol and

TIP 2 Pregnant, Substance-Using Women—Replaced Other Drug Abuse—Replaced by TIP 42 

by TIP 51 TIP 10 Assessment and Treatment of CocaineTIP 3 Screening and Assessment of Alcohol- and Abusing Methadone-Maintained Patients— 

Other Drug-Abusing Adolescents—Replaced Replaced by TIP 43 

by TIP 31	 TIP 11 Simple Screening Instruments for Outreach

TIP 4	 Guidelines for the Treatment of Alcohol- and for Alcohol and Other Drug Abuse and

Other Drug-Abusing Adolescents—Replaced Infectious Diseases—Replaced by TIP 53 

by TIP 32	 TIP 12 Combining Substance Abuse Treatment With

TIP 5	 Improving Treatment for Drug-Exposed Intermediate Sanctions for Adults in the 

Infants—BKD110 Criminal Justice System—Replaced by TIP 44 

TIP TIP 13 6 Screening for Infectious Diseases Among Role and Current Status of Patient Placement 

Criteria in the Treatment of Substance Use Substance Abusers—Archived
 

Disorders—BKD161
 TIP 7	 Screening and Assessment for Alcohol and Quick Guide for Clinicians QGCT13 Other Drug Abuse Among Adults in the Quick Guide for Administrators QGAT13 Criminal Justice System—Replaced by TIP 44 KAP Keys for Clinicians KAPT13 

TIP 8 Intensive Outpatient Treatment for Alcohol

and Other Drug Abuse—Replaced by TIPs 46 TIP 14 Developing State Outcomes Monitoring

and 47 Systems for Alcohol and Other Drug Abuse

Treatment—BKD162 

221 
Behavioral Health Services for People Who Are Homeless 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIP 15	 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

TIP 16	 Alcohol and Other Drug Screening of

Hospitalized Trauma Patients—(SMA) 12­

3686 

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16 

TIP 17	 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 18	 The Tuberculosis Epidemic: Legal and Ethical 

Issues for Alcohol and Other Drug Abuse 

Treatment Providers—Archived 

TIP 19	 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45 

TIP 20	 Matching Treatment to Patient Needs in

Opioid Substitution Therapy—Replaced by 

TIP 43 

TIP 21	 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the 

Justice System—(SMA) 12-4073

Quick Guide for Clinicians and

Administrators QGCA21 

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43 

TIP 23 Treatment Drug Courts: Integrating

Substance Abuse Treatment With Legal Case 

Processing—(SMA) 12-3917

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians—(SMA) 08-4075

Concise Desk Reference Guide BKD123 

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24 

TIP 25	 Substance Abuse Treatment and Domestic 

Violence—(SMA) 12-4076

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Treatment Providers MS668 

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Administrators MS667 

Quick Guide for Clinicians QGCT25

KAP Keys for Clinicians (SMA) 12-3584 

TIP 26	 Substance Abuse Among Older Adults— 

(SMA) 12-3918

Substance Abuse Among Older Adults: A

Guide for Treatment Providers MS669 

Substance Abuse Among Older Adults: A

Guide for Social Service Providers MS670 

Substance Abuse Among Older Adults:

Physician’s Guide MS671 

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26 

TIP 27	 Comprehensive Case Management for

Substance Abuse Treatment—(SMA) 12­

4215 

Case Management for Substance Abuse

Treatment: A Guide for Treatment Providers 

MS673 

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

MS672 

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27 

TIP 28 Naltrexone and Alcoholism Treatment— 

Replaced by TIP 49 

TIP 29	 Substance Use Disorder Treatment for People 

With Physical and Cognitive Disabilities— 

(SMA) 12-4078

Quick Guide for Clinicians QGCT29

Quick Guide for Administrators (SMA)

08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30	 Continuity of Offender Treatment for

Substance Use Disorders From Institution to 

Community—(SMA) 12-3920

Quick Guide for Clinicians QGCT30

KAP Keys for Clinicians KAPT30 

TIP 31	 Screening and Assessing Adolescents for

Substance Use Disorders—(SMA) 12-4079

See companion products for TIP 32. 

TIP 32	 Treatment of Adolescents With Substance 

Use Disorders—(SMA) 12-4080

Quick Guide for Clinicians QGCT312

KAP Keys for Clinicians KAPT312 

TIP 33	 Treatment for Stimulant Use Disorders— 

(SMA) 09-4209

Quick Guide for Clinicians QGCT33

KAP Keys for Clinicians KAPT33 

TIP 34	 Brief Interventions and Brief Therapies for

Substance Abuse—(SMA) 12-3952

Quick Guide for Clinicians QGCT34

KAP Keys for Clinicians KAPT34 

222 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIP 35	 Enhancing Motivation for Change in 


Substance Abuse Treatment—(SMA) 12­

4212
 

Quick Guide for Clinicians (SMA) 12-4097


KAP Keys for Clinicians (SMA) 12-4091
 

TIP 36	 Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues—(SMA) 12­

3923
 

Quick Guide for Clinicians QGCT36


KAP Keys for Clinicians KAPT36


Helping Yourself Heal: A Recovering Woman’s


Guide to Coping With Childhood Abuse 


Issues (SMA) 08-4132


Available in Spanish: PHD981S


Helping Yourself Heal: A Recovering Man’s


Guide to Coping With the Effects of


Childhood Abuse (SMA) 08-4134


Available in Spanish: PHD1059S
 

TIP 37	 Substance Abuse Treatment for Persons With
 

HIV/AIDS—(SMA) 12-4137


Quick Guide for Clinicians MS678


KAP Keys for Clinicians KAPT37


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide (SMA) 08-4127


Available in Spanish: PHD1134


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide for African Americans (SMA) 07-4248
 

TIP 38	 Integrating Substance Abuse Treatment and


Vocational Services—(SMA) 12-4216


Quick Guide for Clinicians QGCT38


Quick Guide for Administrators QGAT38


KAP Keys for Clinicians KAPT38
 

TIP 39	 Substance Abuse Treatment and Family


Therapy—(SMA) 12-4219


Quick Guide for Clinicians QGCT39


Quick Guide for Administrators QGAT39
 

TIP 40	 Clinical Guidelines for the Use of
 

Buprenorphine in the Treatment of Opioid


Addiction—(SMA) 07-3939


Quick Guide for Physicians QGPT40


KAP Keys for Physicians KAPT40
 

TIP 41	 Substance Abuse Treatment: Group


Therapy—(SMA) 12-3991


Quick Guide for Clinicians (SMA) 12-4024
 

TIP 42	 Substance Abuse Treatment for Persons With
 

Co-Occurring Disorders—(SMA) 12-3992


Quick Guide for Clinicians (SMA) 07-4034


Quick Guide for Administrators (SMA) 12­

4035
 

KAP Keys for Clinicians (SMA) 08-4036
 

TIP 43	 Medication-Assisted Treatment for Opioid


Addiction in Opioid Treatment Programs—
 

(SMA) 12-4214


Quick Guide for Clinicians QGCT43


KAP Keys for Clinicians (SMA) 07-4108
 

TIP 44	 Substance Abuse Treatment for Adults in the 


Criminal Justice System—(SMA) 12-4056


Quick Guide for Clinicians QGCT44


KAP Keys for Clinicians (SMA) 07-4150
 

TIP 45	 Detoxification and Substance Abuse
 

Treatment—(SMA) 12-4131


Quick Guide for Clinicians(SMA) 06-4225


Quick Guide for Administrators (SMA) 06­

4226
 

KAP Keys for Clinicians (SMA) 06-4224
 

TIP 46	 Substance Abuse: Administrative Issues in
 

Outpatient Treatment—(SMA) 12-4157


Quick Guide for Administrators (SMA) 07­

4232
 

TIP 47	 Substance Abuse: Clinical Issues in
 

Outpatient Treatment—(SMA) 12-4182


Quick Guide for Clinicians (SMA) 07-4233


KAP Keys for Clinicians (SMA) 07-4251
 

TIP 48	 Managing Depressive Symptoms in Substance


Abuse Clients During Early Recovery—
 

(SMA) 12-4353
 

TIP 49	 Incorporating Alcohol Pharmacotherapies


Into Medical Practice—(SMA) 12-4380


Quick Guide for Counselors (SMA) 10-4542


Quick Guide for Physicians (SMA) 10-4543


KAP Keys for Clinicians (SMA) 10-4544
 

TIP 50	 Addressing Suicidal Thoughts and Behaviors


in Substance Abuse Treatment—(SMA) 09­

4381
 

TIP 51	 Substance Abuse Treatment: Addressing the


Specific Needs of Women—(SMA) 09-4426
 

TIP 52	 Clinical Supervision and Professional 


Development of the Substance Abuse 


Counselor—(SMA) 09-4435
 

TIP 53	 Addressing Viral Hepatitis in People With


Substance Use Disorders—(SMA) 11-4656
 

TIP 54	 Managing Chronic Pain in Adults With or in


Recovery From Substance Use Disorders—
 

(SMA) 12-4671
 

TIP 55 Behavioral Health Services for People Who


Are Homeless—(SMA) 13-4734
 

TIP 56 Addressing the Specific Behavioral Health


Needs of Men—(SMA) 13-4736
 

223 
HHS publication no. (SmA) 13-4736

First Printed 2013

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and mental Health Services Administration

center for Substance Abuse Treatment