There is value in men putting aside some focused time to get to know, befriend and build an emotional vocabulary. Like learning any language, it is not a question of capacity - it is about putting aside time to become fluent in this particular language.

• An emotion is our physiological response to a stimuli, event or thought. Essentially, it is invisible.
  
• What we label emotions influences how we respond to them.
  
• Some emotions are not easily identified.
  
• Emotions are not discrete - sometimes you can feel a range of emotions at the same time. 
  
• Sometimes you can feel a range of ‘competing’ emotions at the same time. 
  
• When uncertain, going in search of what a man is ‘really feeling’ or identifying the ‘core feeling’ can limit rather than expand options. However, in some instances, identifying a ‘primary’ feeling can be useful and allow some focused work.  
  
• Emotions are not facts!
  
• There are no right or wrong emotions. No feelings are negative - just difficult.
  
• People’s responses to emotions are different and can change. What is difficult for one man may be okay for another, and what is difficult in one context may not be in another.
  
• “Good”, “okay” or “bad” are not emotional states, they are judgements or evaluations of emotional states.
  

As identified above, expanding a person’s emotional awareness and vocabulary increases their ability to manage emotional responses in all their intensity. The greater our emotional awareness and vocabulary, the more able we are to select the best tools or options to respond to a particular situation or challenge. To better understand what men are feeling, and their different responses to these feelings, it is useful for practitioner’s to work with men in increasing their emotional awareness and vocabulary. Practitioners might introduce a ‘Feelings’ handout and ask men to consider:

• Are you familiar with all these feelings? 
  
• Are you more familiar with some feelings than others? 
  
• Are there some feelings that are easier to express than others? 
  

Resources

• Cloitre, M., Cohen, L., & Koenen, K. (2006). Treating surivivors of childhood abuse: Psychotherapy for the interrupted life. New York, USA: The Gilford Press. 
  
• List of Emotions: Byron Katie. https://www.thework.com/downloads/work sheets/Emotions_and_Reactions.pdf
  
• Field of feelings: http://www.livingwell.org.au/relationships/men-emotions-and-child-sexual-abuse-or-sexual-assault/field-of-feelings/  
  

At times, men who have been sexually abused can feel overwhelmed, and think that the difficulties they face in recognising and responding to emotions are because of an individual, personal inadequacy and failure. This can add to a sense of personal damage and a diminished life. This is why it is important to map out the challenges men who have been sexually abused face in understanding and responding to emotions, as it highlights the complexity of what they are confronted by.

Dealing with strong emotions - One of which is anger

Men who have been sexually abused or sexually assaulted identify having to deal with strong emotions, such as anger, sadness, fear/anxiety and shame. These are emotions that men worry will completely overwhelm their resources to cope, and lead to them feeling and ‘being’ out of control. Of these emotions, anger is the one that is typically associated with ‘being a man’ (anger has been described as an ‘active emotion’ and men are meant to be ‘active, doers’ that make things happen). Many men will be familiar with anger. They may be able to identify it more easily than other emotions, and provide accounts of how they have dealt with, managed, expressed or not expressed anger at different times and in different contexts. There is a challenge in working with men to build emotional literacy in ways that acknowledges the subject of anger, without foregrounding it as ‘the’ central aspect of emotional work with men.  

Of those survivors who told us about impacts in private sessions, 20.4 per cent spoke about aggression as an outcome of abuse. More male (26.4 per cent) than female survivors (9.3 per cent) discussed aggression as an outcome. This is consistent with research that suggests men may be more likely than women to manifest externalising symptoms of trauma, such as anger, aggression and ‘acting out’, whereas women may manifest internalising symptoms such as anxiety. (p. 92, Royal Commission Final Report, Vol. 3: Impacts)

The relationship between men and anger is complex. Anger, the emotion, is not bad or good in itself; it's different from ‘aggression’, which can be one of the ways of expressing anger. Anger can be evoked when someone is acting against our values, when we witness an injustice, someone is being harmed, or when we think about our self being harmed. While some men who have been abused will have developed a habit of expressing anger in aggressive forms, sometimes to protect themselves when they feel threatened, some men will shy away from anger and any form of aggressive expression. When anger appears, there can be other emotions around, which, because of the presence and men’s familiarity with anger, do not become acknowledged or recognised. In talking with men about anger (including when introducing models, such as the emotional ‘funnel’ or ‘iceberg’) it is useful to focus on increasing emotional literacy, expanding awareness, and the ability to identify a range of emotions that may be present: 

“I am so glad for these professionals I have now, because they have really challenged me to learn not everything’s called “anger”, some things are called “frustration”, some things are called “annoying”… I mean you’re not always mad. So for me being a man, I didn’t know that, I was, like pissed off. There was rage and there was anger. Then there were other feeling you didn’t talk about like intimacy, love, that mushy stuff.” Teram et al (2006)

Men and their bodies

In developing awareness and skills for distress tolerance and emotional regulation, men are invited to increase their awareness of and connection with their bodies. As the process model below identifies, an emotion is our physiological response to a stimulus, event or thought. Hence, developing awareness and better managing emotions involves paying attention to our body and its responses. Paying attention to and listening to their bodies is something some men may not have spent a lot of time doing, especially when you consider that men’s relationships with their bodies are often presented as one of controlling and conquering the body.

According to this script, men are meant to be rational, logical, and in charge of their bodies; ‘mind over matter’, ‘no pain, no gain’. Many men, particularly older men, will be becoming aware of the cost of not paying attention or taking care of their bodies, in terms of health costs, injuries and pain. However, talking about men’s bodies and inviting men to develop greater awareness of bodily responses can still be an uncomfortable conversation for some men. Men are more likely than women to be discouraged to consider the mind-body link, and find it difficult to link physiological reactions to emotions.

Physical signs of different emotions

Depending on men’s emotional literacy, it can be useful to map out and discuss:

• What are the physical signs that you are feeling anxiety? 
  
• What are the physical signs that you are feeling anger? 
  
• What are the physical signs of feeling sadness? 
  
• What are the physical signs of feeling shame?
  
• Where do you feel each of these emotions in your body?
  

To support a discussion of the bodily experience of emotion, it can be useful to introduce images of the body atlas, where scientists have mapped how a range of emotions appear and are expressed in different parts of the body. In presenting these images, it is useful to note that every person is different and may experience and feel emotions in different places. The key is for individuals to develop and maintain awareness of their body’s reactions to, and signs of, different emotions.

Emotional awareness and physiological responses

Practitioners should work in partnership with men in relation to developing ‘bodily awareness’ of their emotions, bringing men’s awareness into the here and now, and enhancing their competence in better managing their emotions. Rothschild (2000) suggests prompting the client initially using questions that they are later able to adapt.

• What are you aware of in your body right now?
  
• It looks like you may be experiencing strong emotions, what is happening for you physiologically?
  
• Were you aware your breathing had changed when you mentioned…?
  
• What feeling were you experiencing when you started moving around in your seat?
  
• What is occurring physically that is suggesting to you that you are feeling sad, fearful, agitated?
  

Improved emotional awareness will be demonstrated by a person’s ability to:

1. Be aware of emotional changes in response to particular stimuli;
   
2. Identify emotional responses and differentiate between emotions with similar levels of intensity, such as anger and fear;
   
3. Identify potential triggers that may precede particular emotions. 
   

Process model of expression and non-expression of emotions

The Process Model of Emotional Expression and Non-expression, with its description of a five-step cognitive-evaluative process, can offer a useful framework to discussing emotional expression with men in order to increase their understanding. This articulation of emotional expression within a staged framework is useful, in that it allows for an initial ‘cognitive’ discussion of emotional expression that acknowledges cultural influences, gender experiences and individual agency. The practical break down (Chart, Framework, Map) resonates well with many men, because it provides an introductory map by which they can make sense of the process of expressing emotions - where to date it may have been unknown/mysterious territory or something to be avoided. It can be demystifying for men, in a way that supports them to identify, value and appreciate emotions, and to experience a sense of choice and how they respond and express them.

Step 1.	Pre-reflective reaction	A potentially emotion-provoking stimulus activates a primary effective state and an accompanying physiological arousal in a person (largely preconscious).
Step 2.	Awareness of affective response	The man typically becomes consciously aware of this experience, however, the training men have received to repress negative or vulnerable emotions may stop them from acknowledging these emotions.
Step 3.	Labelling and interpretation of response	If the man becomes conscious of an emotional response he will typically attempt to label it – ‘I feel angry’.
Step 4.	Evaluation of response as acceptable	Once labelled, emotions are evaluated in terms of beliefs and values to determine if they are acceptable to their understanding of self.
Step 5.	Perceived social context for expression	Even if acceptable, an evaluation is then made of the social context to determine how expression of these emotions will be received and the potential impact on self-prior to any expression.

This process model highlights how individual knowledge and experience, gender expectations, and sense of self, culture and context shape men’s recognition and response to emotions. It provides a guide for some of the terrain and steps to navigate in developing an emotionally engaged life. Men seem to like it because, like an instruction or car mechanics manual, it breaks down and identifies different elements and details of a complex process that can occur in a nano second without conscious thought, and how that process fits together and operates. Some men appreciate the opportunity to adopt a ‘scientific’, thoughtful approach to managing emotions, to practice strategies that chart emotions on a visual scale, or by creating a log or written account. When talking with men about emotions, practitioners should be mindful that a male client’s inexpressiveness is a strength that can be used to help them deal with problems. For example, just stuffing things down and remaining calm and problem focused in times of crisis is a useful skill to possess (Wong & Rochlen, 2005).

Note: physical expression of emotions as a form of cathartic release has been found to be of questionable value in the absence of a time spent on cognitive processing (Lewis & Butcher, 1992).

Practitioner video

This video provides a look at clinical experience regarding the experience of emotions when working with men.

Introduction to managing emotions through distress tolerance and emotional regulation

Below is a limited discussion on the introduction of distress tolerance and emotional regulation. It is understood that practitioners will obtain appropriate training and qualifications prior to introducing these interventions and accompanying strategies. 

Distress tolerance

Distress tolerance is a valuable skill to possess for managing emotions and getting on with life. Developing distress tolerance techniques help to manage and reduce ‘acute, destabilizing emotions and symptoms’ that present in response to trauma stimuli (Briere & Scott, 2006). For men who have been sexually victimised, the suggestion of increasing emotional expression and distress tolerance as a means to manage emotions can feel counter-intuitive. Especially when, in accordance with the male code expectations, they have expended considerable effort in trying to avoid, suppress, contain and minimise expression of distress (fearful that emotions will overwhelm their resources and disempower them). However, there is a cost to this constant effort to contain emotions:

• It uses up a lot of energy
  
• It can increase the sense of pressure of not coping
  
• It can increase the intensity of emotions
  
• It obstructs experiencing positive feelings
  
• It provides a barrier to achieving the individuals identified goals
  
• It contributes to the perpetuating cycle of PTSD symptoms (Cloitre et al., 2006).
  

Resisting tension reduction behaviours

Tension reducing and avoidant behaviours may be deeply ingrained in an individual’s sense of coping, and brought to the client’s attention through emotional awareness. The success of tension reduction behaviours can be such that the individual may not have had an opportunity to challenge their ability to sit with distress, anxiety, anger, fear etc. Resisting tension reduction behaviours is a skill aimed at ‘holding off’ for as long as possible on maladaptive or negative coping strategies (Briere and Lanktree, 2012). It can provide someone with an opportunity to:

1. Evaluate levels of distress they are experiencing
2. Build on their ability to tolerate distress
3. Provide an example of the lack of catastrophe resulting from experiencing their distress
4. Improved confidence in their capabilities to sit with distressing feelings, thoughts etc. 
5. Increase a positive sense of self and view of self as self-sufficient and capable.

Example: For many individuals the first day of school was likely met with anxiety, fear, excitement and distress. However, by being encouraged to tolerate the distress by parents, teachers, friends or siblings and walk into the classroom, we were able to participate in the first day of school. This often led to the knowledge that perhaps school was not as scary as first perceived, and made each day easier to attend before we reassessed school attendance as a tolerable event.

Sitting with distress may be framed through the concept of ‘suffering’, and may be used in conjunction with deep breathing or acceptance of negative emotions (Cloitre et al., 2006). As men begin to practice tension reduction behaviours, the fear of emotional overwhelm will decrease, and they will likely experience a sense of increased control over their emotions and trauma related behaviours. Through this process of developing distress tolerance, men are supported in ‘releasing the pressure in the pressure cooker’.

As a means to increase men’s awareness and attention to stress and distress in the body, it is useful to invite men to introduce mindfulness practices as part of a daily routine. Establishing healthy routines and mindfulness practice (like Body scan) are particularly useful, in that when someone is feeling overwhelmed by emotions and thoughts, it is not the time to be introducing something new. Some men can relate, and prefer to call this quiet time. Routines, such as Yoga, Thai Chi and Pilates are useful in building men’s awareness and connection with their bodies (and, in the case of yoga, in managing the effects of trauma). See section on Useful Strategies to follow.

In noting the value of developing emotional awareness and distress tolerance strategies, there is no suggestions that men ‘should’ be able to reach a kind of ‘Zen’ like space, where they feel untouched by distress, or live constantly with high levels of distress. Distress tolerance is about acknowledging distress, hurt and pain and making room for it, which sometimes will involve crying and emotionally ‘letting go’. In so doing, the person themselves does not become lost. For some men who have been sexually abused, the development of distress tolerance skills can be appealing, in that it can increase a sense of personal competency and ability to cope, a sense of robust self, and of being a man who can manage difficult experiences and situations. Having noted the value of accepting and being emotionally present, it is equally important to develop knowledge and skills in managing emotions through emotional regulation.

Managing emotions through emotional regulation

Knowledge and skills in managing emotions through emotional regulation are useful and a valuable addition to someone’s life skills tool box.

Emotional regulation is concerned with increasing an individual’s capacity to regulate distressing feeling states, reducing the likelihood of someone becoming emotionally overwhelmed (Briere & Lanktree, 2012). Emotional regulation is not only important for increasing a sense of competence and self control in managing distressing emotions, (Cloitre et. al., 2013), but is also a necessary skill to sustain feelings which encourage a full and rich engagement in life.

Prior to introducing any intervention, time should be taken to identify currently utilised affect regulation strategies that the client has engaged in, and to support them in evaluating their ability to reduce intensely emotive states (Cloitre et al., 2006). Approaching this through discussion and reflection, or through a reflection handout, provides the client with a clear summary of skills they currently have in their toolbox, as well as an indication of their effectiveness, and whether this is considered a helpful or unhelpful strategy. 

The Skills Training in Affective and Interpersonal Regulation (STAIR) framework outlined by Cloitre, et al. (2006), is a useful a platform for men to develop skills in emotional regulation. The STAIR triad model is interested in the interplay of awareness of emotional changes in the body state, the interpretation or understanding of the ‘reason’ for the feeling, and subsequent behavioural responses:

• Physiological change: One or more noticeable bodily changes/sensations
  
• Cognitive interpretation: How you understand the physiological change
  
• Behaviour: The action you choose to take.
  

This structured intervention approach moves beyond developing awareness of emotional responses and increasing emotional vocabulary, and towards developing emotional monitoring behaviours, to identifying patterns and actively increasing skills in managing emotions.

Developing emotional monitoring behaviours

Developing emotional monitoring skills involves the use of records or diaries over a period of weeks, to identify feelings, their intensity, triggers and associated behaviours. In addition to continued practice of monitoring behaviours and skill development, this intervention should engage the client to explore patterns in their emotional states (Cloitre et al., 2006). Within the STAIR framework, this is referred to as the ‘Self-monitoring of feelings form’. Variations of this include monitoring observations recorded verbally or in a journal, scheduled at specific times of the day and utilised scaling. Additional to the discussion about monitoring behaviours, Briere and Lanktree (2012) strongly encourage the use of regular and scheduled time to ‘check in’ during appointments, to reinforce reflection of emotion states in the here and now while increasing their emotional vocabulary.

Similarly, traditional Cognitive Behavioural Therapy (CBT) may lend resources to the recognition of causal relationships between thoughts, feelings and behaviours that will assist in identification and naming emotions. The ‘ABC model of thinking and feeling’ provides a clear framework for men to identify the relationship between feelings and physiological reactions as a result of behaviours or actions.

Resources: Copy of ‘Self-monitoring of feelings form’ and ‘ABC model of thinking and feeling’

Cognitive behavioural therapy and STAIR

Cognitive skill development, focusing on identifying and countering thoughts, forms the basis of both the CBT and STAIR frameworks. Building on awareness developed through the self-monitoring of feelings record (STAIR) or the ABC model of thinking and feeling (CBT), the client is encouraged to start active in identifying the unhelpful thoughts that may precede overwhelming emotional states. Given the popularity of this principal strategy in cognitive behavioural therapies, discussion will be brief. 

• Following identification of the unhelpful thought it is challenged, to encourage the client to de-catastrophize, neutralise, and, if possible, introduce a positive self-statement to combat the thought. This requires a firm grasp on self-monitoring behaviours and, if successful, will engage the client in a more stabilised way of thinking, thus reducing intense emotional states. 
  
• Briere and Lanktree (2012) identify that the influence of cognitions should not be underestimated, and that recognition and countering the thought that mediates between a trigger and a trauma-related emotion can increase emotion regulation. 
  
• Through this process, assist the client to develop insight into triggers of overwhelming emotions: thoughts, behaviours or event in the external environment. This will significantly benefit the client to stabilise feelings, thoughts and behaviours associated with nightmares, flashbacks and dissociation.
  

Resources

A number of resources are available via Cognitive Behavioural Therapy Self Help Resources or Psychology Tools. 

Engaging in emotional regulation can be challenging

The concept of enhancing skills to regulate emotion can be overwhelming and challenging for some people who report struggling with the idea that:

1. Distress reduction involves rejection, denial or avoidance of feelings.
   
2. Distress reduction oversimplifies or trivialises feelings.
   
3. Trauma is invalidated due to the belief their suffering is a testament to what they experienced.
   
4. Positive emotion work is incompatible with real life.
   
5. Positive emotions are inconsistent with their view of self and self-worth.
   
6. Creating positive emotions is not genuine (Cloitre et al., 2006).
   

Moving from emotional regulation towards emotionally engaged living

Emotional Regulation involves helping clients slow down and to recognise the interplay between ‘feelings’, ‘thoughts’, and ‘actions’. Additionally, emotion regulation acts to:

• Introduce positive emotions and plan pleasurable activities.
  
• Introduce useful strategies for responding to the three channels of emotions:
  
• Physiological channel: Focused breathing and other relaxation techniques.
  
• Cognitive channel: Attention shifting, calling a friend, planning a holiday or recalling past events, counting by sevens, utilising positive visualisation.
  
• Behavioural channel: take time out, cleaning your home, do pleasurable or neutral activity to distract attention from distress.
  
• Develop skills for Distress Tolerance and Acceptance of Negative Feelings (eg. Acceptance Commitment Therapy: ACT). 
  
• Skills in emotional regulation, self-calming and self-soothing are building blocks for emotionally engaged living and positive relationships. (Cloitre, Cohen & Koenen, 2006).
  

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) strategies are based in the acceptance of difficult emotions and symptoms as an expected feature of complex trauma (Courtois & Ford, 2013).

• Success of skill development in this area is reliant on effective psychoeducation on complex trauma symptomology, and identification of the individual’s related emotions/symptoms as such.
  
• Reframing these emotions as difficult to manage by understandable responses to trauma has been shown to be associated with relief and reduced distress, and increased emotional stability. 
  
• This strategy may be particularly successful with men regarding feelings associated with anger, anxiety and depression. O’Leary and Gould (2010) identify that men tend to naturally subscribe to acceptance strategies to manage complex trauma symptomology rather than the emotion based strategies women favour. Given this, men may find this a useful addition to their toolbox of resources or a modification on an existing strategy. 
  

Medication

For some men, the fluctuating and overwhelming nature of post trauma symptoms can lead to a significant sense of distress and helplessness. The use of medication may be encouraged to stabilise the dysregulated emotional state in conjunction with therapeutic intervention. While some debate remains around the value of medication to treat post trauma symptoms, Briere and Scott (2006) suggest psychoactive medications can assist in reducing anxiety and hyperarousal, however medications should not be relied upon as a ‘cure-all’ for dysregulated emotional states.

In addition to standard information regarding medication, one should be mindful to communicate:

• The use of medication is dependent on client choice.
  
• Medication is not prescribed to compromise control of their health, increase avoidance behaviours or facilitate dissociation.  
  
• Medication is utilised as a measure to assist regulation of post trauma symptoms and is complimented by psychological interventions.
  

When exploring medical intervention as an option for emotion regulation, care should be taken to avoid reinforcing shame and guilt that may be experienced by the client, regarding their inability to self-regulate their emotions. Additionally, impact of previous substance use/abuse as a contraindication for medication should be assessed. Until fairly recently, many clients were prescribed medication in the Benzodiazeprine family – these are highly addictive and can take many years to exit; the SSRI class of medicine is now what is regularly prescribed by conscientious health professionals.

 

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Men and Managing Emotions

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