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College men’s depression-related help-seeking: a gender analysis

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College men’s depression-related help-seeking: a gender analysis
  http://informahealthcare.com/jmhISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2014; 23(5): 219–224 ! 2014 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.910639 ORIGINAL ARTICLE College men’s depression-related help-seeking: a gender analysis May O. T. Tang 1 , John L. Oliffe 1 , Paul M. Galdas 2 , Alison Phinney 1 , and Christina S. Han 1 1 School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada and   2 Department of Health Sciences, University of York,Heslington, York, UK  Abstract Background  : Men’s health help-seeking behaviours vary considerably depending on thecontext. The current empirical literature on the influence of masculinity on college men’sattitudes towards mental health-related help-seeking is largely limited to investigationsinvolving psychology students.  Aim : To describe the connections between masculinities and college men’s depression-relatedhelp-seeking. Methods : Qualitative interviews with 21 college men who were diagnosed or self-identified asdepressed. Constant comparison was used to inductively derive gendered understandingsabout participants’ depression-related help-seeking. Results : Three themes were identified: (1) denying weakness; (2) limiting self-disclosure andmustering autonomy; and (3) redefining strength. Conclusion : The findings demonstrate connections between masculinities and help-seeking thatcan assist health care providers to understand the practices of college men who experiencedepression. Keywords Depression, college-men, masculinities,gender analysis History Received 8 July 2013Revised 7 January 2014Accepted 19 March 2014Published online 29 April 2014 Introduction Social constructionist theories of gender suggest that manymen experiencing depression are reluctant to discuss ordisclose their feelings or seek professional help for depressivesymptoms. Specifically, depression is seen as incongruentwith masculine ideals, or ‘‘hegemonic masculinity’’ which ischaracterized by stoicism, invulnerability and competitiveness(Connell & Messerschmidt, 2005). Since depression caninvoke feelings of powerlessness and diminished control,many men also interpret depressive symptoms as a failure tobe a ‘‘real man’’ (Branney & White, 2008). Likewise, needingprofessional help for depression can contravene masculineideals of self-reliance (Oliffe & Phillips, 2008). Men maytherefore find ways of ‘‘doing’’depression through ineffectualaction-orientated practices including aggression, substanceoveruse, self-harm and suicide (Cochran & Rabinowitz, 2003). College men’s depression and masculinities Depression is ranked among the top five health impedimentsof academic performance among college-age men (TheAmerican College Health Association, 2008). Michael et al.(2006) studied the differential rates of depression and trendsin treatment-seeking among college men and women usingthe Depression Scale of the Symptom Checklist 90-Revised(SCL-90-R; Derogatis, 1994) and found higher levels of depression in males. Of the 99 men in the study, 17 hadclinically significant depression scores; yet only 5 werereceiving some form of treatment. Depressed male collegestudents are also more likely than females to compound therisks associated with depression by concealing pain, with-drawing socially and not seeking help (Courtenay, 1998).Other studies on college men are consistent with the generalmen’s health literature suggesting that adherence to masculineideals can have a deleterious impact on mental health(Courtenay, 1998; Good & Wood, 1995; Levant et al., 2009). Davies et al. (2000) similarly claimed college men’s‘‘male socialization’’ to be a potent inhibitor of health help-seeking, whereby only severe emotional pain prompted mento access campus counselling services as a last resort.Much of the aforementioned evidence has illustratedlinkages between masculinity and men’s depression.However, recent work using Connell’s (2005) masculinitiesframework, which acknowledges a range of gendered idealsand related performances has shown that men’s health help-seeking varies considerably depending on context (Galdas,2009). The aim of the current study is to describe theconnections between masculinities and college men’s depres-sion-related help-seeking. Design Interpretive description, an approach that draws on an array of established qualitative approaches, was used to inductivelyderive findings from the interview data (Thorne, 2008). Correspondence: John L. Oliffe, Professor, School of Nursing, Universityof British Columbia, 302-6190 Agronomy Road, Vancouver, BC, CanadaV6T 1Z3. Tel: (604) 822 7638. Fax: (604) 822 7466. E-mail: john.oliffe@nursing.ubc.ca    J   M  e  n   t   H  e  a   l   t   h   D  o  w  n   l  o  a   d  e   d   f  r  o  m   i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m   b  y   U  n   i  v  e  r  s   i   t  y  o   f   B  r   i   t   i  s   h   C  o   l  u  m   b   i  a  o  n   1   0   /   2   9   /   1   4   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .  Procedure Sampling and recruitment  Following University ethics approval, a total of 21 collegemen, self-identified or formally diagnosed with depression,were recruited through advertisements at student healthcentres, counselling services, and several campus buildingsof a Western-Canadian University (Please see Table 1:Participant demographic data). Semi-structured individualinterviews were conducted. Interview questions focussed onparticipants’ depression-related help-seeking, and included‘‘What are the benefits and challenges to seeking help?’’ and‘‘What is the key to recovery?’’ Probing questions solicitedadditional details and ensured the collection of comprehen-sive ‘‘help-seeking’’ data from which findings are drawn.Interviews lasted 60–90min and were digitally recorded,transcribed, and checked for accuracy.  Data analysis Participants’ interview transcripts were cleaned and labelled(i.e. D1–D21) to ensure confidentiality. Transcripts werecarefully read for participants’ descriptions of their depres-sion-related help-seeking experiences. From this ‘‘parent’’code, a coding schedule was developed, initially assigningdata to one or more categories. By partitioning transcript datainto topic-based segments, and then examining and categor-izing data within these segments, we were able to identifypatterns reflecting broader themes or concepts (Polit & Beck,2008). Constant comparison was used throughout the analysisto discern commonalities and differences and drawconnections between potential themes (Thorne, 2008).Consensus about the findings was reached through discus-sions among the five authors. In theorizing the findings, wereturned to the relevant empirical work on masculinities toconceptually advance understandings about the connectionsbetween masculinities and men’s depression-related help-seeking. Results Three inductively derived themes – (1) denying weakness,(2) limiting self-disclosure and mustering autonomy, and(3) redefining strength – are described in what follows,linking illustrative quotes to individuals using the partici-pant’s age and area of college study. Theme 1: denying weakness For most participants, dominant masculine discoursesabout being strong and stoic featured as significant barriersto acknowledging their depression, let alone admitting aproblem for which they needed professional, peer or familyhelp. Permeating the men’s accounts were recursive refer-ences positioning weak people as predisposed to depressionamid suggestions that men formally diagnosed with depres-sion were inferior to other men (and women). In this regard acontinuum of weakness levels emerged from being suscep-tible to, as well as formally diagnosed with depression. As a21-year-old arts student confirmed, depression makes visible‘‘people who are weak  . . .  persons within inferior groups whoare often neglected.’’ In equating depression with weakness,he went on to explain that a formal diagnosis would renderhim even more vulnerable to being depressed:I have the mindset that if I get involved in the treatmentthen I will automatically label myself as a person or apatient suffering from depression, that can maybe be avicious cycle to get recovery from, so I think if I canhandle it myself, it’s better not to go to treatment.In this and many participants’ interviews, denying weak-ness publically and privately afforded opportunities toembody strength through the concealment of their depression.So powerful were these ideals that many participantswho had sought help and/or received treatment[s] weremeticulous in their efforts to keep those details secret. A24-year-old electrical engineering graduate studentexplained that he eventually stopped seeing his psychiatristfearing he would be known as ‘‘crazy’’ if his friendsfound out:The main reason I stopped going was that the psychiatristwas the main student psychiatrist, so all my friends couldeasily know that I was going to a psychiatrist.Seeking and agreeing to professional help risked revealingadditional signs of weakness. A 23-year-old internationalrelations graduate argued against anti-depressant medicationsas ‘‘the easy fix, the quick way out, the corporate, chemicalsolution’’ in detailing how rising to the challenge oneself wasthe more manly action. Also revealed was how refusingtreatment was key to denying weakness by signalling strength Table 1. Participant demographic data.  N   21Age (years)Mean 22.3Range 19–25EthnicityAnglo-Canadian 5European-Canadian 1East-Indian/South Asian 6Chinese 5Latino 1Middle Eastern 1Mixed 2Sexual orientationHeterosexual 18Homosexual 2Bisexual 1Area of studyArts 7Engineering 8Sciences 5Commerce 1Years in UniversityUndergraduate programs 12Graduate programs 9Formal diagnosis of depression 12Treatment for depression 13Beck Depression Inventory ScoresMinimal 3Mild 7Moderate 5Severe 6 220  M. O. T. Tang et al.  J Ment Health, 2014; 23(5): 219–224    J   M  e  n   t   H  e  a   l   t   h   D  o  w  n   l  o  a   d  e   d   f  r  o  m   i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m   b  y   U  n   i  v  e  r  s   i   t  y  o   f   B  r   i   t   i  s   h   C  o   l  u  m   b   i  a  o  n   1   0   /   2   9   /   1   4   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .  of character and mind to overcome depression inducedchallenges. Ideals about denying weakness were learned andoften reinforced by significant others. A 22-year-old chem-istry student explained how his father’s words, ‘‘no, you’refoolish, no, don’t do it, you will be okay’’ influenced hisbeliefs that seeking professional help was unwise. Similarly, a21-year-old animal science student recounted his mother’snegative reaction to his use of antidepressants, ‘‘you arehealthy, don’t think you are sick  . . .  If you think you arehealthy then you’re fine.’’ Though shocked at first, he ‘‘kindof believed’’ his mother, eventually conceding to the pointthat he discontinued his medications. While affirming thatdenying weakness underpinned men’s need to avoid beingpublicly visible in their help-seeking, family members mayhave also inadvertently denied men’s private requests forassistance.In sum, denying weakness can emerge in a relationalcontext that repudiates having depression, as well as needingand/or receiving professional help. Evident also is that whileparticipants did not necessarily have or even espouse thestrength to overcome their depression, denying weaknesswas key to quelling their concerns about having, and beingknown to have, depression. Theme 2: limiting self-disclosure and musteringautonomy Most participants were vigilant in their steadfast avoidance of inadvertently giving clues that they had a depression. Fearingostracism and ridicule, a 25-year-old engineering graduatestudent asserted ‘‘nobody likes a depressed person. I mean‘‘misery loves company’’, except they don’t.’’ Similarly, a22-year-old engineering graduate student confirmed that‘‘boys don’t cry. . . .  If I tell them [friends] I was reallydepressed last week  . . .  they’re going to laugh at me.’’ Theneed to limit self-disclosure was especially strong whenmixing with other men. A 24-year-old interdisciplinarystudies student explained that despite wanting to discuss hisdepression with friends, he was worried that it would reducehis worth within his peer group:You’re not supposed to open up to other guys about that.You’re supposed to seem confident and strong and you canaccomplish things on your own and stuff like that . . .  That’swhat proves your value to other people I think and so, bydiscussing it with other people . . .  it just lowers yourvalue . . .  so you just shouldn’t talk about it.Unfortunately, restraining self-disclosure about depressiondislocated an important potential source of peer-support.Playing into limiting self-disclosure were participants’concerns of being further marginalized by others. The 23-year-old international relations graduate who had joined afraternity explained that receiving support, no matter howsincere and heartfelt, would ultimately further marginalizehim as a man:Sympathy is good in small doses . . . but I think too muchsympathy, and charity, and patronage . . .  becomes some-thing that’s not empowering for men . . . I think it canbecome very emasculating, and really remove a lot of sense of self-worth.Along with limiting self-disclosure, participants focussed onmustering autonomy toward self-managing their depression inundetectable ways. As the 24-year-old electrical engineeringgraduate student confirmed that ‘‘men are self-fighters todepression.’’ Central to many men’s aspirations for effectiveself-management was avoiding medication therapy. A 20-year-old natural resource conservation student confirmed‘‘it’s the type of thing where it requires a lot of effort on mybehalf, which is why, in a lot of ways, I don’t buymedication . . .  you know, ‘take this . . .  problem solved.’’Similarly, the 20-year-old natural resource conservationstudent who had used antidepressants explained, ‘‘it’s notso much that they weren’t helping . . . but it felt forced,not authentic and not the right way of going about it.’’He elaborated that:Nothing that the body can actually produce on its own,can just as perfectly be synthesized in a pill . . .  I just refuseto accept that. Just like Ecstasy is fake happiness to theextreme sense . . .  some type of prescription medicationthat I get from my doctor that has serotonin in it orwhatever is just as much bullshit to me.In rejecting prescription medications these participants alsodetailed an array of philosophical standpoints and/or specificself-management strategies. In this respect, even amongparticipants who had been treated for depression, the desire toself-manage  their   depression on  their   own terms was stronglyevident. A 21-year-old arts student conceded professionalhelp was ‘‘temporarily useful’’ while a 20-year-old naturalresource conservation student chronicled, self-managementstrategies focussed on ‘‘taking care of myself like, you know,doing everything that’s healthy . . .  being outside in the sun alot . . .  eating well . . .  exercising well.’’ Maintaining physicalhealth and fitness was a way for him to preserve his autonomyas he recovered from depression. The 23-year-old inter-national relations graduate believed that he could overcomedepression:I like doing things myself, and you know, like beingin power of my own abilities. I don’t like making excusesand expecting other people to solve my problems forme.  . . .  And I thought if I build my own mind to, youknow, think productively, and not be so negative, and stopmaking excuses, that I can, you know, overcome itnaturally.For many participants, limiting self-disclosure and musteringautonomy reinstated some control to their lives, though theywere more forthcoming about the details of what they did  not  do (e.g. confide in others, take medications) rather thandetailing specific self-management regimens for theirdepression. Theme 3: redefining strength A few participants traversed many of the somewhat restrictivemasculine ideals detailed in the first two themes. Though less DOI: 10.3109/09638237.2014.910639  College men’s help-seeking  221    J   M  e  n   t   H  e  a   l   t   h   D  o  w  n   l  o  a   d  e   d   f  r  o  m   i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m   b  y   U  n   i  v  e  r  s   i   t  y  o   f   B  r   i   t   i  s   h   C  o   l  u  m   b   i  a  o  n   1   0   /   2   9   /   1   4   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .  predominant than the first two themes, the findingswithin ‘‘redefining strength’’ afford important insights towhy and how some men sought help for their depression.Key to redefining strength as inclusive of depression-relatedhelp-seeking was the permission of other people (especiallyfamily and other men), and/or knowledge that men experi-ence depression. Indeed, the affirmation of others was apotent normalizer of both men’s depression and help-seeking.A 24-year-old electrical engineering graduate studentreported that his mother, who had also experienced depres-sion, assured him ‘‘there’s nothing to be ashamedabout having depression because it runs in the familyessentially.’’ Similarly, a 23-year-old international relationsstudent explained how he had always been supported andsupportive in talking about a range of issues with family andfriends:I’m not unique, but I have a different experience becauseI guess my best friend in high school came out in themiddle of grade eleven and so I spent hundreds of hourstalking to him about feelings and what not . . .  Also, myfamily is very much open with how things should feel.I definitely sense it’s not typical for guys.Revealed was how this participant’s upbringing and pastexperiences had allowed him to normalize talking throughpotentially challenging personal issues. While acknowledgingthat most men ‘‘will just deal with it (depression), or think they can deal with it on their own without telling people’’,and that talking about depression could be seen as ‘‘a signof vulnerability,’’ he knowingly and unapologetically acteddifferently:My entire experience with health care aspects thatI’ve been delivered have been excellent. I can go in andtalk to my GP and sort of talk about these sorts of thingswith him to the same extent I can talk about this withmy counsellor.In crediting his parents, he also defended interactions withhealth care providers as genuine, therapeutic and strengthbased. Similarly, a few participants talked about the benefitsof antidepressants. The 23-year-old international relationsstudent said:Without the medications depression feels like clouds justblocking out everything . . .  so, sort of looking back at it . . . it would sort of be like it was without colour or withoutmusic. Just very bland . . .  not so much sad but just blandlike there was no stimulus coming in.The 24-year-old electrical engineering graduate studentconfided that having peers ‘‘in the same boat’’ made iteasier to seek and accept help. Moreover, he suggested thatrather than women guiding men’s health, the permission of other men was the most potent driver for normalizing men’sdepression-related help-seeking:I think the thing that would help the most to conveythe message to guys are other guys . . .  ratherthan women . . . .[if] you’ve got this big huge burly guythat’s sharing his feelings with you and trying to tell you,‘‘Hey, go seek counselling’’ . . .  I probably think it wouldhelp more than having some puny little girl.Evident here are examples of how masculine strength can berecast in specific contexts. Essentially, by positioning help-seeking as a strength-based action among manly men, ratherthan a passive response to women’s insistence towardsprofessional help, masculine ideals of strength and autonomyare argued as affirming depression-related help-seeking. Thefew participants who argued help-seeking as a manly virtueremind us how health-harming  masculine ideals can beredefined within specific contexts . Discussion Findings from the current study confirm that wanting to passas depression-free can lead college men to avoid completelyand/or conceal their help-seeking efforts. Gender constraintsare predominant in this regard; however, evident also arehow masculinities and depression-related help-seeking arecontextual, relational, and therefore subject to change. Forexample, consistent with Kimmel’s (2008) observation thatmany young men rely on peers to validate their masculinityand initiate them to manhood, our findings highlight thatmany men deny weakness and limit self-disclosure as theconduit toward mustering autonomy for managing theirdepression. This finding supports Courtenay’s (2000) asser-tion that men are taught to uphold values including self-reliance and that college men, in particular, avoid depend-ence on social supports (Courtenay, 2004). Also reflectedare the O’Brien et al. (2007) results reporting a key practiceof masculinity to be the endurance of pain withoutcomplaining, and how exhibiting signs of, or expressingemotional distress is avoided because it contravenes mascu-line norms. Additionally, many participants in our study didnot feel safe to reveal to anyone their fears andvulnerabilities, a finding that echoes Heifner’s (1997)results.While the restrictive nature of masculine ideals perme-ates our study findings, the contextual and relational natureof masculinities, and the means by which ideals and normsshift, offers important insights about hearing men whooperate outside what O’Brien et al. (2007) label the‘‘culture of silence’’ (p. 193). In this regard our findingsresonate with Addis & Mahalik’s (2003) and Emslie et al.’s(2006) observations that men’s help-seeking is highlyvariable in different contexts. For example, redefiningstrength signals the diversity with which masculine idealscan be embodied in the context of depression-related help-seeking. Though fewer in number, our findings chroniclehow some men critically examine and redefine help-seekingas a strength-based enterprise rather than signalling weak-ness. That said, it was also evident that redefining help-seeking was contingent on the permission of significantothers – especially family and male peers. These findingsremind us of the relational aspects of masculinities andhow college men’s actions toward and away from 222  M. O. T. Tang et al.  J Ment Health, 2014; 23(5): 219–224    J   M  e  n   t   H  e  a   l   t   h   D  o  w  n   l  o  a   d  e   d   f  r  o  m   i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m   b  y   U  n   i  v  e  r  s   i   t  y  o   f   B  r   i   t   i  s   h   C  o   l  u  m   b   i  a  o  n   1   0   /   2   9   /   1   4   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .  help-seeking are co-constructed. Resonating with Emslieet al. (2006), some men valued independence in managingtheir depression, and willingly accepted professional help tomaintain autonomy. Clinical implications Clinicians can be supported by gender-sensitive mental healthpolicies as suggested by Bergin et al. (2012) and recognitionof three findings detailed within the current study and thewider masculinities and men’s depression literature. First, asCourtenay (2000) articulated, ‘‘masculinity  requires  compul-sive practice, because it can be contested and undermined atany moment’’ (p. 1393). Therefore, men seeking professionalhelp for depression may attempt to downplay their distresseven when seeking-help (Wide et al., 2011). Second, relatedto this, clinicians must explicitly provide permission for mento talk about their mental health concerns (Brownhill, 2003).Open-ended, loop and prompt questions are importantstrategies for encouraging men to articulate depressivesymptoms. Third, key to men’s depression self-managementis on-going access to reliable resources, and some evidencesuggests that young men effectively use the internet for healthinformation (Robinson & Robertson, 2010). Therefore, formalplanning and evaluation of gender-specific mental healthpromotion interventions, as advocated by Svedberg (2011),is key for clinicians to provide direction to reputableonline resources that will engage men beyond time-limitedface-to-face consultations. Limitations Though the current study is novel in reporting the help-seeking of college men who self-identify and/or are formallydiagnosed with depression future work might benefit byfocusing on issues including health literacy, social class andsocio-economic status among college men as well as acrossdiverse sub-groups of college age men. These approachescould make available comparative studies, the findings fromwhich might guide targeted interventions. The current studylimitations of a small sample size and cross-sectional analysisalso provide important direction for future research focusedon college men’s depression. For example, study designsincluding longitudinal data collection and mixed methodsapproaches could illuminate patterns prevailing across collegemen who are at risk of or experiencing depression. Thesedescriptive studies are important to developing and formallyevaluating much needed college men’s mental health careservices. Conclusion At a time of rising unemployment and economic uncer-tainty, many emergent factors can add to the pressurescollege men experience. In this regard, while some menmay have experience with depression, many college mencan be vulnerable to developing depression. Makingavailable findings such as ours provides important insightsand a foundation on which to build understandings abouthow masculinities can work for and against college men’sdepression-related help-seeking. Acknowledgements Special thanks to research staff, Val Nehdu and Melanie J.Phillips. Declaration of interest This research was made possible by the British ColumbiaMental Health and Addictions Research Network, the MichaelSmith Foundation for Health Research, and the Universityof British Columbia School of Nursing The Monica MaryGreen Fund. References Addis ME, Mahalik JR. (2003). Men, masculinity, and the contexts of help seeking. Am Psychol, 58, 5–14.Bergin M, Wells JSG, Owen S. (2012). Towards a gendered perspectivefor Irish mental health policy and service provision. J Mental Health,22, 350–60.Branney P, White A. (2008). Big boys don’t cry: Depression and men.Adv Psychiatr Treat, 14, 256–62.Brownhill S. (2003). Intensified constraint: The battle between individ-ual and social forces influencing hidden depression in men. Sydney:University of New South Wales.Cochran SV, Rabinowitz FE. (2003). Gender-sensitive recommendationsfor assessment and treatment of depression in men. Prof Psychol: ResPract, 34, 132–40.Connell RW. (2005). Masculinities, 2nd ed. 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DOI: 10.3109/09638237.2014.910639  College men’s help-seeking  223    J   M  e  n   t   H  e  a   l   t   h   D  o  w  n   l  o  a   d  e   d   f  r  o  m   i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m   b  y   U  n   i  v  e  r  s   i   t  y  o   f   B  r   i   t   i  s   h   C  o   l  u  m   b   i  a  o  n   1   0   /   2   9   /   1   4   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
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