How Can Men Be Encouraged to Seek Help for Mental Health?

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Men taught to repress their feelings often underplay their experiences, leaving clinicians in the dark as to what is actually happening for them.
Men taught to repress their feelings often underplay their experiences, leaving clinicians in the dark as to what is actually happening for them.

The Centers for Disease Control and Prevention1 (CDC) has designated June 12 to 20 as National Men's Health Week, and the month of June has been designated by a Congressional Health Education Program as Men's Health Awareness Month.

"The main reason we have Men's Health Awareness Month is that men die sooner than women and need to be more aware of their health,"3 according to Matt Englar-Carlson, PhD, director of the Center for Boys and Men, College of Health and Human Development, California State University at Fullerton. 

One reason men die earlier than women is that men are less likely to seek preventive care or medical treatment.4 This is true even for male physicians, who are less likely than female physicians to seek medical treatment for their own health conditions, according to Michael Myers, MD, professor of clinical psychiatry SUNY-Downstate Medical Center in Brooklyn, New York, and former editorial board member of the Journal of Men's Health. 

If this is true for seeking help for physical conditions, it is even truer for seeking help for mental health conditions. "Mental and physical health are interrelated in men," Dr Englar-Carson told Psychiatry Advisor.

Rugged Independence 

"It is a stereotype that has even become a popular joke that men do not like to ask for directions, which is a minor example of help-seeking," Dr Englar-Carson said. "Consistently over time it has been found that men across the board are less likely to seek mental health help."5

The reluctance to seek help is multifaceted, but much is connected with social norms and expectations. "Men are acculturated to independence and ruggedness," Dr Myers told Psychiatry Advisor. "Men often think, 'I can fix it myself," or "It will go away on its own.' "

Men who accept this traditional cultural script about masculinity, believing they must be brave and self-reliant to be respected, have been found to have more barriers to seeking healthcare compared with men who do not subscribe to these beliefs.5,6 

"The wives and girlfriends are often the ones who make appointments for their male partner," says John Ogrodniczuk, PhD, professor, Department of Psychiatry, University of British Columbia, Vancouver, Canada. "I have had male patients who, when I asked why they are there, said 'I don't know. My wife wanted me to come.'"

Seeking care for a mental health condition compounds the reluctance to seek help. "Men are more likely to seek help for physical than for mental health conditions," Dr Myers observed. 

Male Alexithymia

All 3 experts agree: men are not acculturated to talk about their feelings. Most are raised on adages such as "big boys don't cry," or "man up." They are encouraged to be stoic and to "tough it out," Dr Ogrodniczuk said. Expressing feelings is sometimes seen as the women's domain. 

Men taught to repress their feelings often underplay their experiences, leaving clinicians in the dark as to what is actually happening for them. For example, a study of men with erectile dysfunction found that those with a repressive coping style described themselves as less distressed than men with a less repressive style and "reported their complaints in a manner that protected their self-worth."7 A meta-analysis of 41 studies that included both clinical and nonclinical populations found that men consistently exhibited higher levels of alexithymia than women.

"Male depression is typically masked," Dr Englar-Carlson said. "The man will suffer silently and say, 'I'm fine.' " 

Because the milieu of talking about personal problems is foreign, men are "less likely to say to their male friends, 'this divorce is killing me' than to say, 'let's go on a fishing trip or build a fence together.' And doing things together can be therapeutic, which needs to be acknowledged and respected," Dr Myers said.

Even when men are sitting in a therapist's office, it can be difficult to find words for their feelings. "A lot of men are challenged about how to describe emotions, feelings, and distress in ways that another person can understand," Dr Ogrodniczuk said. "They grapple with words. They may say, 'I feel like shit.' When asked, 'What does that mean?' they may answer, 'I feel bad.' This lack of vocabulary can deter a man from reaching out for help and can make it difficult once he is receiving help."

He advised therapists to capitalize on the patient's need to "fix stuff" and "do" something.

"Start with small victories over concrete issues. If the patient says that all his coworkers have gotten raises except for him, so it means the boss dislikes him, help set up a strategy for meeting with the boss and examine the beliefs preventing him from doing so. When he succeeds in having the conversation, he can say, 'This doc helped me with something specific that was bugging me, and I feel better.' That is a hook."

No Stereotypes

"In our field, we do not talk about 'masculinity' but, rather, about 'masculinities.' How each man experiences and enacts masculinity will be different," Dr Englar-Carlson emphasized.

Many factors intersect to form sense of masculinity, including gender orientation and cultural and socioeconomic background.9-11 For example, "a working class Italian-American from Chicago will have a different masculine identity than an undocumented immigrant in Southern California," Dr Englar-Carlson said. 

There are also generational differences, he pointed out. "My son, age 13, has a different orientation of what it means to be a man than I do at age 46." 

Dr Myers agreed. "As men age, many are more willing to allow themselves to be vulnerable. I have heard men say, 'I'm much better as a grandfather than I was as a father. If my grandson cries, I soothe him, but when my son was young, I wanted him to shut down his tears because that wasn't manly.' " This may translate into greater receptivity to therapeutic intervention.

But vulnerability per se does not necessarily equate with increased expressivity or openness, he cautioned. "Sometimes illness can open people up, but it depends on the person and the nature of the illness."

Dr Ogrodniczuk added, "It is important not to approach a patient with too many assumptions and preconceptions. Although stereotypes have elements of truth, every man is a unique person and defines himself in his own unique way." For example, "I have found some blue-collar workers more introspective and receptive than some seemingly well-off educated guys, who can be more difficult nuts to crack."

Male vs Female Practitioners

Do male patients relate better to female or to male therapists? 

Findings of studies are mixed. A series of 3 studies found that male participants with traditional "masculine" views preferred a male physician via beliefs that men make more competent physicians than women. However, these men who scored higher on masculinity measures were more likely to disclose their symptoms to a female physician.12 

"Many men may be more comfortable talking about sexual issues to women, maybe because they are afraid a male would judge them or they would be in competition," observed Dr Myers, who is the author of Why Physicians Die by Suicide.13

Some men who have been sexually abused are afraid of being judged by male therapists but may feel more affinity with women. "However, with increased focus on male sexual abuse through media stories, this trend might be changing," he said.

He cautioned female therapists to be cognizant of potential erotic transference. "If the therapist has not received training how to detect and handle this issue, it could compromise the therapy and even the therapist's safety, especially if the patient has a history of impulsivity or sexual assault," he warned.

But in the case of "average, high-functioning males, a female psychiatrist should be comfortable working with positive transference onto her," and it becomes part of the therapeutic process.

Tips for Psychiatrists

Meet your patient where he is. "This is very basic to most psychiatrists, but it cannot be stated often enough," said Dr Myers. "Recognize that this man may be terrified or ashamed to be in your office."

Consider cognitive behavioral therapy. "Men who are reluctant to delve into the past or are not introspective may benefit from [cognitive behavioral therapy] to address the negative thoughts that might be contributing to depression or anxiety," Dr Myers suggested.

Validate and normalize the fear of dependence. "I compare the therapist to a dentist or cardiologist, which destigmatizes the experience of receiving therapy and addresses the fear of dependence," Dr Myers said.

If medications are prescribed, emphasize the somatic benefits, when appropriate. "A male patient might not accept that his insomnia is related to depression. But if he feels an antidepressant will help him sleep, he may be more amenable to trying it," Dr Myers said.

Look beneath the surface. "Be sensitive to a man's reluctance to open up, but don't be so careful that you're dancing around the issue," Dr Englar-Carlson said. But it may be helpful to begin with more surface subjects. "Your patient may not be able to get into emotional talk right way." 

Acknowledge the patient's courage. Recognize and verbalize that you understand it took courage for the patient to seek help. This sets the stage for a good therapeutic relationship marked by validation and nonjudgmentalism.

References

  1. Centers for Disease Control and Prevention (CDC). National Men's Health Week. https://www.cdc.gov/men/nmhw/index.htm. Accessed June 20, 2017.
  2. Men's Health Month. Available at: http://www.menshealthmonth.org. Accessed June 15, 2017.
  3. Centers for Disease Control and Prevention. National Vital Statistics Reports. Death: preliminary data for 2009. https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf/ Accessed June 22, 2017.
  4. Gorman BK, Read JG. Why men die younger than women. Geriatrics Aging. 2007;10(3):182-191.
  5. Berger JM, Levant R, McMillan KK, Kelleher W, Sellers AI. Impact of gender conflict, traditional masculinity ideology, alexithymia, and age on men's attitudes toward psychological help seeking. Psychol Men Masculin. 2005;5(1):73-78.
  6. Himmelstein MS, Sanchez DT. Masculinity in the doctor's office: Masculinity, gendered doctor preference and doctor–patient communication [published online December 24, 2015]. Preventive Med. doi: 10.1016/j.ypmed.2015.12.008.
  7. Wiltink J, Subic-Wrana C, Tuin I, Weidner W, Beutel ME. Repressive coping style and its relation to psychosocial distress in males with erectile dysfunction [published online March 30, 2010]. J Sex Med. doi: 10.1111/j.1743-6109.2010.01787.x
  8. Levant RF, Hall RJ, Williams CM, Hasan NT. Gender differences in alexithymia. Psychol Men Masculin. 2009;10(3):190-203.
  9. American Psychological Association. Issues in psychotherapy with lesbian and gay men: a survey of psychologists. http://www.apa.org/pi/lgbt/resources/issues.aspx. Accessed June 26, 2017.
  10. Dolan A. 'You can't ask for a Dubonnet and lemonade!': working class masculinity and men's health practices. Sociol Health Illn. 2011;33(4):586-601. doi: 10.1111/j.1467-9566.2010.01300.x
  11. Courtenay WH. Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med. 2000 May;50(10):1385-1401. doi: 10.1016/S0277-9536(99)00390-1
  12. Himmelstein MS, Sanchez DT. Masculinity impediments: Internalized masculinity contributes to healthcare avoidance in men and women [published online October 7, 2014]. J Health Psychol. doi: 10.1177/1359105314551623
  13. Myers MF. Why Physicians Die by Suicide. Michael F. Myers: 2017.
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