Effect of Masculinity Norms on Psychological Help-Seeking Behaviours

Introduction

Depression and anxiety are the two most commonly occurring mental health issues in England and the two are often comorbid (McManus, Bebbington, Jenkins, & Brugha, 2016). Depression is characterised by a continuous low mood and sense of self-esteem, feelings of hopelessness, guilt, a loss of interest in everyday life and suicidal ideation. Generalised Anxiety Disorder often involves one or more of the following symptoms: excessive worrying, feeling agitated, restlessness, fatigue, difficulty concentrating, irritability, insomnia or trouble sleeping, irrational fears, panic attacks, and a fear of social situations.

It has been well evidenced that men access psychological healthcare services less than women (Berger, Levant, McMillan, Kelleher, & Sellers, 2008; Addis & Mahalik, 2003) recent statistics show that only 38% of men with anxiety or depression access IAPT services (NHS Digital). It is clear however that this is not due to men possessing better mental health overall, as men are around three times more likely to commit suicide (Office for National Statistics, 2016). This disparity suggests that men’s mental health problems are being underreported and subsequently undiagnosed. It has been proposed by some researchers that the higher rate of male suicide may partly be due to the lower rate of help-seeking in this population (Biddle, Gunnell, Sharp, & Donovan, 2004). It is therefore important that current research is directed towards understanding the barriers that men face to accessing healthcare and how these may be overcome.

Male adherence to traditional masculine ‘norms’ has been consistently identified as a barrier to accessing psychological well-being services for common mental health issues such as depression and anxiety and may go some way towards explaining why men are not accessing psychological help as frequently as women (Mahalik & Rochman, 2006; Roness, Mykletun & Dahl, 2005; Oliver, Pearson, Coe, & Gunnell, 2005; Addis & Mahalik, 2003). Hegemonic traditional masculine norms such as ‘being strong and invulnerable’, ‘being in control of one’s emotions’, and ‘relying on oneself’ have commonly arisen as predictors of negative help-seeking behaviours in men when tested quantitively using highly validated questionnaires such as the CMNI-94 (conformity of masculine norms inventory) (Mahalik et al, 2003) and the MRNI (male role norms inventory) (Levant, Wimer, Williams, Smalley, & Noronha, 2009; Yousaf, Popat & Hunter 2015). In a recent meta-analysis involving 78 different samples Wong, Wang & Miller (2017) found the masculine norm of ‘emotional control’ to be significantly and inversely associated with psychological help-seeking with a medium effect size of – 30. These norms are embedded in society, as Vogel, and Heimerdinger-Edwards, and Hammer and Hubbard, (2011) correctly point out, one of the first things young boys are frequently told is ‘boys don’t cry’.  Although such norms may serve to encourage men in a myriad of positive ways – gaining independence, providing for others, being hard-workers – they can equally have negative effects, especially when it comes to inhibiting help-seeking behaviour.

There is much corroborating evidence that such masculine norms negatively affective help-seeking behaviours in men from multiple qualitative studies (see Seidler, Dawes, Rice, Oliffe, & Dhillon, 2016 for a review; Berger, Addis, Green, Mackowiak, & Goldberg, 2013). In a relatively recent and comprehensive review of 14 qualitative studies that focus on men’s coping strategies for depression Spendelow (2015) identified ‘promote traditional masculinity’ and ‘social concealment and minimization’ as two meta-categories that negatively impact men’s help-seeking. ‘Promote traditional masculinity’ as a thematic category involved coping strategies for depression such as ‘ignoring or concealing negative emotions’ and engaging in ‘risky behaviours’.

Such strategies uphold the traditional masculinity norms of ‘emotional control’ and ‘risk taking’ and lead to participant’s attempts to manage their depression symptoms alone, or to substance and alcohol use respectively. These actions which were held in high regard amongst men as coping strategies serve to increase men’s reticence for help-seeking, either interpreted as a solution to depression symptoms or as a distraction from them. The traits that were valued most across the studies were ‘self-reliance’ and ‘autonomy’ which often resulted directly in purposeful non-engagement with professional services. The category of ‘social concealment and minimisation’ involved behaviours that downplayed the extent of men’s mental health issues to others in order to preserve masculinity, reputation or self-view (Spendelow, 2015). It appears from the wide scope of the literature available that men deem asking for help predominantly as a threat to the traditional masculine norms of self-reliance and emotional control, which in turn threatens their masculinity.

Other factors that studies have shown negatively impact on men’s psychological help-seeking include ‘Alexithymia’ which is characterised by an inability to recognise and properly express or describe one’s emotions using language (Nemiah, Freyberger & Sifneos, 1976) and gender role conflict or GRC (O’Neil, 1981). Alexithymia has been shown to be negatively correlated with UK men’s help-seeking and in one study fully mediated the relationship that another factor ‘fear of intimacy’ had on men’s help seeking (Sullivan, Camic & Brown, 2015). If one considers alexithymia as a type of handicap to perceiving and expressing emotions this finding can be interpreted as unsurprising, as the less inclined one is to recognise, value and articulate their emotional states, the less likely they are to experience the emotion of a fear of intimate relations and subsequently to allow this to deter them from accessing help. It may be that men who score highly on tests for alexithymia are simply more logical and emotionally reserved characters to whom healthcare services need to identify a way of reaching out.

GRC is a psychological state in which adherence to sexist, strict gender norms and expectations from society impact negatively on a person’s well-being, their self-concept or on other people. GRC has been tested prolifically throughout the literature using the GRC scale which is composed of four factors that contribute to the phenomenon. The ‘restrictive emotionality’ factor of GRC (RE) was the biggest predictor variable of men’s negative attitudes to help-seeking in a study involving 401 undergraduate American men (Good, Dell, & Mintz, 1989). RE involves harbouring or hiding one’s emotions either to oneself or to others and is in this respect similar to the traditional masculine norms of ‘emotional control’ and ‘self-reliance’.  It is noteworthy that multiple studies that have investigated the effects of GRC on male help-seeking behaviours have also frequently implicated the MNORMS of ‘emotional control’ and ‘self reliance’ as contributing to RE (see O’Neil, 2008, for a review).

Another possible explanation for men’s lower rates of psychological help-seeking may come from the generalised ‘stigma’ that is attached to mental health and associated with accessing psychological help. One review showed that ‘stigma’ has a small to moderate negative effect size on help-seeking and added further support for women being more likely to seek help than men (clement et al, 2015). It has also been shown that embarrassment is more likely to prevent help-seeking in men than in women (The Campaign Against Living Miserably [CALM], 2016). Self-stigma or feelings of inadequacy or disapproval men have towards themselves as a result of depression or anxiety has been shown to have a negative effect on attitudes to seeking help (Vogel et al., 2011).
Many of the barriers to men accessing psychological healthcare that have been mentioned thus far occur cross culturally, across all ages and sexual orientations (Wong et al., 2018; Keohane & Richardson, 2018; Lynch, Long & Moorhead, 2018; Clark et al, 2018; Levant & Richmond, 2016; Umubyeyi et al, 2015; Masuda, Anderson & Edmonds, 2012; Valkonen & Hänninen, 2012; Levinson & Ifrah 2010;).  However, there are very few studies that focus exclusively on men aged between forty to around sixty; a period often referred to as ‘middle-age’ or ‘midlife’, with a substantial amount of previous literature having instead used convenience samples composed of college-age graduates (see Seidler et al, 2016, for a review; Wahto & Swift, 2014).

The notion that general life satisfaction and happiness over time is in fact ‘U-curved’ with people tending to reach their lowest enjoyment of life during the period of ‘midlife’ between the ages of forty and sixty has been supported in the literature both in the UK and America, and across the world (Edsel, 2017; Cheng, Powdthavee, & Oswald, 2017; Blanchflower & Oswald, 2008). Blanchflower & Oswald (2016) found that across 27 different countries in Europe people in their late forties (45-54) were the most likely to be using anti-depressants. Data from the UK office for national statistics (ONS) shows that the age group 40 – 54 have consistently rated themselves as lower for ‘life satisfaction’ and for ‘happiness’ every year from October 2011 – September 2017. Men also gave lower scores than women for these values and in the most recent report on suicide from 2015, the ONS revealed the highest rate in the UK was for men aged between 40 and 44. The overall underuse of psychological healthcare services by men when considered alongside the evidence for a midlife ‘nadir’ or dip in general life satisfaction, a higher usage of anti-depressants and overall rate of suicide provide strong motivation for studies to explore this age-group of men’s attitudes towards seeking psychological help, the specific barriers they face, and how these might be reduced.

One study conducted in Germany found that levels of male anxiety were highest during midlife and were accompanied by reduced self-esteem and resilience (Beutal et al 2010). Another online study in Australia found that depression increased with age (Rice et al, 2012). These, along with the studies mentioned above highlight the correlation between depression and anxiety and midlife in men, however they are qualitative in nature and so do little to inform about the actual lived experiences of middle-aged men going through depression and anxiety. They also weren’t not conducted in the UK, it is important, given the current rate of suicide in midlife UK men, that research attempts to understand more about the lived experiences of male depression in this high-risk age category so that we may formulate new and effective ways of helping them to help themselves.

This study uses an interpretative phenomenological analysis (IPA) of semi-structured interviews with a specifically selected and carefully considered sample of men who have self-diagnosed as having had symptoms of depression and / or anxiety between the ages of 40 and 55. The study aims to explore these men’s reasons for not having accessed psychological healthcare services in their times of need and what facilitating factors may have encouraged them to do so during that time. This is the first study to focus exclusively on UK men who have experienced symptoms of anxiety and depression during ‘midlife’ and it is hoped that the study can be used to further inform and add support to existing research on how to improve help-seeking behaviours in men.

Current research on how to improve men’s help seeking behaviours for mental health issues has produced a variety of recommendations for both specific and broader approaches. Increasing levels of male mental health literacy MHL has been positively correlated with improved attitudes to help-seeking in the UK and Australia (Clark et al., 2018; Gorczynski, Sims-schouten, Hill, & Wilson, 2017) though the male participants in these studies were either adolescents or at University and not representative of the wider population in either country. There is also some evidence that increasing MHL through internet-based interventions can be successful (Christensen, Griffiths, & Jorm, 2004) though such randomised control trials have predominantly taken place in Australia, and research is lacking into the efficacy of internet MHL programmes elsewhere.

Men have also shown differences to women in the way that they prefer to engage with mental healthcare services, some research suggests that men are more likely to engage in help-seeking than women are if they are prompted to do so by a female partner or family member (Lemkey et al., 2015; Norcross, Ramirez, & Palinkas, 1996). It is perhaps having someone whom men feel they can trust and open up to that increases this likelihood. One qualitative study involving the discourse analysis of 38 interviews with men with formally diagnosed or self-reported depression established ‘genuine connection’ as a discursive frame. This term captured the men’s desire to be listened to and understood by a healthcare professional with whom they had established a genuine rapport. This is in direct contrast to the dominant masculine norms of self-reliance and emotional-control which instead encourage non-communication. Men in this study wanted to play an active and empowering role in their own recovery, assisted by their trusted healthcare professional. This shows that the traditional masculine ideals of strength and hard work can be reframed positively in the context of help-seeking if this means finding the strength to help oneself effectively (Johnson, Oliffe, Kelly, Galdas, & Ogrodniczuk, 2012). Similarly in his meta-analysis Spendelow (2015) suggests that adopting a flexible attitude to traditional male gender norms can render them compatible with help-seeking for men and may help to improve coping strategies for depression. Liddon et al (2017) assessed the differences in preference for psychological treatment and help-seeking between a sample of men and women using online surveys and found that men were more likely to indicate that there is a lack of ‘male friendly’ options than women. Men in the study also showed a significant preference for social support groups than women which is a finding that has been echoed in the data from IAPT services showing that men prefer occupational support to counselling (Digital NHS). Low rates of help-seeking for depression and anxiety requires further exploration into the ways in which services can be made more accessible and appealing to men, and in particular to those men who sit within the particularly vulnerable age bracket of midlife.

It is expected in this study that adherence to traditional masculine norms and the stigma associated with mental health will arise as barriers that participants face to help-seeking, as is consistent with much other research in the field. It is also expected that possible mitigating factors to such barriers will include increasing men’s mental health literacy and having someone close whom one can trust to open up to. Though these expectations are based on the extant literature on this topic, it is important to note that this study uses a qualitative IPA analysis in which specific hypothesis themselves are not required. The predominant aim of the study is to explore the narrative accounts of the participants themselves in the hope that they may expand current understanding of the barriers this particular age group of men face to engaging with professional psychological assistance.

Method

Participants

Participants were three middle-aged Caucasian British men aged 57, 53, and 47 (n = 52) of a total five who expressed interest in participating in the study. Participants were recruited using flyers, email-shots and via word of mouth advertising in pubs, barber shops, hotels, the high street and from two main engineering companies in a local business park. Participants were briefed about the study via a phone call through which their eligibility was considered, particularly the age at which participants reported having experienced their depression or anxiety symptoms (53, 50 and 47 respectively). Of the final three participants, one was diagnosed with clinical depression after being made to attend a doctor’s appointment by a friend. Another self-diagnosed as having symptoms of both depression and anxiety and the other as having only depression symptoms. All participants were given the relevant contact details of various support services where they could access suitable aftercare if required.

Data Collection

A semi-structured interview guide was used during the interviews. The guide was developed with a view to extract as much information from participants as possible structured around two central research questions:

1. What barriers limit this age group of men’s accesses to professional psychological help? (i.e making initial contact)?

2. What things might increase the likelihood of accessing and engaging with mental health care for this age group of men?

Eleven questions were devised for this purpose and used in the guide (see appendix a). The structure of the interview guide was aimed at gauging a true-insight into the informant’s life and world during their experience of having had depression or anxiety.

Materials / Apparatus

Interviews were audiotaped using an I-phone 7 and transferred to an encrypted file in a secure password protected laptop.

Procedure

After a telephone briefing and verbal consent was given, the participants were asked to attend a 30 – 60-minute interview at the School of education building at the De Havilland campus at the University Of Hertfordshire in Hatfield. All three who had been invited attended over the course of two days in August 2018, signed their consent forms and were interviewed for between 32 – 45 minutes. Follow-up questions were used to extract more detail from informants about their responses. The interviews were conducted using the principles described by Pietkiewicz & Smith (2012) by building trust and rapport with the participants, using active listening techniques and asking open ended questions which are aimed at exploring exactly what is being communicated, consistent with an independent phenomenological approach.

Data Analysis

The interviews were audiotaped, transcribed and analysed using interpretative phenomenological analysis (IPA) which was chosen for its usefulness in eliciting the richness of the individual experiences of informants. IPA draws its theoretical influences from the principles of phenomenology, hermeneutics and idiography. It is fundamentally concerned with the way in which participants make sense of their own experiences and examines this according to how they describe or recount them without using any pre-determined categories, biases, or assumptions. This is particularly useful for this study as it focuses on exploring the individual experiences of the participant’s symptoms and how these may have contributed to not engaging with psychological healthcare services.

Phenomenology has its roots in Edmund Husserl’s 20^th century philosophical movement, the aim of which was to identify the fundamental components of experiences, objects, and phenomena that make them unique. Phenomenological research therefore aims to do the same about a person’s conscious experience of something through analysis of their understanding, perceptions, beliefs, opinions and feelings of it. It is hoped that through interpreting multiple accounts of similar experiences one should be able to ascertain something truthful about the phenomena itself.

Hermeneutics is defined as the branch of knowledge that deals with interpretation (OED 2018). Husserl’s Phenomenology was further developed by Martin Heidegger who recognised that people only recount the phenomenon of their conscious experience through language, which is already interpreted individually. The pure phenomenological goal of capturing the essence of something is therefore never fully realisable as all lived conscious experience must be communicated in some other form, usually via language. Smith and Osborn (2008) described IPA analysis accordingly as a process that makes use of a ‘double hermeneutic’. That is, it first relies on the meaning made by the interpretation of the conscious experience by the participant, and then on the researcher’s interpretation of that meaning, all of which is mediated by the language used. The IPA researcher attempts to understand the phenomena of the experience as it is from the participant’s perspective and simultaneously forms analytical questions regarding the true nature of that experience, such as – is there something that is being alluded to but not spoken? What is really meant by such an expression in this context? Is there anything I am aware of that my participant is not? Such questions enrich the analysis by utilising a two-pronged approach leading to a more expansive and detailed interpretation.

IPA involves the thorough analysis of individual accounts of experiences before any general thematic content or connections are made between data. It is this initial focus on the individual meaning of experience which ensues before any general interpretation of the phenomena in question that constitutes the idiographic approach to research. IPA focuses on detailed individual case exploration to accumulate extensive detail of each participant’s interpretation of an experience. It is only after each case has been individually analysed in enough detail that a researcher begins to look for themes and meaning between cases.

The interviews were transcribed verbatim and analysed using the methods outlined by Pietkiewicz & Smith (2012). The transcripts were firstly read several times and the audio recordings were listened to several times. Notes about language being used, the content of what was being said, certain syntactical features such as pauses and exasperations, initial interpretations of meaning beyond explicit words, contextual details and any emotional responses or reactions were written in the right margin. These notes were then considered for the meaning they may contain and subsequently interpreted using a more overarching and abstract approach, the results of which were then written in the left margin.

Emergent themes were then looked for by collecting and grouping these abstract descriptions together based on their conceptual similarities and giving each of these groups a descriptive title that summarised the nature of their similarity. These titles were considered as emerging subthemes for the transcript and were collated on a document along with quotes that provided evidence for them. This process was the repeated from the beginning for both the remaining transcripts, each time using an idiographic approach by considering each transcript as a new and individual case.

Once all the transcripts had been analysed in this way and three documents containing emergent themes had been produced, these were then analysed for any coherence and patterns between them and supplemented by any relevant quotes as evidence. The final collection of themes and subthemes were then collated into a table and used to create a thematic structure which was based both on individual experience but also contributed something of meaning about experiencing depression or anxiety in midlife, and not accessing psychological healthcare services. After all the themes and subthemes had been merged or discarded, the thematic structure that is presented below was created.

Results

The thematic structure (see table 1.) refers to the various barriers that men face to accessing psychological healthcare services and factors that may help to mitigate these as they were perceived during the interviews and through interpretations of the transcripts of the participants. The various subthemes are then presented and supplemented with evidence from the transcripts.

Overview of the thematic structure

Themes	Subthemes
Barriers from experiencing depression and anxiety	A confused sense of self Feelings of hopelessness Coping mechanisms that delay or discourage help-seeking
Barriers from the masculine norms ‘emotional control’ and ‘self-reliance’	Pride and self-reliance Responsibility and emotional control
Barriers from perceived stigma	Embarrassment Professional Life
Barriers from current understanding of mental healthcare services	Lack of knowledge and awareness Not enough time to talk
Mitigating Factors	Removing the stigma Things healthcare services can do Honest relationships, friends, family and talking Things the affected can do

Barriers from experiencing depression and anxiety

All informants reported barriers to psychological help-seeking that were rooted in how their experience of depression or anxiety affected their mindset during the time. These predominantly took the form of emotional obstacles and attitudes, though they also involved ‘coping mechanisms that can delay help-seeking.

A loss of a sense of self

Informants expressed having difficulty integrating their sense of self with their emotions during their period of depression or anxiety. Many reported having feelings of emptiness and ‘like nothing really mattered much at all’ embedded in these feelings was a sense of hopelessness and a wish to withdraw from the world. One informant clearly recounts how not identifying with his sense of self manifested through his symptoms.

Adam

P: “I also thought a lot in the third person, er which was really strange..
I : As in using your own name for things?
P: Erm I would talk about ‘he’… ‘he’ or, or ‘****’ and I would, in my thoughts…
I : Yea?
P: I wouldn’t think about ‘me’
I:  Right.
P: Erm and it err, it, I mean I it was weird, it was very very strange”

It is easy to consider that in such a confusing state where one struggles to identify with themselves that making the choice to access help may seem far out of reach. Informants also recounted being very self-critical during their depressive episodes. When asked what he might say to himself if he could go back and talk to his past depressed self, one informant answered:

Adam

P: “Erm, I would say that I should be erm kinder to myself, and less critical of myself and err I would not   be erm as hard on myself in terms of making myself just keep ploughing on
…
I :Right.
P: the negative stuff was so much more powerful than the positive stuff whereas if for somebody who worked for me I would never treat them like that, you know I would never just pick up on the things that they hadn’t done as well as they could. “

During his depression Adam focused on whatever he deemed to have been disappointing in his own performance and used this to justify criticising himself. It is an example of the self-critical and neglecting world that depression forced him to inhabit. This type of negative reinforcing belief and behaviour-pattern is in direct conflict with the type of self-compassion that encourages help-seeking.

Feelings of hopelessness

Informants mentioned feelings of isolation, loneliness, emptiness and as though there was ‘no way out’ that were caused by their depression and anxiety. Adam describes here the extent to which he believed that the cause of his depression could not be solved:

Adam

P: “I think well one of the things that was was a real, yea, it erm, yea not being able to see a way to sort things out.
I: Right.
P: In fact, believing that there wasn’t a way. It wasn’t even thinking ‘I’m sure there must be a way but I’m not clever enough to work it out’ it was actually really believing there was no way to sort it all out.
I: Mmm
P: Erm and you know I felt really suicidal. And erm I’m not saying I’ve never ever thought about that in the past but it was real all the time. And it was that because it it was thinking that that was a way out. “

This apparent conviction in a lack of possible ways to exit ones uncontrollably debilitating emotional state may explain why some men dismiss healthcare services as not being able to help them as they don’t provide any obvious solution to the direct causes of their root distress, subsequently they may be deterred from seeking help. Adam’s sense of hopelessness was so strong that he even considered taking his own life as a way of re-establishing control, something that many men within this age group have done.

Coping mechanisms that delay or discourage help-seeking

All participants mentioned things that they did to deal with either depression or anxiety other than seeking help. Although such behaviours are not necessarily direct barriers to help-seeking, they still provided informants with alternative ways of dealing with their mental health and so, acting as a form of self-medication, had the ultimate effect of either delaying help-seeking or collectively replacing it altogether. All participants mentioned increased alcohol use as one such coping mechanism, and most saw this as unfavourable. When comparing himself to his friends who have accessed healthcare services Geoff views his alcohol indulgence as the least favourable of the his coping mechanisms.

Geoff

P: “They have had that experience themselves and they have sought and received comfort from professional help whereas I’ve just always taken myself to an art gallery or
I: ok
P: Regrettably had too much booze or just indulged in friendship or other indulgences. “

He also speaks about acting in an impulsive manner as a coping mechanism and a way to gain a sense of control over his life.

Geoff

“ P: Where I’ve maybe err compensated or tried to cope by slightly going crazy I suppose. Doing things that are a bit outlandish or you know, impulsive.
I:  Right so kind of acting out in a way?
P: Yea just feeling kind of very constrained and depressed and repressed by by all the kind of traumatic experiences and sometimes trying to break free from that and trying to, erm to contain those those forces and trying to, maybe re-assert control “

Coping mechanisms are not necessarily harmful and in some cases like ‘friendship’ can even be positive, and as mentioned they’re not necessarily direct barriers to help-seeking. However, because they offer a short-term sense of distraction or lift in mood, they can ultimately be indulged in as a way of ignoring or avoiding one’s depression or anxiety.

Barriers from the masculine norms of ‘emotional control’ and ‘self’reliance’

The masculinity norms of ‘emotional control’ and ‘self-reliance’ arose as a main theme in all interviews. All informants adhered to these norms in their reports of how they dealt with their depression or anxiety, emphasising a sense of pride in their relying on themselves, or a sense of responsibility to others that required emotional control.

Pride and ‘self reliance’

Informants described or alluded to having or knowing of a sense of ownership over their mental health issues that made these private and personal phenomena which they were reluctant to let anyone else be a part of. There was a sense of pride for informants for being able to cope with their issues alone accompanied by the implied veracity of beliefs such as ‘resilience is strength’ and ‘seeking-help is weakness’.

Michael

“I: Mmhm, ok. That makes sense. Erm you, erm so why do you think that you felt like you couldn’t show people how you were feeling?
P: Well, I err didn’t want to, mm, I think at the time I just felt like it was my business you know, at the end of the day it was my stuff that I was going through and I just thought I could deal with it on my own or at least work out what was happening first”

Michael clearly has a strong sense of ownership and pride in dealing with his own depression.

Geoff describes having the same type of thoughts but with less conviction that dealing with everything alone was the right course of action, suggesting that this may be a default perspective men take but that it is not impenetrable to doubt.

Geoff

“I: in terms of having considered seeking help seeking healthcare erm have you had difficulty doing that is it something that you considered?
P: It’s not it’s, it was something that was suggested to me on many occasions. But err maybe stupidly or, err I don’t like to think arrogantly but maybe stupidly or (sighs) I just decided that err, I could handle things on my own terms without seeking professional help.
I: yea. “

Perhaps it’s this sense of ownership and privacy over one’s mental health that puts some men who have a high level of self-reliance from accessing healthcare services. Michael expressed this attitude when talking about visiting the G.P.

Michael

“ P: taking it to that level is like a whole other thing you know, it makes the way you feel, err something that you can’t deal with and fix yourself, and that’s not something I’m used to doing, no way. “

Here Adam talks about how men have an aversion to talking openly about feelings that might convey vulnerability, instead perceiving this as weakness.

Adam

“P: / and erm I think they also have this, and I don’t like to generalise but I think, erm, they’re probably more er self-conscious about admitting anything that’s in some way weak, about how they are or how they feel”

Responsibility and emotional control

All informants talked about blocking out or controlling their emotions to some extent in order to deal with the responsibilities they had in their day to day lives. There were many references to not being able to jeopardise job roles and responsibilities in this respect. There was a real sense of a threat of failure if informants were to somehow break their public persona at work.

Adam

” P: And I think I kind of closed everything down before it happened until one day my psyche or whatever said ‘hold on a minute we’re not having this’ and it was, you know, it was a bit of a riot for a while, while everything sort of just burst out that I, that I had been controlling.
I: Mm.
P: /because I had to control it all so that I could do my job.”

as well as not wanting to become unable to provide for one’s family or partner due to illness.

Michael

“ P: my job comes with quite a lot of expectations, I mean you want to be able to still do what you gotta do, it doesn’t matter what you’re going through on the inside when you’ve got fifty people who need you to tell them what to do the next day, I err, you know you’ve got your daughter’s play to see, bills coming in and all the rest, it’s either a case of ploughing through it all and just dealing with it, or letting things get to you I think.
I: Mhmm, right. Ok I can understand that.
P: Yep well I mean that’s how it saw it at the time anyway. “

This consideration was often accompanied by the concern of becoming some sort of a burden to the family or partner which was deemed unacceptable.

Adam

“P: As I say, my partner, we’ve been together for thirty years and I didn’t tell them everything at the time or in the time leading up to it because I didn’t want to worry them.”

The final element that was mentioned as part of this subtheme was the phenomenon of Alexithymia. Although this may not take the form of blocking or controlling emotions, it does involve men being less able to express them properly or in some cases at all.

Adam

“ P: I mean I think, I mean men are crap at talking about how they feel generally I think. … men generally are less able to erm verbalise what they’re feeling than women I think. “

Barriers from perceived stigma

Informants described men as feeling embarrassed by their depression and anxiety because of the general ‘stigma’ surrounding mental health in British society. They also mentioned concerns about how this might affect their professional lives if they were to access healthcare services.

Embarrassment

Michael was particularly concerned about disclosing information to healthcare services regarding past experiences connected to his mental health issues that he considered to be shameful.

Michael

“P: So, I guess, well that was one other reason I erm felt I needed to deal with my stuff alone you know, I felt, well I’ve always known we were up to no good and I didn’t want anyone knowing all the things I got up to I think I was feeling embarrassed sort of. “

This is most likely a common barrier that men face to accessing mental healthcare services if their mental health issue is connected to abuse or any other type of sensitive topic that people find difficult to talk openly about.
Geoff highlighted that there are certain cultural norms in Britain that may further embarrassment over seeking mental health support by maintaining that composure and persistence in the face of the difficulties one faces should be encouraged and revered.

Geoff

“I: I mean what is that shame about, I’m asking what is that, where does that shame come from?
P: Well because our culture is predicated upon notions of machismo and the old British thing of stiff upper lip, and err, those ideas of batten down the hatches and get on with it. Keep calm and carry on.
I: yea true, there’s a big marketing thing for that isn’t there?
P: Absolutely. “

Professional Life

Michael relayed concerns over how he may be perceived in his professional life for having depression or anxiety at work.

Michael

“ P: Also like, I think I probably would’ve been worried about what people at work might think you know. I’m a manager so I probably wouldn’t want anyone to know if I’d had mental health problems or if I was on meds or something. “

It was also suggested that men “don’t like to be on record” for fear of some sort of repercussions via digital or paper trail.

Barriers from current understanding of healthcare services

All informants expressed barriers to accessing services that were based on men’s current understanding of those services and what they can offer. Often this understanding was skewed, incomplete or highlighted a lack of available information about services. Many had previously conceptualised an incomplete or inaccurate picture of therapy and used this formulation to reject it as being of no personal benefit.

Lack of knowledge and awareness

Informants spoke about how a general lack of awareness of mental health services among men regarding wards, medication, and counselling can be a barrier. Michael explicitly mentioned that had he known more about how depression specifically affects men that it might have helped him at the time.

Michael

“ I: So erm can you think of anything that would have been helpful for you at the time but you didn’t have?
erm, (clears throat) well I think, erm, just a bit more sort of information really, about depression and how it erm, well how it affects different people. I did read a website about it, and I remember thinking ‘Ok, some of that sounds about right’, but then not so for everything. I don’t know, it wasn’t really enough to just look at the symptoms at say ‘oh, yep that’s me, I’ll give them a call’. I mean it, I don’t know. I, I didn’t feel like, it didn’t make me want to do anything about it. Maybe if there were some more facts or, to make it more personal, about men, or stories or quotes or something…”

All informants showed either suspicion of talking based therapies or knowledge that this is common amongst men due to stereotypes about counselling. Geoff admits to being ‘suspicious’ of psychotherapy after having seen that it is not always successful.

Geoff

“P: but I think maybe I’m a little bit suspicious of psychotherapy. Although I have no grounds to be suspicious because I don’t know, I don’t know it well enough. And I yea, I think I just, I’m just not really convinced you know I’ve seen a lot of people come in and out of all sorts of different kind of behavioural therapies and such and not generally having had their lives improve one iota. “

Adam speaks of how many men may view therapy as a result of stereotypes.

Adam

“ P: I guess if you don’t know or have any experience of what of what talking therapies, counselling, whatever you wanna call it are, and you’ve got the sort of stereotypical view of lying on a couch with a man in a white coat sitting on the end asking you, you know about your mother, erm I think you would think that, how could that do you any good? Especially if you don’t like talking about it in the first place.“

He then went on to summarise the nature of how this subtheme is a barrier very effectively:

“ P: I think it’s about lack of awareness and lack of just knowing what’s available and knowing and imagining how, if you don’t know how something can help you, you’re not going to try and access it are you?
I: No, sure that makes sense.
P: And I think there’s a lot of ignorance around what help can be given. “

Not enough time to talk!

Most of the informants expressed that the time constraints under which General Practitioners are under for appointments can be a barrier to men wanting to access mental healthcare services due to feeling that they need longer to express their sensitivities.

Geoff

“P: We’re talking about a group of people who are under ridiculous amounts of pressure to get people in and out of the door.
I: Yea, of course
P: and, my, the surgery to which I am affiliated err had a I think it was a ten-minute maximum appointment and I’ve stretched those boundaries in the past and and felt guilty about it, you know so the idea of opening up to them is quite a stretch. “

Mitigating Factors

Informants made multiple suggestions as to how the above barriers may be mitigated.

Removing the stigma

All informants consistently mentioned removing the stigma associated with mental health would encourage help-seeking behaviours in men. Current efforts to do this via Television adverts, stories in TV soaps, Railway and billboard adverts, Internet campaigns and celebrities being more open about depression and anxiety were praised. Adam suggested that people who have been through such issues, including himself, should be open about them as it may help them.

Adam

“P: I don’t shout about it but I’m not ashamed of it I talk about it if people ask me. I think it’s good to talk about it. It helps me but I also think it might help them. “

Geoff insinuated that advertising must be of a serious and hard-hitting nature if it is to really affect people’s pre-conceived stereotypes about MH.

Geoff

“P: but I don’t think advertising material either in magazines or posters anything like that will remove that stigma I think people need to be spoken to very directly erm and I think er
With real life examples
With real life examples, exactly, in a medium which conveys the message accurately and adequately like television or new media or erm yea where you can actually see someone’s face rather than just a  slogan. “

Things healthcare services can do

Suggestions leading to this subtheme largely revolved around utilising current technologies to ensure better communication between healthcare services and the families of those affected with depression or anxiety, and to increase men’s mental health literacy. Suggestions for an anonymous counselling ‘drop in’ service to combat men’s fear of being traced were also made by two informants, alongside longer Doctor’s appointment times for mental health concerns.

Adam

“P: . If there was a way that somebody could access some help which wasn’t through a recorded medical route. I think that could help. “

Honest relationships, friends, family and talking

The large extent to which family and friends want to help sufferers if they can was conveyed by all informants, and the positive influence family and friends had on their suffering was regularly praised. Services attempting to involve friends and family in the detection and treatment of issues was put forward as a method of encouraging help-seeking. Emphasis was consistently placed on the benefits of being able to talk to someone about one’s suffering and how family and friends occupy a unique position of trust which may enable them to reach out to men in the early stages of their depression or anxiety. Most informants mentioned the importance of trusting someone as a pre-requisite for opening up about their problems, and Geoff said that they he more able to do so when he shared vulnerability with his confidant.

Geoff

“ P: He was placing his faith and his trust in me as I was in him. Whereas a G.P doesn’t need to place his faith or trust in anybody, he can just come up with a professional opinion. That’s not to say I don’t trust my G.P. Err I couldn’t have more admiration for my G.P or for anyone in the NHS. I, you know it’s incredible
I: Ok, so what was it then, that made it easier to confide in this man?
P: it’s just that I was sharing vulnerability with somebody that I knew could easily be comprised by me.
yea.

Things the affected can do

All informants proposed talking to others as a route to recovering from depression and anxiety. Michael highlighted the benefits of the shift in perspective that this enabled him to take and how this may mitigate the barrier of ‘self-reliance’.

Michael

“I: So not to try to deal with things on your own as much as you did?
P: Yea I think that is really important, because I think most blokes think, well, ‘no matter how hard something is, I can sort it out for myself’ and I mean actually sometimes you just need another person’s perspective on something, that’s all it takes is someone else to talk with you properly and well, it can really change your mind, it can erm, it just helps you to release stuff and yea it really helps. “

Geoff emphasised the importance in being able to talk about one’s feelings well.

“P: the thing that made me get better the thing that helped me more than anything else was being able to talk about how I felt.
I: mm.
More than anything. Because I could, I could, I could be, I was good, even when I was really ill, I was good at describing exactly how I felt and that allowed the people around me to help me. “

Discussion

The thematic structure (see Table.1) from this study supports much of the literature mentioned previously yet also expands on it from informant’s personal accounts of their depression and anxiety and the barriers they faced.

As expected, the masculinity norms of ‘emotional control’ and ‘self-reliance’ were identified as barriers to accessing psychological healthcare services as is consistent with much previous research (Mahalik et al, 2003; Spendelow, 2015; Wong, Wang & Miller, 2017). The insights from the lived experiences in this study revealed that some men take real pride in their ability to deal with their mental health alone.  This finding is consistent with the research of Johnson et al (2012) who found that ‘self-reliance’ can be compatible with men’s help-seeking if the latter is viewed as an active and independent decision to choose the path of recovery. Although other qualitative studies have identified that men may commonly delay help-seeking to see if they can first ‘deal’ with their problems (Smith et al, 2008) the pride they take in doing so has yet to be explored fully in the literature and warrants further research into how this can be approached sensitively or re-framed to encourage help-seeking accordingly. Emotional control was also identified as a barrier, which is consistent with the ‘restrictive emotionality’ factor of GRC (O’Neil, 2008). The potential motivations for such control being due to maintaining working responsibilities, and one’s role as a provider were made clear by informant’s accounts in this study. Perhaps efforts to combat the negative effects of these norms in men could involve attempts to raise awareness of the negative effects that over-working and family pressures may be having on their mental health.

Alexithymia and not wanting to burden family members also arose as part of the barrier of emotional control. Alexithymia represents a difficult barrier for men’s help-seeking and it notoriously difficult to overcome (Vanheule, Verhaeghe & Desmet, 2011), in this study an informant suggested that expressing one’s vulnerabilities was easier if to another vulnerable man, the idea of an anonymous support group also arose, one informant also highlighted that being able to express his emotions to others is what ‘allowed the people around me to help me’. Perhaps such a group in which vulnerabilities were shared with other men may encourage those with Alexithymia to be more forward with their emotions through example. Studies have shown that such online support groups can be successful in helping with depression (Griffiths et al, 2012).

Such an anonymous counselling type ‘drop in service’ was suggested in this study and would perhaps be effective in mitigating the barriers men face from perceived stigma, particularly that which surrounds concerns about one’s image in their professional life. The anonymity of such a group may also encourage the sharing of sensitive information that men may be otherwise put-off disclosing because of ‘embarrassment’. Another mitigating factor that may help to reduce ‘embarrassment’ is the influence of friends and family as confidants. The informants in this study conveyed their considerable belief in talking about their emotions as helpful for depression and anxiety. As was predicted, they also stressed the importance of having someone trustworthy and close to confide in. This supports the prior research by Johnson et al (2012) and really highlights the need for this age group of men to find such relationships. It was suggested by informants that the higher rates of suicide for men during midlife may be precisely explained by the lack of such relationships in men aged 40 -55. ‘Higher divorce rates’, ‘children leaving home’, and ‘parent mortality’ were all given as potential reasons that men during midlife may find themselves without a close relationship they feel able to confide in. Further consideration should thus be considered as to how healthcare services can be pro-active in engaging with and supporting this demographic of men.

Communicating pro-actively with men who are considered to be at high-risk of depression, anxiety or suicide may also help to mitigate other barriers that have arisen as part of this study. The number of men engaging in coping mechanisms which delay accessing help would reduce if they were given more options and ways of accessing psychological healthcare and prompted to do so more often. Men who are convinced there is ‘no way out’ or ‘escape’ of their depressed or anxious state, as suggested by informants, may feel entirely de-motivated and reluctant to look for help. If healthcare services were to more frequently target these men directly this may remove the need for them to have to make this effort. This may also serve to directly encourage help-seeking in the midlife male population targeted by this study. Informants suggested that current technologies and databases should be used to inform healthcare services in their efforts to be more pro-active in such ways. For example, a campaign which uses recent divorce statistics to target vulnerable midlife men and offer them support.

As expected and is supported by current literature (Clark et al., 2018), increasing men’s mental health literacy arose from informants as a mitigating factor. MHL may help to reduce a general lack of awareness of mental health services which currently provides a barrier for men accessing them. Services offered by mental health wards, details of medications and side effects, and an accurate portrayal of therapeutic services and how they work, were all identified as areas that men could benefit from more information about. This study evidenced that there is still a misrepresented understanding circulating among this age group of men around talking therapies. In light of current evidence, the patient’s learning how to manage their emotions in such therapies as ACT and CBT should be emphasised to men in order to appeal to the masculine norms of ‘self reliance’. Current efforts to reduce stigma and inform the public via the media were valued highly among informants. Future efforts and campaigns to this aim should include advertisements containing real life stories and more facts and figures, as this was suggested by informants as a direct way to appeal to men.

Another barrier involved the perception that informants would be unable to receive an adequate time window to feel comfortable disclosing their mental health concerns to a general practitioner who was under substantial pressure to be efficient. This concern highlights the lack of communication from healthcare services about what is available to men with mental healthcare concerns considering that it is perfectly possible to book a ‘double’ appointment if one feels they require it simply by asking. Two out of three informants raised this to be a substantial barrier for them, which goes to show that there needs to be more information pro-actively given by GP surgeries to men about how they handle mental health concerns.

Limitations and Conclusions

The current study has many limitations. The most obvious is the small number of participants. Although IPA qualitative studies are not expected to produce generalizable results, the study could have benefited from perhaps one more man who fit the recruitment criteria to share stories for richness and variation in the data.

Another limitation is that the coding was conducted by one assessor and therefore not subject to a second interpretation, leaving it more open to bias and mis-interpretation. The study was originally devised to explore the experiences of a select group of men who had not accessed healthcare services despite self-diagnosing as having had depression or anxiety. The study could have benefited from accounts of middle aged men who had instead voluntarily accessed healthcare services to learn what factors encouraged them to do so, and future research could address this area.

A final limitation of note is that the thematic structure that has come from this analysis is not generalisable to all middle-aged men simply because it came from men who experienced depression during middle-age. Many of the themes are reflective of male depression in general and should be considered as such, more research into the specific experiences of male depression during midlife is needed to verify which, if any of these themes could be said to be specific to this age group.

Through the interpreted analysis of three men’s accounts this study has explored the lived experience of depression and anxiety in men during midlife, their interpretations of their experiences not having accessed healthcare services, and their understanding as to how others may be encouraged to do so.

The following recommendations have been identified from the themes and the accounts of the informants that may help to reduce barriers middle aged men face to accessing healthcare services:

• There is a need for healthcare services and the media to be more pro-active in targeting men in midlife who may be alone, and have no one to confide in. Trusting relationships provide men with a safe environment to talk about their feelings and this high-risk group need to be given more options to enable this.
• There is a need for efforts to combat the negative effects of the masculine norms of ‘self-reliance’ and ‘emotional control’ in so far as they discourage men from psychological help-seeking. This could involve attempts to raise awareness of the negative effects that over-working and family pressures may have on this group’s mental health.
• There is a need for friends and family of middle-aged men to become more involved in the initial detection of their mental health issues, and the support that is provided for these men. Ideally friends and families will be given the assistance of increased mental health literacy and guidance as to how to effectively communicate with men in their care.
• There is a need for advertising, internet campaigns and personal accounts to continue to reduce the general stigma associated with having mental health issues through an increased presence in day to day life. Media should aim to include more facts, figures and real-life accounts of success stories of people who have lived with and overcome depression and anxiety.
• There is a need for some form of advice or counselling service that is anonymous and does not carry a paper or digital trail. More random control trials of anonymous internet support groups would be useful with a view to eventually increasing the available options for men to be able to share their experiences, support each other, and receive professional advice or signposting.
• All names used in the above study are Pseudonyms to protect the identity of participants.