‘It's all about rapport’: Australian therapists' recommendations for engaging adolescent males in counselling and psychotherapy

Objective: What are the recommendations provided by Australian therapists to engage and retain adolescent males in psychotherapy? This question is considered in


| INTRODUC TI ON
Australia aligns with global trends that show young males are reluctant to seek out, engage and remain in psychological treatment (Burke et al., 2022;de Haan et al., 2013).However, this developmental period appears critical for the trajectory of young men's mental well-being (Rice, Purcell, & McGorry, 2018), with approximately half of all mental health disorders developed by the age of 18 years and the peak age of onset being 14.5 years (Solmi et al., 2022).Despite this, young Australian males are a group at high risk of experiencing psychological distress yet are the least likely of any demographic group to seek out and engage with professional mental health services (Islam et al., 2020;Slade et al., 2009).When young males do seek help, they attend fewer sessions than females (Seidler et al., 2020) and are more likely to discontinue therapy prematurely (de Haan et al., 2013).
The construct of masculinities remains a key determinant of young men's limited uptake of and engagement with mental health services (Rice, Purcell, & McGorry, 2018).In Western societies, socialisation to traditional masculine ideals of self-reliance, dominance and stoicism remains socially esteemed and internalised by young men (Evans et al., 2011;Kågesten et al., 2016).Qualitative studies have described how Australian young men view contact with mental health practitioners as akin to weakness, preferring to remain self-reliant and avoid feelings of shame that may accompany seeking help (Clark et al., 2018).When they do engage, young men have reported unfamiliarity with the process and tasks of therapy, and unease discussing emotions (Rice, Telford, et al., 2018), highlighting an apparent mismatch between psychotherapy and young men's preferences and relational styles (Kiselica, 2003).This mismatch has prompted calls for gender-sensitive adaptions to psychotherapy with young men to address the relative disparities in young men's uptake of and retention in psychological services (Rice, Purcell, & McGorry, 2018;Robertson et al., 2015).
In response to these calls, recent guidelines for psychological practice with boys and men have been produced espousing male-friendly adaptations (American Psychological Association [APA], 2018).Male-friendly counselling is considered a therapeutic approach that acknowledges the impact of masculinities and addresses men's reluctance to engage in psychotherapy by utilising interventions that appeal to them and their relational styles (Brooks, 2010;Kiselica, 2005).Scholarly reviews of male-friendly counselling with adult males have highlighted how adaptions to practice focus on appealing to men's preferences, such as utilising an action-oriented, problem-focussed approach, strength-based assessment and tailoring language to incorporate humour and self-disclosure to build connection (Beel et al., 2018;Seidler et al., 2018).However, primary data in these reviews were scarce, with the bulk of included texts being commentaries emanating from the United States.This is consistent with a review of male-friendly counselling with adolescent males, which highlighted a gap in both primary qualitative research and research outside the United States for this population (Boerma et al., 2023).As such, region-specific primary research from other Western nations is presently lacking.
Investigating therapist perspectives from other countries, such as Australia, is one avenue of research that may contribute to both knowledge of region-specific male-friendly practices and broader scholarly recommendations for counselling adolescent males from various cultural perspectives.Therapists' perspectives in qualitative research aid in identifying therapist factors and therapeutic approaches that facilitate or impede psychological treatment (Campbell & Simmonds, 2011;Ryan et al., 2021).Although a multicultural nation comparative to other Western nations, Australia maintains unique idealised hegemonic masculinities characterised by self-reliance, durability and nonchalant attitudes that are expected of males, both individually and as a group (Sharp et al., 2023).In part, adherence to these idealised Australian masculinities may both contribute to the reticence of some young men to engage in psychotherapy and influence how Australian therapists relate to and approach counselling with this population.Although two previous studies were identified that explored Australian therapists' perspectives on counselling adult men (Beel et al., 2020;Seidler et al., 2021), to our knowledge, no previous research has examined the experiences of Australian-based practitioners who provide psychotherapy to adolescent males.This aligns with broader research, indicating a gap in the literature of practitioners' perspectives of adapting counselling to the needs of young men (Grace et al., 2018;Johansson & Olsson, 2013).

| Aims
Despite the availability of mental health services, adolescent males underutilise and prematurely drop out of psychological treatment.

Implications for Practice
• Male-friendly counselling practices can be incorporated into any counselling or psychotherapeutic encounter with adolescent males, regardless of the therapeutic modality used or the specific training of the mental health practitioner.
• Placing particular emphasis on rapport building and gaining commitment from adolescent males may benefit the engagement of young men in therapy.
• Interpersonal adjustments and deliberate interpersonal interactions by therapists framed through the knowledge of masculinity and gender socialisation may assist therapists in facilitating psychological safety for young male clients.

Implications for Policy
• This qualitative study is the first to explore recommendations from a diversity of Australian mental health practitioners who work with adolescent males.As such, the results both inform Australian perspectives and permit comparison with broader global research on malefriendly counselling.
• Therapists' current practice with adolescent males was largely informed by their previous clinical experience rather than from current practice guidelines or gendersensitive training.Further research is needed to develop gender-sensitive guidelines that are informed by the experiences and perspectives of mental health practitioners who work with adolescent males.
Therefore, exploring the experiences of Australian therapists may elucidate salient recommendations for male-friendly psychotherapy with adolescent males.The aim of this study was to complete an initial exploration of male-friendly practices derived from the experiences of a diversity of Australian therapists who provide psychotherapy to young men.The guiding research question was as follows: What are the thematic recommendations provided by Australian therapists to engage adolescent males in counselling?

| Design
This research collected a diverse range of data from mental health practitioners providing counselling to adolescent males in Australia.
To achieve this, a cross-sectional, qualitative online survey was conducted.This method allows shared patterns of meaning to be generated across a diversity of therapists' experiences, perspectives and geographical locations (Braun & Clarke, 2021;McEvoy et al., 2021).
The survey was first piloted with mental health practitioners (four psychologists, two counsellors and one social worker) to confirm that the survey questions were understandable and relevant to their practice (Braun et al., 2021).The study also adhered to the Consolidated Criteria for Reporting Qualitative Research (CORE-Q) checklist (Tong et al., 2007).
Participants first answered questions relating to demographic information, professional practice and whether they had completed specific training for counselling adolescent males.Participants then responded to open-ended questions related to their experiences and recommendations for engaging adolescent males (Table 1).
Notably, two questions included in the survey were as follows: 'In your opinion, what things do you think are likely to be unhelpful in therapy when counselling adolescent males?' and 'In your opinion, what things do you think are likely to be helpful in therapy when counselling adolescent males?', which were adapted from the seminal American practitioner survey on helpful practices for working with males (Mahalik et al., 2012).Participants were provided an indefinite word limit for qualitative responses to provide as much depth as they liked.

| Participants
Purposive sampling was used to recruit practitioners through professional association publications and social media groups.The inclusion criteria for participation included the following: identifying as a mental health practitioner, working in Australia and regularly providing individual therapy services (incl.telehealth) to adolescent males aged 12-18 years.Of the 104 participants who started the survey, 67 completed the full questionnaire, with their responses included in the final analysis.The final sample size is considered mid-range for this study following Braun et al.'s (2021) suggested guidance for text-based, qualitative research data.Participants were aged between 25 and 68 years (M age = 42.64,SD = 11.43) and predominantly women (n = 59).The majority were psychologists (n = 35, 52%).Most participants practised in metropolitan areas (68%), in education (39%) or in private practice (36%), and most worked with clients in individual therapy (95%), with only a few indicating a combination of individual therapy and other formats (e.g., groups and assessments).Notably, 23 therapists indicated that they had a special interest in working with adolescent males, while 36 indicated a neutral interest and eight indicated no specific interest.Clinical experience (73%), supervision (58%) and independent learning/professional development (59%) were cited as primary sources of learning for understanding and counselling adolescent males in therapy.Full participant characteristics are presented in Table 2.

| Data collection
Ethics approval was obtained by the University of Southern Queensland Human Research Ethics Committee (#H22REA100).
Approval to promote the study was also obtained from the major associations representing mental health professionals in Australia.The

| Data analysis
The qualitative analysis software NVivo (v12) was used to code and classify data and develop themes.Inductive reflexive thematic TA B L E 1 Qualitative questions on the therapists' experiences of counselling adolescent males in Australia.S1 for analytic process).

| RE SULTS
Three themes and 10 subthemes were developed from the data set and are depicted in Figure 1.The themes are presented in a linear yet expectedly iterative progression from the commencement of therapy to continued therapeutic interactions.The themes highlight the need for therapists to (1) create a context of safety within their therapeutic work with adolescent males; (2) undertake practices that develop rapport and engagement; and (3) enact masculinityaware adaptions to tailor the process and tasks of therapy to the needs of young men.

| Theme 1: Create a context of safety
A core notion held by many participants was the necessity for therapists to create a therapeutic space in which adolescent males felt psychologically safe and accepted such that they may express openly without feeling judged.A salient aspect of participants' responses was that although many of the recommendations provided and detailed in the proceeding theme could be regarded as conventional aspects of good practice, an awareness of masculinity perceived as threatened and unsafe in the therapeutic space was a consideration that was interwoven throughout many responses.Respondents described how attending counselling may violate traditional norms of masculinity for young men, such as toughness, stoicism and control.
Thus, establishing a safe space was considered a necessary precur-   (P37-F-social worker) The notion of flexibility in therapists' perspectives and practice was emphasised by participants to accommodate the preferences of young men.Adaptability in response to each client's relative tolerance for assessment questions, emotive language and session duration was seen to increase the client's sense of comfortability in the therapy space: Being flexible to work together in a way that makes them feel most comfortable, which should be the starting point of building a trusting relationship.

| Be aware of your own assumptions and stereotypes of adolescent males
Participants advised that therapists should first reflect upon their own assumptions of adolescent males and the attitudes they hold towards masculinity.They described how therapists are not immune to holding critical assumptions and biases towards young men as a result of their own socialisation and suggested that unexamined and unfettered judgements impact the sense of safety and acceptance young men perceive in treatment: Leave your assumptions at the door.They deserve for us to take their unique identity and sense of masculinity with sincerity and respect, just like we would anyone else.The boys I have worked with have 'grown' the most when they are allowed to be themselves and the therapy room not being another arena of criticism and stereotypes.
(P67-F-social worker) Some negative stereotypes raised by participants included placing blame on young men for the challenges they are experiencing and their reluctance to receive support, the assumption that young males have deficits in their emotionality and that young men are often seen by therapists as '…future therapy failures' (P67).The implication of these descriptions is that if therapists do not consciously consider their implicit biases, they could inadvertently reproduce invalidating environments within the therapy space, thereby perpetuating gendered stereotypes and compromising the sense of safety for young men as clients.As such, participants  (P46-F-psychologist)

| Demonstrate therapeutic relational qualities
As a response to acknowledging potential biases and stereotypes therapists may have towards young men, participants emphasised that interactions with male clients should be underpinned by an authentic, warm and non-judgemental approach.Many participants recognised the hazard in disconnecting from a therapeutic stance of empathy and unconditional positive regard and reverting to more judgemental interactions characterised by criticism and condescension: Judgment will not help.Accept them as they are (while seeing their potential and holding hope for a better future). (P50-F-psychologist) One respondent spoke of the importance of explicitly communicating her stance towards issues and behaviours that may be sensitive for young men, such as substance use, which remains a concerning health challenge for this population (AIHW, 2021a): I also found it's very important to communicate I won't judge them about drug use, which is high, particularly in the Trades students. (P33-F-psychologist) For this participant, the antidote to judgement is curiosity, allowing male clients to appraise their behaviours and their typical coping strategies in a safe and supportive environment: 3.1.4| Establish the therapy space as safe to express Many participants resolved that connecting with and verbalising emotions remains a core aspect of effective therapy yet explained that many young men present as ill-equipped, aversive or resistant to engaging with their emotional selves.This was attributed to restrictive norms of masculine socialisation, reinforced by societal and peer expectations, that young men should conceal vulnerability and emotional expression to not appear weak.Hence, adolescent males may attend therapy ashamed and highly sensitive to the unspoken expectation to verbalise emotions and physically emote during therapy: They have been socialised to not share and their development emotionally may have been impacted by this, so they need to be taught what emotions are. (P39-F-psychologist) Respondents took the position that the reason why many young men struggle with expressing their emotions is not due to a deficit in capacity, but rather a deficit in practice expressing a range of emotions.
Thus, this premise inevitably implies that young men can expand their emotional literacy, yet participants cautioned that this would only succeed if young men perceived the therapist as safe to express with: They can and will talk, if you take the time to create the right conditions for them; you need to overcome their (often) lack of experience having conversations about emotional and social situations. (P47-M-psychologist) Participants spoke of gradually incorporating emotional language into the discussion of events and consequences of significance to their clients.Participants highlighted the importance of therapists modelling appropriate emotional expressiveness and monitoring their own reactions to spontaneous displays of emotions in their clients to facilitate a sense of safety in vulnerability.Finally, participants described how therapy can be a unique opportunity for young men to safely reflect upon their idiosyncratic masculine identity and evaluate the assumptions they may hold that impede their willingness to express and seek out support: You have stacks of things to sift through -mostly peer, (P2-F-counsellor) Overall, the participants highlighted the importance of therapists creating a safe and accepting environment for adolescent males in therapy.This includes avoiding critical assumptions and stereotypes and demonstrating authentic and non-judgemental interactions.
Additionally, participants advised that therapists should make the therapy space a safe place for young men to express unfamiliar or uncomfortable emotions.This may involve teaching young men about emotions and helping them navigate societal expectations that may have impacted their emotional development.

| Theme 2: Developed rapport pays off
A key theme that was present across participants' responses was that (P41-F-social worker)

| Do activities together while talking to lessen pressure
It was emphasised that to build intimacy and trust in relationships, young men often engage with each other through shared activities, such as sports and video games, and that the dynamics of these interactions are typically less personalised.This contrasts with therapy conversations, in which many treatment modalities require the continual transaction of private, emotional exchanges.Respondents spoke of a figurative pressure that builds within some male clients as a response to extended periods of focus on their inner worlds.Thus, to mitigate potential unease that adolescent males may experience in dyadic discussion, therapists recommended strategies that appeal to their preferred relational styles: Sitting and sharing is not their natural go to, so like when working with kids, having an activity and talking while doing it reduces the anxiety and assists conversation to flow. (P7-F-counsellor) Doing activities together was believed to lessen pressure on young men as the shared experience shifts the focus away from more emotionally intense personal relating.Nontypical therapy activities were encouraged by respondents in the effort to relieve potential pressure clients may experience when expected to talk at length about themselves: Sometimes having a task to do while talking, so like

| Use humour to build connection
Maintaining a warm, conversational style of communication that incorporates humour was often emphasised as an inlet to deeper intimacy with young men.Participants spoke of the need '… to bring appropriate humour and playfulness into the therapy context' (P47) as a means of diffusing tension and breaking down barriers between therapist and client: The judicious use of humour and plenty of warmth are really valid tools for engagement.

| Show interest in their interests
A recurring pattern across participants' responses was the need for therapists to present as genuinely engaged in the interests and pursuits of their young male clients.Rather than being perceived as waylaying therapy progress, these expansive discussions were seen by therapists to be important for both developing greater therapeutic rapport and understanding clients' motivations, passions, strengths and their broader social environment: Talking about school will lead you to their sense of connectedness to it. (P60-F-psychiatrist) Therapists explained that by allowing young men to share their interests at length, it provides opportunity for their strengths and personal qualities to be acknowledged, in contrast to a singular focus on their current symptomology and challenges: I've had students show me their favorite music, video games, books, hobbies, it gives them a chance to demonstrate knowledge, skill, expertise and have an adult just be interested in them. (P33-F-psychologist) Recognising the significance of well-established rapport on any ensuing psychological treatment with adolescent males was underscored as a crucial therapeutic task.This process in therapy acts to reinforce the context of safety offered to young men in male-friendly therapy, develop familiarity and trust between the therapist and the client, and connect the dyad to future therapy tasks undergirded by the client's motivations and goals.

| Theme 3: Masculinity-aware adaptions to therapy process
Participants portrayed adolescence as a critical time for males in developing their autonomy and independence and emphasised how a sense of control in therapy appears significant for young men.Many young males attend therapy at the request or mandate of others, such as parents and schools (de Haan et al., 2013), and participants explained that the therapeutic relationship can be strained from the onset if therapists are perceived as aligning with caregivers.This pathway into treatment may adversely impact young men's attitude and motivation to engage.Moreover, participants spoke of how young men strive to present as self-reliant and independent, and suggested that these behaviours seek to uphold their image of manhood.Thus, the implication of this theme is that therapists may facilitate choice and decision-making in therapy where appropriate with young men to intentionally position the young male as the primary client, uphold their sense of choice and respect, and enhance their engagement by establishing a sense of possession of their goals: Specifically at this time they are seeking to develop independence and they benefit from a sense of agency and appropriate (respectful) control, you can provide this in a safe therapeutic space. (P14-F-psychologist)

| Maintain a collaborative approach to therapy
As noted, given the oft-mandated entry to therapy, developing a collaborative relationship with young men which imparts choice and responsibility to them was emphasised to reduce the distance between therapist and client and enhance their commitment to therapy: Genuinely being collaborative.Boys can feel that they are a problem for their parents and counsellors to fix.
Being collaborative and giving them some autonomy allows for them build a sense of ownership and participation.This means counsellors cannot be experts, they cannot be authority figures. (P19-F-psychologist) Participants explained that a central task in developing a collaborative relationship is to socialise clients to therapy.This includes providing transparency of the tasks and process of therapy, explaining reasons why a specific intervention is offered and positioning the young male as the primary client, rather than their parents.These approaches aim to ease adolescent males' appre- (P32-F-psychologist)

| Link therapy goals and tasks to what the client values
In Theme 2, the importance of therapists being attentive to the interests and perspectives of their male clients was highlighted, while the previous subtheme recommended therapists position the young men as the primary client.The current subtheme extends this guidance by emphasising the need to incorporate the concerns of young male clients into collaborative therapy goals that are meaningful and relevant to them.Yet, participants acknowledged the need to balance the needs of young men as their primary clients with the parallel concerns and perspectives of caregivers and other referrers.
Participants cautioned that undertaking therapy with goals exclusively set by others risks disengagement or reactance by adolescent clients yet maintained that effective therapy goals incorporated psychological and behavioural changes that benefit both the client and others.As such, respondents recommended that therapists explore therapy goals that are relevant to young males to gain commitment, but also positively influence their extended social context: Spending time getting buy in from the client: why is this important for them and what will they get from it?
Even if that is mum off their back, less suspensions at school, better relationships with who they are dating.
Buy in works.
(P42-M-social worker) Respondents recommended that a clear connection between the reason for referral and practicable outcomes relevant to their client be established early on in therapy to direct progress and between-session tasks.Although participants indicated that many young males prefer to be task-focussed and action-oriented in therapy, a connection between how their emotions influence their behaviour was underscored as an important aspect of goal setting and how underlying skill could be developed: Although they can be rational and like problem solving, it needs to be connected to how they feel and tangible outcomes that they care about for them to buy in. (P19-F-psychologist) Many young men are referred at the concern of others and make initial contact with mental health services with less than favourable attitudes towards therapy.The recommendations provided by participants in the third theme aim to empower adolescent males to take control of their own experiences of therapy and collaborate on goals meaningful to them with their therapists.

| DISCUSS ION
This study sought to collate recommendations for counselling adolescent males from a diverse sample of mental health practitioners in Australia.This is the first known qualitative study to explore how Australian therapists adapt their practice to engage and retain young men in counselling and psychotherapy and build upon the small body of research examining Australian therapists' perspectives of providing psychological treatment to men (Beel et al., 2020;Seidler et al., 2021).As discussed below, the recommendations provided by Australian therapists are in consensus with the experiences of both therapists and adolescent male clients from other Western nations.This implies that the principles of male-friendly counselling espoused by Australian therapists are applicable to the broader trends of gender-sensitive psychotherapy for young men.
As reflected in Theme 1, creating a safe and accepting environment for adolescent males was indicated as a precursor to deeper therapeutic interactions.Young men in previous qualitative research have described how engaging with mental health professionals can be intimidating and threaten their sense of masculinity (Sagar-Ouriaghli et al., 2020).Adolescent clients report initially feeling vulnerable in receiving help, and ambivalent or distrustful towards therapists due to limited choice in initiating therapy and parental involvement (Binder et al., 2011;Gibson et al., 2016).
Moreover, some young men have indicated that discussing emotions with therapists is confronting and intrusive as it signifies to them that their problems are genuine, thus leading to greater self-stigmatisation (Clark et al., 2018).Thus, a sense of threatened masculinity and consequential self-stigma appear salient barriers to young men's perceptions of safety in therapy (Sagar-Ouriaghli et al., 2020).Therapists in the current study suggest that adaptions to intrapersonal attitudes and interpersonal exchanges may reduce initial reluctance and unease experienced by young men contacting mental health services.A key recommendation included offering non-judgemental spaces where therapists can employ curiosity to explore the influence of beliefs related to masculinity on young men's identity, current coping strategies and expression of emotions.Non-judgemental stances-unencumbered by therapist assumptions and biases of masculinity-related norms-were seen to uphold respect for client autonomy, which remains a current ethical guideline for many professions (APS, 2017), yet also allow therapists to support male clients in safely reflecting upon their masculinity without implicitly impinging their own judgement or values onto young men in the therapeutic space.Overall, it appears crucial to develop safety and trust quickly in the therapeutic relationship to reduce uncomfortableness and premature disengagement.
Theme 2 builds upon Theme 1 and highlighted the importance of building rapport with adolescent males to keep them engaged in therapy.Respondents encouraged therapists to adapt their therapeutic approach to align with the relational styles of young men.This is consistent with the existing Western literature and guidelines emphasising gender-sensitive adaptions that accommodate the preferences of adolescent males of diverse backgrounds to enhance engagement (APA, 2018;Kiselica, 2003).Participants emphasised engaging in activity together and extending the time discussing young men's unique interests as formative in building familiarity and rapport.Additionally, this extended focus on rapport-building tasks affords therapists the indirect opportunity to explore each young male's individual beliefs about mental health and masculinity when discussing his interests and worldview, which may progressively inform their approach to further rapport-building and latter therapy goals.As proposed by Sagar-Ouriaghli et al. (2020), initially shifting focus away from mental health with male clients may paradoxically promote connectedness and trust with the therapist.The findings from the current study support research recommending therapists incorporate humour and play into therapy (Kiselica, 2003), allow extra time for young men to develop trust (Binder et al., 2011;Stige et al., 2021) and prioritise the interests and concerns of young men (Robertson et al., 2015).The final theme highlighted masculinity-informed adaptions that may be applied to enhance adolescent males' engagement in the tasks of therapy.Masculinity is a central component of young men's psychological treatment (Boerma et al., 2023), and previous qualitative research has highlighted the importance adolescent males place in maintaining a sense of control in therapy to uphold internalised masculine ideals, as well as the perceived vulnerability they may experience when relinquishing that control to health professionals (Gibson et al., 2016).Yet, young men are predominantly referred by and for the concerns of others (de Haan et al., 2013).This may result in less-than-optimal initial contact and stymie the development of perceived autonomy in therapy (Stige et al., 2021).Moreover, autonomy in therapy remains pivotal for men across the lifespan, with a lack of perceived autonomy contributing to therapy disengagement in adult males (Kwon et al., 2023).Thus, it appears crucial to be collaborative and offer autonomy and choice to young men, despite their initial pathway into counselling, and link therapeutic goals to their desired outcomes.Addressing issues of therapist authority, alignment with caregiver concerns and the focus of goals and content discussed in therapy appear to be important considerations for developing a collaborative therapeutic alliance for both therapists and adolescent clients (Binder et al., 2008;Gibson et al., 2016).Choice and autonomy are positioned by therapists in our study as key facilitators of retaining young men in counselling and align with previous guidance advocating egalitarian relationships and shared decision-making in therapy with males (Boerma et al., 2023;Seidler et al., 2018).
Overall, the findings from this study demonstrate how therapists are clearly tasked with approaching rapport-building differently with adolescent males.Respondents' recommendations of conveying acceptance, interest and respect towards young men denote an underlying commitment and therapeutic stance therapists must possess towards young men if they are to engage this population meaningfully.This aligns with previous qualitative research with young men and therapists who recognise the unique challenges of building rapport within the context of adolescent development and traditional masculine norms.Both seemingly suggest that for therapy to be effective, a different way of relating in the therapeutic space is necessary.For example, studies exploring adolescent males' perspectives indicate that they often prefer a therapeutic relationship characterised as a friendship with a competent adult, rather than a hierarchical relationship between practitioner and patient (Binder et al., 2011;Gibson et al., 2016).
As independence from caregivers remains a central task of adolescence, it is suggested that adolescent clients may have a stronger commitment to supports that advocate their autonomy (Gibson et al., 2016).This may be a novel encounter for young men, who may benefit from a close relationship with an adult outside their familial and social milieu that permits both autonomy and choice, yet also deep connection (Binder et al., 2011).
Therapists too highlight the difficulties in developing a therapeutic relationship with young men who may be ambivalent, resistant or ashamed to be receiving psychotherapy.Derived from their own experiences counselling this population, therapists have indicated how they adapt their practice to propitiate young male clients in therapy.For some, enabling young men to determine the conditions of contact and therapy goals while being authentically interested in their concerns reduces potential reluctance to engage and conveys commitment and egalitarian respect (Binder et al., 2008;Johansson & Olsson, 2013).For others, normalising mental distress and psychotherapy for young men is primarily achieved through creating safe and meaningful relationships that validate the unique challenges they face.This is accomplished through a strength-based approach that emphasises positive aspects of young men's masculinity (Grace et al., 2018).Our findings support these views and suggest that therapists should prioritise relational adjustments in therapy with young men to facilitate an environment of safety, and esteem practices that support autonomy and choice for young men.
The aforementioned relational dimensions underpinning these The findings from this study offer an Australian perspective of gender-sensitive practices for psychotherapy with young men yet must be considered in the light of the study's constraints.The focus of the survey could have attracted practitioners with a specific interest in or ideological perspective of gender-sensitive therapy with young men.However, most participants (65%) indicated either neutral or no specific interest in working with young men and reported clinical experience (73%) as their primary source of learning, suggesting a more diversified sample of practitioners.Moreover, a majority of respondents were female (88%).This gender split is commensurate with current mental health workforces among Western nations (AIHW, 2021b;APA, 2015).In the current study, no differences were identified in the data set between the male and female respondents in how they related to adolescent male clients.Currently, the impact of therapist gender on therapeutic engagement and outcomes in adolescent counselling remains equivocal (Ryan et al., 2021); however, we speculate that the gender of therapists may offer some distinct influences on the therapeutic alliance.Young males may perceive a maternal quality in female therapists, which may influence their comfort in displaying emotions, while male therapists may model flexible and expansive representations of masculinity.However, future research is needed to explore this avenue of inquiry.
The use of open-ended online survey questions permitted extensive responses from participants, yet it did not allow us to clarify the responses, particularly to determine whether some recommendations were inexplicitly directed towards working with particular subgroups of adolescent males of differing racial and cultural backgrounds.Although the previous literature has encouraged practitioner awareness to the diversity of how masculinity is expressed within and between cultures and has proposed specific considerations for different populations (e.g., Horne & Kiselica, 1999), the impact of intersectional social identities on men's lives remains a growing area of research that may offer an additional lens for therapists to possess in therapy with males (Wong et al., 2017).In contrast to Mahalik et al. (2012), where US therapists identified the importance addressing diverse sociocultural identities with men, the recommendations provided by respondents in the current study focus on an awareness of how the masculinity of their client may influence engagement in therapy, and, accordingly, how therapists can adapt their practice to be more male-friendly.As conformity to harmful stereotypical masculine gender norms, such as toughness, dominance and avoidance of emotions, appears strongest in adolescence for males (Kågesten et al., 2016), we contend that therapists in the current study view addressing masculine norms that may impede engagement in therapy an essential task to initially complete.Thus, although generalisability should not be claimed, we do claim broader relevance for the findings as they align with current guidelines for psychological practice with boys and men (APA, 2018), scholarly reviews (Boerma et al., 2023) and therapists' and clients' perspectives (Gibson et al., 2016;Johansson & Olsson, 2013).Future research may explore the themes of intersectionality and masculinity in greater depth and compare their relative importance to both practitioners and young men receiving psychotherapy, perhaps in paired-dyad studies.In addition, ascertaining whether young men find reviewing the concept of masculinities early in therapy may speak to their perspectives of its utility as a therapeutic task.
Finally, exploring the experiences of caregivers and therapists who strive to provide autonomy to young men in therapy may inform areas of strength and weakness in this approach.

| CON CLUS ION
Concern remains given that adolescent males tend to underutilise mental health services and maintain a high rate of therapy dropout.Several thematic recommendations have been developed from responses provided by Australian practitioners on how to engage and retain young men in psychotherapy.Despite diversity in mental health professions represented, there was broad agreement on therapeutic practices that are likely to appeal to and suit young men.These male-friendly practices not only extend past physical and interactional adaptions to therapy but also require therapists to assume a stance of acceptance and positive regard towards young men in therapy.The findings provided by Australian therapists align with previous research from Western nations and emphasise the importance of creating safe and accepting spaces for adolescent males, building rapport through activity and time together, and offering autonomy and control in therapy.

ACK N O WLE D G E M ENTS
This study was approved by the University of Southern Queensland Human Research Ethics Committee (#H22REA100).Participants electronically signed an online informed consent form before participating.The data set that supports the findings of this manuscript is available upon reasonable request.
study was subsequently promoted by the Australian Psychological Society (APS), Australian Association of Social Workers, Australian Counselling Association, Psychotherapy and Counselling Federation of Australia, and the Royal Australian and New Zealand College of Psychiatrists via newsletters, listserv emails, unpaid social media sites (e.g., Facebook and LinkedIn groups), or research webpages for a 3-month period (14 July 2022-21 October 2022).
analysis, followingBraun andClarke's (2006, 2021) suggested protocol, situated within a critical realist worldview, was used to analyse these data.This method was used to answer the research question primarily from an inductive orientation to give voice to the participants, both in the semantic meaning of recommendations provided and in the perceived latent themes shared by therapists across the data set.The primary researcher (M.B.) coded the data using open coding to record data relevant to the research question and then clustered the coded data that appeared to have shared patterns of meaning into candidate themes (Braun & Clarke, 2021).A second researcher (N.B.) then reviewed the codes and candidate themes across the entire data set.The themes were then refined, provided with definitions and subsequently reviewed by the research team (M.B., N.B. and C.J.) until consensus of the final themes was achieved.M.B. then developed the written report that contained illustrative excerpts from therapists, indicated by their participant number, gender and profession (e.g., P33-Fcounsellor) to represent participants' voices in relation to the developed themes that were agreed upon by the research team (see Table to further therapeutic work.Participants consequently highlighted the need to convey welcoming relational qualities towards young men through intrapersonal adjustments and deliberate interpersonal interactions.This was thought to foster the necessary conditions for the client and therapist to explore previously uncontacted emotionality and vulnerability without shame: I spend a lot of time…building a sense of safety/trust before[hand] to set the pre-conditions for change/ healing before I start what we are more likely to call "counselling".(P14-F-psychologist) TA B L E 2 Summary of participants' characteristics (N = 67).
3.1.1| Adjust expectations of what therapy looks like Participants emphasised the relative distinctiveness of what the process and progress of counselling may look like when working with adolescent males in contrast to other client populations, such as female or adult male clients, and urged therapists to adjust their expectations accordingly.The conventional requirements of counselling both expected and enacted by therapists, such as extended face-to-face contact, verbalisation of emotions and extensive questioning, were described as incompatible with how many young men build rapport and form relationships: …this cohort is engageable, but expectations need to changed about what this looks like, that it may not look like the traditional model of treatment and engagement.
cautioned therapists to avoid holding negative attitudes towards adolescent males and relying on preconceived notions of young men in therapy and instead ground their interactions with a mindset of curiosity: Do not make assumptions or rely on stereotypes of what being 'male' is -be openminded to what the young person might be interested in, their values, and beliefs.
Being interested instead of judgemental, e.g., when told about drug use don't jump straight to 'you know it's dangerous to use drugs and operate the machines in the workshop -I'm going to have to talk to your teacher/employer'.Instead, 'do you think the drugs are helping?how? do you think they are affecting your work/study?how? do you think others have noticed?' (P33) societal and family beliefs around "what a man is" and therefore adhering to unhelpful gendered stereotypes is still upmost important to adolescent males … which I see as a barrier to fully engaging properly in therapy and in being real about feelings and thoughts.
therapeutic rapport is essential to engaging adolescent males meaningfully in psychological treatment.Considered more than an aspect of psychotherapy, participants denoted rapport as the cornerstone of psychological treatment with young men such that all other aspects of therapy are positioned in relation to the quality of the therapeutic relationship.Respondents described a general reluctance of adolescent males to engage in initial counselling sessions and emphasised how adapting to ways of relating that appeal to young men is crucial in building familiarity and trust.Rapport was portrayed as a hard-won task but invaluable once developed in facilitating young men in verbalising their inner experiences and committing to shared goals in therapy: It's all about rapport.If you can get their trust and for them to like you, they're more likely to share themselves and listen to what you have to say.Do whatever it takes to build rapport.(P8-F-psychologist)3.2.1 | Allow extra time to engage and synchronise pace with the clientRespondents indicated that developing rapport with adolescent males was a much slower undertaking in contrast to adolescent females.Yet, once engaged, young men were viewed as being just as willing to participate in therapy.Thus, therapists should slow down the process of developing familiarity and synchronise with their client's pace:I have found that despite the counselling process being a slow start, once a strong trusting relationship is formed, young adolescent males are very willing to talk about how they are feeling and the challenges they face.
playing hackey sack, or a game, is often how adolescent males in my experience feel more open in the counselling process.It lessens the pressure off them to 'bare all.' (P2-F-counsellor) hension of involuntary participation by providing education and choice of the psychological intervention they receive to increase their commitment to engaging in therapy: Check and collaborate about the focus of the counselling and therapy.Ensures (sic) the session and interventions are focused on what he wants and values.
therapists' recommendations appear to be largely absent in the discourse in practice guidelines for working with men and boys(APA, 2018; APS, 2017), showing a possible disconnect with practitioner-derived recommendations.We recommend authors of treatment guidelines ensure consideration of research, inclusive of the views and experiences of practitioners working with adolescent males, when formulating psychological practice guidelines.This is to help ensure the guidelines meaningfully connect to therapeutic contexts, given practitioners are primary target audiences for the guidelines, and also serve as the interface that connects clients and treatment provision.Respondents in this study largely drew upon their clinical experience and emphasised the importance of acceptance and relational qualities actively conveyed by therapists towards young men in order to keep them engaged.This research adds to practitioner-based findings that can inform scholarship and guidelines for working with young men.
17461405, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12716 by National Health And Medical Research Council, Wiley Online Library on [04/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License It is truly amazing what can be gained from talking about their interests.Talking about sports will lead to discussion of friendships in the team, who takes them, who mentors them.Discussion about music will lead to what calms them down, what lyrics impact them.
17461405, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12716 by National Health And Medical Research Council, Wiley Online Library on [04/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License