“I just need to man up and get out of this rut…”

Phrases like this were not infrequent in a men’s mental health group I used to run. Also, many of those passing through the group expressed great ambivalence towards seeking help.

I was therefore very interested to read this study by clinical psychologist Luke Sullivan and colleagues. They wanted to use a large-scale survey design to determine whether masculine norms, difficulty with emotional expressiveness (also known as ‘alexithymia’) and fear of intimacy in close relationships were associated with UK men’s attitudes towards seeking professional psychological help.

The study is pertinent when you realise that men are three times more likely to take their own lives compared to women (ONS, 2013), and have much higher rates of alcohol and drug abuse (Thom, 2003), incarceration (Prison Reform Trust, 2015) and homelessness (Jones et al, 2010). Men’s mental health and their attitudes to seeking help is certainly an area that we need to pay attention to.

Methods

The Survey

The survey consisted of  a handful of established measures and was hosted on a website. There were 5 main parts to the survey.

1. Demographics, including whether they had previously received support from a mental health professional;
2. “Fear of Intimacy Scale” (Descutner et al, 1991) which prompts the participant to imagine they were in a close dating relationship and asks 35 questions like “I would be afraid of sharing my private thoughts with…”;
3. “Normative Male Alexithymia Scale” (aka difficulty expressing emotions) (Levant et al, 2006) which asks participants the extent to which they agree with 20 questions like “I find it is very hard to cry”;
4. “Male Role Attitudes Scale” (Pleck et al, 1994) which asks patients how much they endorse statements of traditional masculine ideology like “it is essential for a man to get respect from others”;
5. “Attitudes towards Seeking Professional Psychological Help – Short Form” (aka Help Seeking) (Fischer & Farina, 1995) which asks people how much they agree with 10 questions like “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.”

Recruitment

Sullivan used a ‘snowball’ approach to advertise and direct people to the survey. This included using Facebook, Twitter, emails, and 1,000 postcards and business cards handed out in socially different areas. Statistical predictions suggested a target of 210 participants was needed. They managed to get an impressive 581 people to complete the survey.

As would be expected from an online survey, the participants were dominated by younger folk. The authors accounted for this by using a weighting-variable in their analysis to ‘turn the volume up’ on the responses from older groups.

Results

The survey found some interesting, and predictable, relationships.

Those saying they would be less likely to seek help were also:

• …more likely to endorse traditional masculine ideology (from the male role attitudes scale) (r = -.191; p<.01). Masculine ideology accounted for 4% of the variance in help seeking.
• …more likely to find it harder to express their emotions (from the alexithymia scale) (r= -.327; p<.01). Scores on emotional expressiveness accounted for 11% of the variance in help seeking.
• …more likely to fear intimacy in close relationships (from the fear of intimacy scale) (r= -.245, p<.01). Fear of intimacy accounted for 6% of the variance observed in help seeking.

When analysing the effect of the masculinity-related measures together, they accounted for 12% of the variance in help seeking. They also found that the role played by fear of intimacy was fully mediated by emotional expressiveness.

Although these numbers seem fairly small, Sullivan et al point out that in the very specific context of men and male development they are meaningful.

Demographics

I think the results got really interesting when the demographics were thrown into the mix. Demographics accounted for 5% of the variance in help seeking and 17% when combined with the other measures. The education level of the participants accounted for 1% of the variance in help seeking.

The effect of demographics also seemed to dampen down the role of the other measures; with masculine ideology reduced to 2% and emotional expressiveness to 3% of the variance in help seeking. This might, of course, be due to demographics being a much broader category (it includes lots of things like income, education, age etc) compared to more specific measures like emotional expressiveness.

Furthermore, when looking at the demographics of the men who started the survey we see that those who dropped out were more likely to be:

• Single;
• From minority ethnic groups;
• Shop workers, tradespersons, factory workers, medical services, businessmen

Psychology trainees, mental health workers and managers were more likely to complete the survey.

Perhaps the higher dropout rate of these groups of men reflects a general apathy towards seeking help.

I found some hope in the finding that those who had received support from a mental health professional had significantly more positive attitudes towards seeking help (p<.001). However, as the authors point out, we can’t say anything about their attitudes before seeking help. Perhaps they were already confident about seeking help before contacting a professional or perhaps that contact was crucial to them changing their negative attitudes – we just don’t know.

Conclusions

Sullivan et al concluded that:

In this online study of 581 males from the United Kingdom, regression analysis showed that men’s negative attitudes towards seeking psychological help were most closely related to higher normative male alexithymia and greater endorsement of traditional masculine ideology.

The authors’ conclusion is reasonable and their discussion pays careful attention to the limitations and implications of the research.

Limitations

There were three main limitations that I think were most important in considering the results of this study. The authors embrace these and other limitations fairly in their report:

1. The demographics of the survey didn’t closely resemble those of the general male population, so we have to be careful about drawing conclusions despite attempts to statistically control for this.
2. Another subtle limitation is that those completing the survey on their own might have felt less pressured into conforming to more dominant masculine norms. The respondents’ attitudes and behaviours might be quite different in the real world, among the expectations of society, than what they report in a survey completed anonymously, on a computer and on their own.
3. Lastly, the validity and reliability of this study is dependent on that of the measures. How accurately ‘masculinity’ can be measured by a questionnaire is open to debate, especially when there’s not a great deal of research to inform such questionnaires.

Implications

The authors suggest that clinicians and services need to understand that even when they do present, the nature of the interactions may be excruciating to men who find it difficult to express their emotions. Perhaps less intimate forums like the internet and technology may be of benefit for those who find services difficult to access. “CALM” is a nice example of this.

On the other hand, although the study helps to show that there are important differences within men, I do wonder if gender is a bit of a red herring. For example, MAC-UK is a mental health service rooted in the interests and identity of the people they work with, despite not having an explicit focus on gender.

Overall, this study was a good way of showing the merits and challenges of online survey research and has been reported in a fair way that grounds it in clinical implications. I’d really like to see further research related to this area to help us understand what enables different men to seek and access professional help. I don’t think this should be solely an academic pursuit either. Service-user involvement at the most local of levels is surely key to making efficient services that meet the needs of those they’re meant to serve.

Links

Primary paper

Sullivan L, Camic PM, Brown JS. Masculinity, alexithymia, and fear of intimacy as predictors of UK men’s attitudes towards seeking professional psychological help. Br J Health Psychol. 2015 Feb;20(1):194-211. doi: 10.1111/bjhp.12089. Epub 2014 Jan 30. [PubMed abstract]

• For further discussion on men’s mental health, the British Psychological Society has published fascinating articles on the history of masculinity and mental health and a questioning look at the extent to which mental health services are feminised.

• A good source of information about men’s mental health can be found on Men’s Minds Matter, an organisation aiming to raise awareness to the experience of being male, including links to more survey based research that you can contribute to.

• I’m also excited about this upcoming film from the US:

Other references

Descutner, C. J., & Thelen, M. H. (1991). Development and validation of a fear-of-intimacy scale. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3 (2), 218–225. doi:10.1037/1040-3590.3.2.218

Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 35, 79–90.

Jones, A., & Pleace, N. (2010). A review of single homelessness in the UK 2000–2010. London, UK: Crisis UK.

Levant, R. F., Good, G. E., Cook, S.W., O’Neil, J. M., Smalley, K. B., Owen, K., & Richmond, K. (2006). The normative male alexithymia scale: Measurement of a gender-linked syndrome. Psychology of Men and Masculinity, 7 (4), 212–224. doi:10.1037/1524-9220.7.4.212

Office of National Statistics (2013). Suicides in the United Kingdom, 2011. Retrieved from http://www.ons.gov.uk/ons/rel/subnational-health4/suicides-in-the-united-kingdom/2011/stb-suicide-bulletin.html

Pleck, J. H., Freya, L., & Leighton, C. (1994). Attitudes towards male role among adolescent male: A discriminant validity analysis. Sex Roles, 30 (7–8), 481–501. doi:10.1007/BF01420798

Prison Reform Trust (2015). The prison factfile. London: Prison Reform Trust.

Thom, B. (2003). Risk taking behaviour in men: Substance use and gender. London, UK: Health Development Agency.