The reason he won't go back to therapy
- Brad Sorte
- 5 days ago
- 7 min read
KEY TAKEAWAYS
Therapy was built by men when women were excluded from the profession.
Women transformed the field starting in the 1970s. The workforce is now 75-82% female.
Managed care made it cheaper to pay psychiatrists for 15-minute med visits. Therapy got handed to other disciplines.
44.8% of men drop out of therapy. 55% say they couldn't connect with the clinician.
Men die by suicide at nearly 4x the rate of women. Over half had recent contact with mental health services.
The problem isn't the men. It's the room.
A wife contacted us about her husband. He was 38, two kids, solid career. He'd been to three therapists over four years and couldn't tell you why he stopped seeing any of them. That's the part people miss. It's never a blowup. Nobody storms out. It's a canceled session that doesn't get rescheduled. A voicemail that doesn't get returned. Six weeks go by, and the therapist closes the file. He tells his wife it ran its course. I've been doing this work for over twenty years, and I can tell you that phrase, "it ran its course," is how men say "I sat in a room and had no idea what I was supposed to be doing in there."
What his wife noticed was everything around the edges. The drinking wasn't falling-down drunk. It was a second bourbon becoming a third becoming a fourth, on a school night, alone in the kitchen after the kids went to bed. He wasn't mean to his children. He was just less there. Less patient over homework. Checking his phone during dinner. Walking out of the room mid-sentence. She said she couldn't name when it started. It was like the temperature changed so slowly she didn't realize the house was cold until she could see her breath.
When we asked her what she observed during the times he was actually attending therapy, she thought about it for a while and said: "I think he really did go. I think he sat in those rooms and tried. I just don't think he knew what he was supposed to talk about, if that makes any sense."
It makes complete sense. I hear some version of that sentence almost every week.
A 2021 study of 1,907 men found a therapy dropout rate of 44.8%. More than a quarter attended one session and never returned. The most common reason: they couldn't connect with the therapist (Seidler et al., 2021). Men who reported feeling emasculated by the process were significantly more likely to quit.
When nearly half of men leave therapy before completing it, the question the field has been slow to ask is whether the problem is the men or the model. The answer involves a hundred-year structural shift that nobody planned.
A brief history of who therapy was built for
Psychotherapy was developed by men. Freud, Jung, Adler, and their contemporaries built the foundations of talk therapy in the late 19th and early 20th centuries, working primarily with male patients and constructing theory around male psychology.
This was not a reflection of clinical insight. It was a reflection of who held power. Women could not vote in Austria until 1918. Freud published The Interpretation of Dreams in 1899. Women were excluded from medical schools, universities, and professional life. When they appeared in the clinical literature, they were frequently subjects of study rather than recipients of care. The diagnosis of "hysteria," applied almost exclusively to women, pathologized female distress rather than treating it.
The correction
Beginning in the 1970s, women entered the mental health professions in numbers that transformed the field. This was among the most important developments in the history of clinical care.
In 1971, women earned approximately 45% of psychology bachelor's degrees in the United States. By 2020, that figure reached 79.3% (AEI/NCES). At the doctoral level, women represented 33% of new psychology PhDs in 1976 and 75% by 2017 (Frontiers in Psychology). Master's programs now enroll roughly 80% women (APA Monitor). In social work, women represent 82% of the profession, and among social workers under 34, men account for less than 10% (BLS).
What women brought to the profession was critical and overdue: relational attunement, emotional processing, reflective listening, and a clinical posture that prioritized the therapeutic relationship as a primary mechanism of change. Research consistently identifies the therapeutic alliance as the strongest predictor of treatment outcomes across modalities (Wampold, 2015). That emphasis on relational connection did not come from Freud. It came from the women who rebuilt the field after they were finally allowed inside it.
Millions of people have gotten better because of what women brought to clinical practice. That is the foundation everything below rests on.
The unintended consequence
As the workforce changed, the training culture changed with it. No one made a deliberate decision to orient therapy around a particular way of processing distress, but the defaults shifted. The standard therapeutic frame today, the fifty-minute session built around open-ended questions, reflective silence, and invitations to explore feelings, emerged from a clinical culture that is now 75-82% female (APA, 2017).
For many clients, this approach works well. For a meaningful number of men, it does not. They experience the standard therapeutic posture as evaluative, performative, or simply foreign. They sense that there is a correct answer to "How does that make you feel?" and they do not have it. After several sessions of this, they conclude that therapy does not work for them.
A 2025 study found that therapists' own endorsement of traditional masculinity ideologies correlated with worse perceived outcomes for their male clients (Logoz et al., 2025), suggesting the mismatch operates on both sides of the relationship.
His second therapist wrote "resistant to emotional processing" in her notes. What she meant was he sat there and couldn't do the thing the room was asking him to do. What he told his wife was simpler: "I don't know what I'm supposed to say in there."
The role of managed care
A second structural shift compounded the problem. For decades, psychiatrists provided both medication management and psychotherapy. Managed care in the 1990s changed the economics: it was cheaper to reimburse psychiatrists for 15-minute medication visits and pay lower-cost clinicians for the therapy hour.
A Columbia University study tracking data from 1996 to 2016 found that the percentage of psychiatrist visits involving psychotherapy dropped by half, falling to 21.6% (Tadmon et al., Columbia). Over half of U.S. psychiatrists no longer practice any psychotherapy (ScienceDaily).
Therapy was effectively transferred to the disciplines that had grown fastest in female representation. The people prescribing stopped relating. The people relating were trained in a clinical culture that had, without intention, moved away from the men who struggled most to engage.
The cost of the gap
Men die by suicide at nearly four times the rate of women. Over half had contact with mental health services in the 12 months before their death (AFSP, Seidler et al., 2022). They entered the system. Something about the system did not hold them. How we got to this point, from Freud through managed care to the present, is a longer story worth understanding.
He wasn't in crisis. He'd just quietly closed the door on the idea that anyone could help. Three therapists, four years, nothing. At some point you stop blaming the therapists and start blaming yourself. That's the dangerous part.
What we do differently
Action before insight. Each session produces a concrete task. A conversation to have, a pattern to observe, a behavior to change. Insight tends to emerge as a byproduct of behavior change rather than a prerequisite for it.
Directness inside relationship. "Here's what I think is happening. Here's the pattern I see. Here's where the data suggests this goes if nothing changes." That level of candor, delivered inside a genuine relationship, can produce more movement in one session than months of reflective listening.
Integrated systems coordination. Our client's psychiatrist saw him for twelve minutes. His therapist saw him for fifty. Neither spoke to each other. We coordinate across clinical, medical, and environmental dimensions so everyone is working from the same framework.
Accountability as care. The men who make the most sustained progress are those who feel appropriately challenged. Not shamed. Pushed. Once trust exists, most men want someone who will call them on their patterns.
The outcome
The husband whose wife contacted us has been working with our team for seven months. He engages weekly. His wife describes a version of her husband she hadn't seen since before their wedding.
He didn't need to be fixed. He needed a room that was built for how his mind actually works.
If your family is navigating something similar, contact YES Family Consulting.
This article is adapted from Brad's ongoing work on The Wanting Economy, a forthcoming book exploring how systems designed to help people often fail the people who need them most. The extended version of this argument, including the workforce data, managed care economics, and what Freud and Jung got wrong, is available here.
Sources
Seidler, Z.E., Wilson, M.J., Kealy, D., Oliffe, J.L., Ogrodniczuk, J.S., & Rice, S.M. (2021). Men's Dropout From Mental Health Services: Results From a Survey of Australian Men Across the Life Span. American Journal of Men's Health, 15(3). https://journals.sagepub.com/doi/full/10.1177/15579883211014776
Logoz, M. et al. (2025). Psychotherapists' Endorsement of Traditional Masculinity Ideologies and Their Assessment of Gender Differences in the Treatment of Depressive Disorders. Counselling and Psychotherapy Research. https://onlinelibrary.wiley.com/doi/abs/10.1002/capr.70008
Wampold, B.E. (2015). How Important Are the Common Factors in Psychotherapy? An Update. World Psychiatry, 14(3), 270-277. https://pmc.ncbi.nlm.nih.gov/articles/PMC4592639/
Tadmon, D. et al. (2021). Psychiatrists Providing Talk Therapy Declined by Half Since the 1990s. Columbia University Department of Psychiatry. https://www.columbiapsychiatry.org/news/psychiatrists-providing-talk-therapy-declined-half-1990s
Psychiatrists providing talk therapy declined by half since 1990s (2021). ScienceDaily. https://www.sciencedaily.com/releases/2021/12/211208110244.htm
Moffic, H.S. (2019). The Changing Face of Psychiatry Over 50 Years: Remembering Integrities Lost and Found. Psychiatric Times. https://www.psychiatrictimes.com/view/changing-face-psychiatry-over-50-years-remembering-integrities-lost-and-found
Perry, M.J. (2021). Animated Chart of the Day: Female Share of U.S. Bachelor's Degrees, 1971-2020. American Enterprise Institute / NCES data. https://www.aei.org/carpe-diem/animated-chart-of-the-day-female-share-of-us-bachelors-degrees-1971-to-2020/
Willyard, C. (2011). Men: A Growing Minority. American Psychological Association Monitor on Psychology, 42(6). https://www.apa.org/monitor/2017/07-08/women-psychology
APA Center for Workforce Studies (2018). Doctoral-level psychology education data. APA Monitor on Psychology, December 2018. https://www.apa.org/monitor/2018/12/datapoint
Lau, A. & Stevens, H.B. (2022). The Gender Gap in Psychology: A Bibliometric Analysis. Frontiers in Psychology, 13. https://pmc.ncbi.nlm.nih.gov/articles/PMC9302360/
Bureau of Labor Statistics / Mic.com: Gender demographics in social work professions. https://www.mic.com/articles/30974/almost-82-percent-of-social-workers-are-female-and-this-is-hurting-men
American Foundation for Suicide Prevention. Suicide Statistics. https://afsp.org/suicide-statistics/
Seidler, Z.E. et al. (2022). Protocol for a randomized controlled trial of the Men in Mind training for mental health practitioners. BMC Psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9288021/
