Hello and welcome to the Nice-ish Ramblings podcast with me, The Nice-ish Psychologist. Today’s episode is the second half of a longer discussion about men’s mental health and whether anyone cares about it. But briefly and for context, these episodes developed after some discussion I had on my Instagram page following some statements made by UFC fighter, Paddy “The Baddy” Pimblett, a few days after a friend of his took his own life. These are the sound bites played at the start of the episode.
The statement about there being no funding for men’s mental health and that no one cares about men’s mental health struck me as odd, so I put a question about this to my followers to get a wider perspective of views. These were essentially broken down into two camps – some noted that there were internal barriers to men seeking help for their mental health while the other noted more external barriers. The internal barriers were discussed in part of one this discussion (which is episode 14 if you want to go and listen), while the external barriers will be discussed here. And hopefully there will be some conclusion as to whether there is a lack of mental health provision for men, and if in fact no-one cares about men’s mental health.
This section, this discussion around external barriers to men seeking mental health support, I found really fascinating – mostly because some of the things discussed from this side of things I had not really considered before, and some I am a bit like, “Yeah, I see where you’re coming from, but you’ve not really convinced me.”
But before I continue, it might be worth noting that this section will contain reference to the categories of primary, secondary, and tertiary healthcare. And seeing as I, someone who works in NHS healthcare, have not always understood the difference between the three I thought it might be helpful to quickly explain the differences. According to the Mind Charity website, primary healthcare is often the first point of contact when someone has any healthcare needs. This is covered by professions like GPs, dentists, and pharmacists. Secondary healthcare are services which will generally require referrals from a GP. In terms of mental health services, this would be things like psychiatric hospitals, psychological wellbeing services (such as IAPT services – which stands for Improving Access to Psychological Therapies), as well as community mental health teams (CMHTs), and Crisis Resolution and Home Treatment Teams (CRHTs). Tertiary care is healthcare that is considered specialised treatment, and in the case of mental healthcare this would be considered something like secure forensic mental health services. Huh! Turns out I work in tertiary healthcare. Who knew!
Also, this episode is not meant to diminish anyone’s mental health struggle. I am very aware the mental health services in the UK are stretched, underfunded, and generally not accessible for these reasons. There are long waiting lists, burnt out staff, and there remains a general persistence in terms of the stigma and lack of understanding about mental health that generally makes it more difficult for everyone to get the help they need. Also, as I noted in the previous podcast, I am not taking aim at Paddy Pimblett and the intention of his initial messages. In fact, there has recently been something in the news about someone saying that Paddy Pimblett’s words saved his life. Which is amazing. The aim of this podcast, rather, is to look at the accuracy of some statements made, which by and large appear to be an accepted narrative around men’s mental health. So, with that in mind I hope you can listen to to this episode with an open mind.
Anyway, external barriers.
So, one of the areas that I can understand where people are coming from, but I also don’t buy it wholly, is the idea that therapy is “feminised”. Yes, you heard me correctly: therapy is feminised.
The premises of this particular barrier appear to be two-fold. Firstly, therapy and therapists, and in fact the field of mental health and psychology in general, is a female dominated field. Secondly, alongside this is the idea that most therapies are emotions-focused and require talking about feelings. Again, these things are not wrong, which is why I can appreciate the idea that therapy is feminised: lots of women in the field and the primary modality of therapy is something that has been classed as feminine – that being talking – and that the main focus is on emotions – again, as aspect of being human that is associated with femininity.
Therefore, the issue that supposedly arises is that men might be less likely to engage with and discuss their difficulties with women. And that talking about their emotions is something men generally struggle with, so a focus on talking about emotions may dissuade them from accessing therapy because supposedly men are more solution-focused and prefer doing rather than talking.
OK, so there are a few things to point out that highlight that this is a somewhat strange, if not flawed argument.
The first thing that I find interesting or wonder about this idea of therapy being considered feminine by virtue of the fact that woman primarily work in this field: does the same concern apply to the area of general healthcare? Is general healthcare considered feminine, too? Because there is a strong gender bias of women working in the caring professions, but I wouldn’t consider general healthcare feminine. I wonder if this is because despite women making up 77% of the NHS workforce they still make up the minority of senior positions, so maybe there is less consideration of general healthcare being thought of as feminine because those in more senior, perhaps more visible positions are men. But still if the worry is that mental healthcare is female dominant, why does the same worry not exist for general healthcare. Not sure any men are refusing to go to the general hospital because there are too many female NHS staff there.
Perhaps it does have to do with the fact that most senior positions are filled by men. So, by that logic you would imagine that if more visible positions within general healthcare are filled by men, that on the whole men would be OK with visiting primary healthcare services like a GP, which up until 2017 was primarily dominated by men. (Some of you may be interested to know in that year in the UK 54% of GPs were women). However, that’s not the case – in an article by The Guardian written in 2102 (so five years before women occupied just over half of all GP positions) men were still only likely to visit the GP four times a year, while women would visit their GP on average six times a year (so, 50 percent more). Similarly, men were likely to visit a pharmacy four times a year compared to women’s average of 18 times a year. The same article highlighted that nine in ten men did not want to trouble a doctor or pharmacist unless they had a serious problem, leading the article to conclude that “men aren’t taking full advantage of the support to maintain good health which is available free of charge on their doorstep.”
Also, I don’t know about you, but I only really realised how female dominated the field of psychology and mental health was once I entered it. I might be wrong, and being an imperfect human there is usually a high chance that I am wrong about this, but I think the predominant perceived gender of therapists and psychologists is still largely masculine and male, based on those who are considered to have pioneered the development of psychology. Like Freud, Jung, Beck, Rogers, and so on and so forth. I am not sure that the average Joe would know that most therapists or psychologists are women. In fact, there was an Australian study done in 2003 (which is over 20 years ago, I admit, but the results are still intriguing to me) where adults were asked to draw images of what they thought a typical psychologist looked like. Based on 119 drawings, it was found that psychologists were largely perceived as middle-aged men.
But the shift in psychology becoming female dominated is relatively recent. In a 2011 article examining the shift in gender in psychology (which I won’t lie, if you read the article it feels a bit like a panicked “what are we going to do now that all these females are entering psychology” piece), it was noted that “the percentage of psychology PhDs awarded to men [had] fallen from nearly 70 percent in 1975 to less than 30 percent in 2008.” But whilst this shift might be noticeable to those in the field, I do wonder how much this is picked up on in the general public. But again, I am potentially wrong about that as this shift has been occurring for like the last 20 years. But if anyone wants to do a follow-up to the 2003 Australian study to see if the perception of psychologists and therapist has change, go for it.
Something else that I found interesting was the apparent inference that men would have difficulty opening up to a female therapist. One of the things about the current state of masculine culture is about not looking weak in front of or admitting ones weaknesses to other men. So, the question I ask is would a man feel OK with opening up to another man more than a woman? Because, if we are agreeing with this gendered stereotype of how therapy is viewed, surely if men are looking for someone to listen to them who stereotypically would be able to understand and empathise and would not be judgmental of their experiences would they not want that to be (again, stereotypically) a woman? I mean, this is all rhetorical because while I do believe that the gender of a therapist can influence a therapeutic relationship and has its barriers (as a male psychologist working in a women’s prison I am acutely aware of this particular therapeutic barrier), it can also serve as a facilitator. It’s possible some men might find it tough to talk to a women therapist, equally, some men might find it more reassuring and containing.
And my final thought on therapy being feminised is this: so what? If it is feminised, and it is something that is considered more feminine, why is that so bad? While delving into this topic, there has been a further inference that men are potentially a “hard to reach” target population and therefore therapy and mental health intervention should be tailored to be male-friendly. There is literature out there to suggest that in order to make therapy more accessible to men it should be masculinised. How should this be done? Well, in their textbook Perspectives in Male Psychology , John Barry and Louise Liddon suggest eleven ways in which to make therapy more male friendly; relating to the therapist, the type of therapy, and techniques.
In relation to the therapist, considerations suggested are: being empathetic, client-centred, value masculine norms, utilising a client’s characteristics (the example here is to use sport as a metaphor for recovery if a male client likes sport - which, again, sure but also metaphors are common practice to help clients understand concepts, etc. Also, women understand sport metaphors, too), considering demographics (like age, ethnicity, education level, and the sex of the therapist, which I have touched on already and might be something important to consider.
In relation to the therapy, it is suggested that male’s might prefer an indirect approach (the example given here is that men might try solve a problem rather than want to focus on their emotions), and that all male groups should be offered alongside individual therapy.
While in relation to therapeutic techniques, it is suggested that therapists consider the language they use, might think about using non-verbal communication (like avoiding direct eye contact which could make men feel uncomfortable), and last but not least, therapist should try use banter.
I suppose what’s interesting is that apart from two things mentioned (that being valuing masculine norms and the interesting suggestion to avoid eye contact, which… yeah, not sure what to make of that one), everything else is pretty much exactly the same as how I, and any other therapists I know, would work with clients… While I am not saying that all of this won’t be helpful, my query is why is it necessary, especially when there is loads of research to suggest that the current therapy modalities work for both men and women. In a 2014 editorial review of research looking into the differences in outcome of the treatment of depression between men and women, the editorial concludes that “patient-centered treatment using medication and/or psychotherapy that explores the psychosocial context of depression is likely to give the best chance of patient compliance and satisfaction, regardless of gender.” Basically, if the person seeking therapy is the focus of the intervention and their mental illness is formulated in a way that is specific to that person, and takes into account all the things about that person (one of which can be their gender) then the intervention should work. Therefore, there is no specific need to masculinise therapy because if a man seeks therapy he will already be masculinised by virtue of the fact that the therapist will focus on and deal with things specific to that man and his circumstances.
Okay, so I seem to have said a lot more about therapy being feminised that I intended, my bad. Moving on…
The second external barrier highlighted from my online discussion was that of the responses of services to men who seek mental health support. So, this was one of the more interesting points that I had not considered. In a very brief discussion with one follower – a fellow psychologist in the south of the country – they noted that their community mental health team saw an equal number of men and women referred to the service, but that men were sometimes deemed too risky to work with for reasons of verbal and physical aggression. As a consequence, these men were often signposted to local charities to receive support for their mental health. Which is an interesting response. And it has made me think two things.
The first is the fact that the men who have mental health issues are not the only ones that hold onto ideals of masculinity. It is very possible that those who work in the services that men access may also hold onto those views, as with the example of turning men away because men are automatically assumed to be more violent than women, which may be further exacerbated when coupled with the potential unpredictability of how some men present when mentally unwell (I would like to caveat this by highlighting that not everyone who is mentally ill can become violent or aggressive, but in this instance it seems to be noteworthy).
But at the same time there is also some evidence to the contrary because at the level of CMHT referral and above (so here we are talking about secondary and tertiary mental healthcare) there is a lot more provision for men than women. Let me explain…
So, in general, there are less psychiatric beds for women than there are men. In terms of psychiatric provision, everything is always measured in the number of beds - but across the UK, there are far more psychiatric beds available for men than there are women, and this only gets more concentrated when you move into forensic psychiatry too. I can’t find like an official document that evidences this, but I know from my years working on psychiatric wards this to be the case (at lease anecdotally). Again, someone let me know if I am wrong. Along side this, there is relatively recent literature to suggest that even when admitted to psychiatric services, women’s needs have not been fully met, and here I quote from an executive summary of a 2018 report commissioned by the UK Department of Health and Social Care: “[mental health services] have been designed, whether consciously or unconsciously, around the needs of men.” The executive summary also goes on to say that women’s roles as mother’s and cares were not considered in terms of the support they received, and that the relationship between gender based violence, trauma, and poor mental health was overlooked. At the same time, I would argue that the impact of trauma should be considered in relation to mental illness regardless of gender.
So, there seems to be a bit of a paradox in terms of responses to men by services. On the one hand, services may be influenced in some way by underlying assumptions and biases about men when they are mentally unwell; but at the same time there appears to be lot more resource provision when they do become acutely or chronically unwell and their needs may be more automatically catered for while in these services.
One of the final points that was made in the overall discussion about this was that there was no promotion for men or reaching out to men to access mental health support. As noted earlier, some would consider men a “hard to reach population”. Now, this is somewhat tricky because I would agree and disagree with this: I would argue that some men might be a harder to reach than others, and this would depend on which type of men we are talking about. I would argue that men that fall into any number of intersectional categories could potentially be harder to reach than others.
As part of their effort to try and reduce health inequalities, the NHS has looked into where different health inequalities exist, and they have identified that often, health inequalities - and in this instance mental health inequalities - exist in relation to sexual orientation and gender, ethnicity, which would also include race and potentially migrant status, disability, and accommodation type. So, men who fall into these categories I would argue are probably the ones who could be considered hard to reach. In an interview for the Metro for an article about male suicide in the Black community, Alex Holmes, therapist and author of the book A Time to Talk (great book by the way, you should definitely get it) – had this to says: “The specific intersection of what it means to be a Black man, a Black trans and, or, queer man, or a Black differently-abled man, at this time is definitely impacting our mental health. The systems are not in place to support us, and there are still many cultural stigmas (both intra-culturally and inter-culturally) that impact how we show up to the world.”
At the same time, I also am stumped by the assertion that there is no effort to engage men in mental health discussions or create awareness. I purposefully held back on releasing this podcast episode in November 2022 because it is also the month of Movember, and entire month dedicated to raising awareness about men’ physical and mental health. And I didn’t want this episode to be received at a time when the focus should be on further creating awareness around men’s mental health – I think the irony might have offended some. Not only that, but there is also Men’s Health Week in June, which is also used to raise awareness about men’s mental health issues.
Alongside this, there are a number of charity organisations that are explicitly aimed at fostering environments for men to open up more about their struggles. For example, “Man Down” in Cornwall, a non-profit charity that offers peer-support groups for men; then there is “Andy’s Man’s Club”, a men’s suicide charity that similarly offers peer-support groups in various locations across the UK; HUMEN, currently offers non-judgemental online support groups every Monday for men who may be struggling with their mental health and thoughts of suicide, and may be moving towards in person support groups. Then there is The Changing Room, supported by the Scottish Association for Mental Health (SAMH), an initiative providing a 12-week programme using football to bring men together to discuss mental health. And those are just some examples. These organisations are linked in the show notes, but they come from quite simple Google searches. I know this is not a competition, but just to give some context there is not necessarily the dearth of mental health support charities and groups for women.
The other interesting thing to think about is that it is commonly understood that there is a gap in male health across the world. According to the website Manual, a website that offers advice of men’s health issues - anything from hair loss, to sexual health, and also mental health - they define a health gap as “differences in the prevalence of disease, health outcomes (both physical and mental), or access to healthcare across different groups”. And the men’s health gap is defined as “a male health gap is when women are generally healthier across their lives than men.” The top ten countries that have male health gaps largely fall within the region of Eastern Europe, with Georgia ranking as the country with the worst male health gap followed by Belarus, Kazakhstan, Mongolia, Ukraine, Armenia, Moldova, the Russian Federation, Mauritania, and Slovakia. And because mental health falls under over all health provision, one would imagine that countries that had male health gaps would also then have male mental health gaps, right? So, if the UK does indeed provide poorly for men’s mental health and it is something not considered then you might expect the UK to have a male health gap, too. Right?
Interestingly though, the UK is not one of the countries without a male health gap. In fact, in the UK it is quite the opposite. According to the same website, the UK ranks 12th in the top countries that have female health gaps. So, just to be clear, overall in the UK health outcomes are worse for women than they are men; and again, this would include mental health outcomes.
So, I guess this seems like a good point to try and answer the overall question of this exploration into men’s mental health provision, that being: “In the UK does no one care about men’s mental health?” And I guess I might cop on this one a bit and let you make up your own mind. I think for me to come to an absolute conclusion would be somewhat arrogant as I am not someone who is potentially affected by difficulties with their mental health. To say one way or the other is potentially invalidating for anyone listening. But, the one thing that I have learned from doing these two episodes to thinking about barriers to men accessing men’s mental health is that there are a lot of things to consider. Some of them are internal, and there do appear to be a few external barriers. How insurmountable are they? Well, I guess it depends on the colour of your skin or who you fall in love with, and whether you think something being considered feminine is more of an issue than your mental health needs. There also appears to be quite a lot of available support and efforts to promote men’s mental health - something that does not seem to be equally championed for other genders. I hope, though, at the very least I have provided some evidence to make you think about the question and come to a conclusion for yourself.
If you are a man who is struggling with their mental health, please do consider getting in touch with your GP. Alternatively please look up any of the charities mentioned in this podcast and find a group of lads who will listen. There is also the option, if it is possible, to talk to our friends and family. I know this makes it sound a lot easier than it might actually be, but if there is anything I have learned in my time working with men, and even my own hesitancy and resistance to admitting when things are tough, it’s that we can sometimes be our own worst enemy.
Thank you very much for taking the time to listen to this ramble. As always if you think someone somewhere would find this episode interesting or may benefit from listening to it, please share it. Please also like, share, rate and leave a comment. It helps so much with letting others know about the show. Until next time - take care.
20 - Men’s Mental Health - Who Cares? Part 2