Men's mental healthcare – striving for better reach

Health professionals and society more broadly continue to blame men for their failure to seek help; they reportedly lack emotional communication skills, insight into their psychology, and the foresight to reach out before hitting crisis. This overwhelmingly negative narrative of masculinity, focused on what men can't do, is epitomised in the assertion that 'women seek help – men die' (Angst & Ernst, 1997). The staggering and rising male suicide rate would look to confirm this statement, if it wasn't for the fact that men are seeking help. The problem is, when they do, clinicians struggle to diagnose, communicate with and treat men's mental health issues as they often manifest in an atypical way, with externalising symptoms like anger, irritability and substance misuse (Addis & Mahalik, 2003). It's time we stop passing off such behaviours as 'boys will be boys' and learn to address these effectively – as a call for help.

Increasingly, research demonstrates our narrow perspective may be driving this bias. But this is changing, with a slow shift from a rigid construct of 'traditional masculinity' (e.g. strength & stocisim), to a more nuanced conception of multiple masculinities, neither all negative nor positive, that result from our complex socialisation (Kiselica & Englar-Carlson, 2010). These masculinities are diverse, intersecting and often contradictory, like the fact that an Indian man in the army who is homosexual has a web of masculinities that must co-exist.  With this new wave of masculinity studies, the idea that psychological treatment is 'the antithesis of masculinity' is being challenged, leading to questions about what works for men within our existing mental health services, and why. Asking these questions will enable us to adjust from a largely 'gender blind' mental health service, to a more tailored 'gender sensitive' one (Owen et al., 2009). If we shift our perception of masculinity away from deficit, to one of understanding and using its strengths and diversity to our advantage, we may overcome barriers to men accessing effective psychological treatment (Seidler et al., 2018). The almost 5000 men who lose their lives to suicide each year in the UK must be a catalyst for change.

Researchers and clinicians have been saying for decades that men do not seek help, especially when it comes to psychological concerns like anxiety or depression. What recent research has supported, though, is that men do want to seek help, and will engage in treatment, if they are given the right type of help (Fogarty et al., 2015; Seidler et al., 2017). Indeed, more men are seeking help for mental health concerns than ever before (Harris et al., 2015). However, as these men may already have to overcome self-stigma, discomfort, and negative beliefs surrounding help seeking before initiating treatment, it follows that clinicians should do their utmost to ensure that their efforts do not go wasted through the provision of an inappropriate treatment style (Pederson & Vogel, 2007). The cost of failing to lay a groundwork of trust, respect and rapport with a male client is poor attendance, premature dropout, a negative treatment experience and risk of future avoidance of services altogether (Johnson et al., 2012). 

Here is what is needed practically to have real implications on this treatment dilemma:

1. Clinicians need to be trained to better understand, integrate and adapt their practice when working with men. Clinicians with greater gender-competence (much like multicultural competency) have reliably better outcomes with male clients (Owen et al., 2009). Without consideration of the impact of masculine socialisation on both themselves and the male client in treatment, the status quo of relying on restrictive and often negative assumptions and beliefs about masculinity will remain.
2. Men may need a stronger emphasis on education and orientation to mental health services to improve insight and understanding into their symptoms, treatment and the potential interplay of their masculinity. An emphasis on active problem solving can be addressed through the inclusion of decision trees, progress reviews and session goals.
3. Research has shown that the therapeutic alliance is key in engaging men by providing a collaborative, transparent and strength-based framework for treatment that promotes men's empowerment or autonomy over dependence (Seidler et al., 2017).
4. Plenty of 'traditionally masculine' traits are both amenable to, and useful within a psychological treatment setting. Men's desire to proactively problem solve, be action-oriented and goal-focused in their attempts to overcome mental health issues translates well into almost all treatment approaches.
5. Positive and pro-social practices of masculinity (e.g. mateship or family 'protector') are gaining traction in the field, and introducing them more readily into practice will only have benefits with male client engagement (Kiselica & Englar-Carlson, 2010). 
6. Language is central when relating with and engaging male clients and therefore more purposeful self-disclosure and use of colloquial, metaphorical or de-stigmatising language may help improve male retention in treatment (Mahalik et al., 2012).

Importantly, the integration of specific male-centred treatment styles and strategies into practice should remain separate from any particular treatment orientation, because the types of treatment preferred and most effective amongst men are diffuse. Rather than focusing on what treatment is offered, attention should be directed to the how of treatment. While these elements are considered 'micro-skills' that make up good therapy regardless of the client's gender, it is becoming increasingly clear that a purposeful amplification of these skills may have greater impact in engaging male clients.     

'Pro-health' men do not need to abandon their masculine ideals of strength or self-reliance, rather they can redraw more flexible boundaries. These men can symbolically 'fight' their mental health issues through the courageous act of seeking help but may withdraw from the process if psychological treatment is not tailored to them. Men across multiple studies have described feeling that their clinicians have preconceived ideas about them as men leading to a consequent failure to build a therapeutic alliance (Seymour-Smith et al., 2002). Instead, collaborative and male-centered modes of working, built on trust, transparency and respect are key for men, leading to better engagement in psychological treatment (Seidler et al., 2017).

The proliferation of mental health awareness campaigns encourage men to seek help to narrow the gender gap. But once they reach out for assistance, it is imperative that the system they are drawn into is capable of effectively treating their needs and concerns in an engaging way. Including the client's masculine socialisation and its impact on their presenting issues throughout assessment and formulation, seeking and reinforcing positive masculinity in the client and understanding the impact of gender beliefs and attitudes on one's own practice will only serve to improve men's psychological treatment. It seems psychological therapy needs to 'Man Up', or at least muscle up, to support what is hoped to be an influx of these men in coming years. 

- Zac Seidler is a Registered Psychologist, MPsych (Clin)/ PhD (Candidate), in the School of Psychology, Faculty of Science, at the University of Sydney. 

The vote over a Male Psychology Section of the British Psychological Society is currently live – find out more.