Abstract
Background:
This study describes barriers to accessing mental health services among men currently experiencing a mental health concern.
Methods:
Mental health help-seeking survey data from 778 male respondents who self-reported experiencing a mental health concern were analyzed.
Results:
Of these men, 65% (n = 513) wanted treatment and 35% (n = 265) did not want treatment. The most frequently endorsed barriers to mental health treatment were believing that a lot of people feel sad and down (80%; n = 620), not knowing what to look for in a psychotherapist (counselor; 80%; n = 618) and needing to solve one’s own problems (73%; n = 569). Compared with men who wanted help for their mental health concern, those men who did not want help were significantly more likely to be unsure if psychotherapy (counseling) really works or is effective, not tell their physician if they were feeling down or depressed and prefer to solve their own problems.
Conclusions:
The high endorsement of both structural (e.g., cost) and attitudinal (e.g., beliefs) barriers by respondents suggests that service delivery must adapt to better respond to dominant masculine ideals while also improving men’s ease of access into a transparent treatment process.
The past decade has seen accumulating evidence attesting to men’s reluctance to seek help for mental health concerns (Seidler et al., 2016; Yousaf, Popat, & Hunter, 2015). Repeatedly implicated in these low levels of mental health help-seeking are prevailing masculine ideals (e.g., self-reliance), whereby many men’s socialization restricts self-disclosure about vulnerabilities regardless of the distress levels that they are experiencing (Lynch, Long, & Moorhead, 2018; Möller-Leimkühler, 2002; Pederson & Vogel, 2007). While such attitudinal barriers have been featured in previous research (e.g., Levant et al., 2013), structural barriers to accessing mental health services—including transport costs or knowledge about finding a clinician—remain under-explored. Considering the profound social and economic burden of men’s untreated mental illness (White et al., 2011) and globally high male suicide rates, there is an urgent need to better understand men’s barriers to accessing mental health services and to employ those insights to build and evaluate resources tailored to increase men’s engagement in care (Affleck, Carmichael, & Whitley, 2018).
Recognizing that multiple factors influence men’s attitudes towards and experiences of mental health care services, empirical insights are vitally important to breaking with stereotypes generalizing ‘men don’t seek help’, to report and act on the patterns and diversity inherent to men’s mental health help-seeking (Seidler, Rice, River, Oliffe, & Dhillon, 2018). Although there have been emergent efforts for investigating men’s barriers to accessing mental health services, much of this work has been limited by small samples of non-clinical, college-aged men or men responding to vignettes based on imagining a potential future mental health concern (Levant et al., 2013; Rochlen et al., 2010; Seidler et al., 2016). This study purposefully examined men’s attitudinal and structural barriers to accessing mental health services drawing from a community sample of men, all of whom self-reported a current mental health concern. Moreover, these men indicated whether or not they wanted treatment for this concern, allowing for examination of associations between perceived barriers to accessing psychological care and men’s intention to seek or not seek treatment.
Methods
Procedure
Ethical approval was granted by the University of British Columbia and all participants consented to involvement. Participants were recruited via the HeadsUpGuys website, an online resource that provides male-specific psychoeducation and information for management of depression and suicide risk (Ogrodniczuk, Oliffe, & Beharry, 2018). Individuals were eligible to participate in the survey if they (a) were an adult male aged 18 years or older, (b) self-reported a mental health concern for which they were not currently receiving treatment and (c) were able to read and understand English.
Measures
Along with demographic information (i.e., age, ethnicity, sexuality, education), respondents indicated whether or not they had sought treatment for a mental health concern in the past and whether or not they would want to receive treatment for their current concern.
Respondents’ perceptions of barriers to accessing mental health services were surveyed using items selected from the Barriers to Mental Health Services Scale–Revised (BMHSS-R; Pepin et al., 2015). The BMHSS-R is a self-report scale that assesses factors known to prevent individuals from seeking help. To minimize respondent burden, the present study used 18 items from the BMHSS-R: 6 were structural (e.g., ‘My insurance does not cover mental health care’) and 12 were attitudinal (e.g., ‘I need to solve my own problems’; see Table 1). Items were answered using a 4-point Likert-type scale (Strongly disagree, Disagree, Agree, Strongly agree). To facilitate analysis and interpretation for the present study, responses were subsequently re-coded as 0 (disagree) and 1 (agree).
Group differences, inferential tests and odds ratios predicting men not wanting treatment.
OR: odds ratio; CI: confidence interval; BMHSS-R: Barriers to Mental Health Services Scale–Revised.
Values in boldface represent significance at Bonferroni-adjusted p < .008.
Included in logistic regression.
Social barrier.
General psychological distress among respondents was assessed using the Kessler Psychological Distress Scale (K6; Kessler et al., 2003), a 6-item measure scored on a 5-point Likert-type scale from 0 (None of the time) to 4 (All of the time). Scores were summed with a maximum score of 24, with higher scores indicating greater levels of distress.
Data analysis
Descriptive statistics were used to characterize the sample. Inferential tests (t-tests, chi-square tests of association) evaluated group differences for those who did and did not want mental health treatment, reporting Cramer’s V effect sizes. Barrier items found to significantly differ between groups were included in a logistic regression analysis to identify which were uniquely associated with men not wanting mental health treatment (want treatment = 0; do not want treatment = 1). To account for any confounding effects, differences in previous therapy experience and distress scores across groups were analyzed but only distress scores were significantly different and thus controlled for in the first step of the subsequent regression model. Model interpretation was guided by the Nagelkerke R2 value and odds ratios (employing a Bonferroni adjusted p value to account for multiple comparisons; p < .008) with 95% confidence intervals (95% CIs).
Results
The sample consisted of 778 men who reported currently experiencing a mental health concern while not currently receiving treatment for this concern. The mean age of respondents was 35.63 (standard deviation (SD) = 13.45, 18–77) years, most identified as heterosexual (84%, n = 656) and Caucasian (70%, n = 542), had some post-secondary education (72%, n = 564) and were currently employed (69%, n = 537). Thirty percent (n = 231) of respondents reported currently struggling with problematic alcohol or drug use. In addition, 44% (n = 341) of respondents indicated receiving mental health treatment in the past. Of these men, the majority reported having engaged in treatment over a year ago (70%, n = 238). Mean distress scores reported on the K6 were 15.44 (SD = 4.51, 6–29); 64% (n = 534) of respondents had a score of 13 or more on the K6, which is considered a threshold for ‘serious mental illness’ in the general population (Kessler et al., 2010).
Men who did not wish to receive treatment for their mental health concern had lower K6 distress scores on average (M = 16.31, SD = 4.84) than did those who were willing to seek treatment (M = 14.94, SD = 4.26), t(776) = 4.279, p < .001.
The most highly endorsed barriers to mental health services among all 778 respondents included a mix of attitudinal and structural barriers (see Table 1). ‘A lot of people feel sad and down’ and ‘I do not know what to look for in a psychotherapist’ were endorsed by 80% of the sample, while ‘I need to solve my own problems’ (73%) and ‘I cannot afford psychotherapy’ (72%) were also agreed as barriers to care for a vast majority of men. The least endorsed items concerned not knowing why people went to therapy (26%), getting transportation to appointment (26%) and being able to afford such transportation (20%).
Group comparisons using chi-square tests of association revealed significant differences between men who wanted treatment and men who did not want treatment on five barriers (see Table 1). Men who did not want treatment were more likely to endorse the following barriers: ‘a psychotherapist (counselor) would not understand me or my problems’ (p = .002, V = .11), ‘I would not tell my physician if I was feeling down or depressed’ (p < .001, V = .15), ‘I am not sure if psychotherapy really works or is effective’ (p < .001, V = .15) and ‘I need to solve my own problems’ (p < .001, V = .18). Conversely, the item stating ‘I would not know how to find a psychotherapist (counselor)’ was more often endorsed as a barrier by those men wanting treatment (p = .001, V = .12).
Logistic regression was undertaken to identify which of these five barrier items were predictive of men not wanting treatment for their mental health concern, and to what extent. The overall model was significant, accurately predicting 70% of cases, χ2(6) = 76.24, p < .001, Nagelkerke R2 = .160. Within this model, employing Bonferroni corrections to account for multiple comparisons (p < .008), there were four significant barriers as predictors (see Table 1 for odds ratios, 95% CIs and p values). Those men who endorsed the items ‘I would not tell my physician if I was feeling down or depressed’, ‘I am not sure if psychotherapy (counseling) really works or is effective’ and ‘I need to solve my own problems’ were approximately two times more likely to not want treatment than those who did not endorse these items. Contrastingly, those who endorsed the item ‘I would not know how to find a psychotherapist (counselor)’ were half as likely to not want treatment than those who did not endorse it.
Discussion
The current study examined perceived barriers to accessing mental health care services among men who acknowledged experiencing a mental health concern. Moreover, significant associations were observed between several perceived barriers and whether men intended to seek treatment. The findings reveal both attitudinal (e.g., ‘A lot of people feel sad and down’) and structural barriers (e.g., ‘I do not know what to look for in a psychotherapist (counselor)’). In terms of attitudinal barriers, the endorsement of ‘I need to solve my own problems’ and ‘It’s hard for me to admit that I need professional help’ by over two-thirds of respondents resonates with previous findings drawing connections to men’s alignments to masculine ideals of self-reliance and avoidance of self-disclosing vulnerabilities (Möller-Leimkühler, 2002; Yousaf et al., 2015). Importantly, of the five barriers that differed significantly in being more fully endorsed by men who did not want treatment for their current mental health concern, four of these were attitudinal. Those not wanting treatment were two times more likely to endorse the item ‘I need to solve my own problems’, potentially pointing to an increased adherence to rigid masculine ideals in these men. The structural barrier more fully endorsed by men who wanted treatment was ‘I would not know how to find a psychotherapist (counselor)’. Given the higher distress scores in men wanting treatment (compared with those not wanting treatment), some of these men may have been actively working to seek out where and how to engage with services and hence were more likely to feel hindered by this practical concern.
The current findings regarding treatment barriers validate recent efforts to increase health literacy in men, educating them on the benefits of mental health treatment, including when and why to engage with services (Ogrodniczuk et al., 2018). Those items that were among the least frequently endorsed barriers by men in the present study (e.g., ‘I do not know the reasons people go to psychotherapy’) suggest that continuing to target men’s attitudes and promote awareness regarding the mental health system is central in facilitating treatment seeking. Of note, however, there were significant differences on some of these items between those men wanting and not wanting treatment, suggesting that men who do not want treatment are significantly more likely to conceal their distress and doubt whether a psychotherapist would understand or be able to effectively respond to their issues. All three of these items tap into a similar issue that draws attention to the role of masculine norms in dictating how and when it is safe for men to disclose and rely on someone. Existing research suggests that more meaningful relationships with a family physician, for instance, may curb this withholding of distress and is associated with men choosing more active depression treatment (Kealy, Rice, Ferlatte, Ogrodniczuk, & Oliffe, 2019). As the potential effectiveness of therapy was more often called into question by those men not wanting treatment, this could reflect both a structural barrier, in that there is a paucity of information about how therapy works for men, and an attitudinal one, with some men socialized to doubt the benefits of disclosing vulnerability as it triggers feelings of shame or weakness. These differences highlight how public health campaigns must continue to demystify help-seeking and therapeutic processes while de-stigmatizing emotional disclosure, to engage this hard to reach sub-group of men.
The current findings that revealed both structural and attitudinal barriers to mental health services point to the need for a multi-pronged approach for boosting male mental health help-seeking and tailoring services to be more inviting for men. Promoting gender-sensitized campaigns that challenge common myths propagating stigma and fear about mental health symptoms and treatment among men may be useful. This could involve leveraging dominant masculine ideals like bravery and risk-taking as central in a strength-based framing of mental health treatment that dispels the common conception that it is the ‘antithesis of masculinity’ (Englar-Carlson, 2006). By tapping into a growing shift in young men’s alignment towards more health-related masculine values like emotional strength, such efforts could promote flexibility in how men construct their sense of masculinity and aid in minimizing the role of barriers like ‘I need to solve my own problems’ (Oliffe et al., 2019; Seidler et al., 2018). However, this study also highlights that alone, these efforts to shift men’s attitudes will not be sufficient in promoting service use, as structural barriers including treatment costs (direct and indirect) and knowing where and how to locate a clinician remain significant issues for men. Indeed, there is potential interplay and overlap between structural and attitudinal barriers for some men and future research would benefit from clarifying how respondents are interpreting and rating items using mixed-methods analyses. From a more clinically focused perspective, creating a monitored register of practitioners specializing in working with men with transparent information describing the differences in therapeutic approach, frequency, cost and potential length of treatment may help reduce uncertainty and promote tailored service engagement (Seidler, Rice, Oliffe, Fogarty, & Dhillon, 2017).
The current findings present practical public health intervention entry points and highlight the changing landscape of men’s mental health as more men begin to understand the role, effectiveness and importance of psychotherapeutic treatments. However, our findings might also imply that the impact of socialized, dominant masculine ideals including self-reliance, stoicism and emotional concealment may continue to obstruct men’s pathways to care. Thus, mental health services must do more to tailor their delivery to better align with and respond to men’s needs (Seidler et al., 2018).
The current study should be considered with the following limitations in mind. First, the data were drawn from a cross-sectional survey and the barriers included were pre-determined and not exhaustive; therefore, some important barriers may have been missed. Second, given that many of these men had previously sought mental health treatment, self-disclosed a current mental health concern and were recruited through a self-help e-mental health resource (HeadsUpGuys), we are limited in what can be said of other men including those who lack insight or refuse all potential help for mental health care services. Moreover, it is unknown what, if any, effect was had by respondents’ interaction with the website resources on depression and help-seeking prior to undertaking the study survey. Nevertheless, as a large sample of men self-reporting a current mental health concern, this study provides useful insights to a range of barriers for men who would likely benefit from mental health treatment[s].
