Men’s Mental Health: Beyond Victim-Blaming

Introduction

Investigating the impact of gender on mental health is an enduring tradition in psychiatric research. Much of this has focused on women’s mental health, examining the social exposures that influence the onset and course of mental disorders with a high prevalence in women. This includes classic work exploring the role of chronic and acute stress in the aetiology of depression in women ^1,2 and research on the relationship between media consumption and eating disorders. ^3,4

In contrast, a definable field of men’s mental health has only emerged in the last decade, and even then, this has been a quiet emergence. ^5,6 This developing field is based on epidemiological findings that men experience much higher rates of certain mental health outcomes in comparison to women. For example, research consistently shows than men make up around 75% to 80% of all completed suicides in Canada and other western countries. ^7,8 Likewise, rates of substance use disorder are significantly elevated in men, with around 3 out of 4 cases being male. ⁹ Moreover, men still tend to under-utilize mental health services, with figures indicating that only around 30% of people who use mental health services are men. ¹⁰

All this is instantiated in recent years through examination of statistics related to Canada’s ongoing fentanyl crisis. Statistics released by the B.C Coroner’s office indicate that over 80% of deaths in this crisis are male, mirroring statistics in other jurisdictions. ¹¹ This has led researchers, commentators, and journalists to describe men’s mental health issues (and male suicide in particular) in ominous terminology: a ‘silent epidemic’, ¹² a ‘quiet catastrophe’, ¹³ ‘a gender gap that is a matter of life and death’ ¹⁴ and ‘an invisible crisis’. ¹⁵ Given this situation, this in review series attempts to amplify the discussion about men’s mental health, illuminating concepts and underlying issues.

The 2 papers that make up this in review series advance the literature on men’s mental health. The first paper, by Affleck et al., investigates the social determinants of men’s mental health, and implications for mental health services. The second paper, by Bilsker et al., outlines critical issues in men’s mental health, examining clinical interventions and population-health initiatives to tackle underlying issues. Although each paper touches on unique concerns, it is interesting to note that both papers 1) adopt a public-health approach to the underlying issues, moving beyond the common tendency to ‘victim-blame’ men who have mental health issues; 2) emphasize the importance of documenting and addressing the oft-ignored social determinants of men’s mental health; and 3) encourage critical reflection on the configuration and nature of mental health services vis-à-vis men’s mental health.

Beyond Victim-Blaming

A term commonly used in public health research is ‘victim-blaming’. ^16,17 This refers to a tendency for health researchers and clinicians to place sole responsibility for an illness on the individual attitudes, behaviours, and lifestyle choices of the illness-bearer. Victim-blaming is inconsistent with an amassed body of public health and social science research, which indicates that health outcomes are determined by a constellation of factors, many of which exist beyond the individual-level. ^{18 –20} This includes social context, population-level variables, and health service-related factors.

Health services that proceed from a victim-blaming ideology may (often unintentionally) stigmatize their patients. ²¹ Much research indicates that this can be an alienating experience, contributing to under-utilization, drop-out, and a dysfunctional therapeutic alliance. ^22,23 Indeed, the field of women’s mental health has benefited from an approach that studiously avoids victim-blaming; for example, in the treatment of eating disorders. It would be crass and superficial to blame a female patient for the onset of an eating disorder, and it would be considered grossly insensitive to glibly suggest that all she needs to do is ‘eat more’. Instead, much research on eating disorders has focused on social context to help understand and combat the illness. ^3,4,24

Numerous scholars have noted that the wider social discourse around men’s health per se has often adopted a narrowly focused, deficit-based approach that borders on victim-blaming, eschewing a multi-level, social context-oriented approach. ^23,25,26 This narrow focus often singularly attributes the cause of a health problem to the attitudes and behaviours of men, rather than acknowledging a highly complex web of causation. ^27,28 This discourse often centres on the concept of ‘masculinity’.

For example, a 2017 report from the European Parliament blames mental health issues in men on ‘masculinity which may encourage suppression of emotions or resort to anger’. ²⁹ Likewise, the World Health Organization has encouraged ‘programmes with men and boys that include deliberate discussions of gender and masculinity’. ³⁰ The limits of such an approach are summarized in a recent editorial in the American Journal of Public Health, aptly titled ‘Men’s Health: Beyond Masculinity’. ²⁵ The authors observe that many current approaches, policies and programs aiming to improve men’s health ‘have located the problem as masculinity [and] suggested the problem is in men’s heads’, without an appropriate consideration of social context and the social determinants of health. Men’s health scholars in Canada have made a similar critique. For example, a recent report from the Men’s Health Initiative of British Colombia notes that approaches that focus solely on the allegedly pathological role of masculinity risks ‘blaming the victim; undervaluing positive male traits; and alienating men in whom we seek to instil healthy behaviours’. ⁶

This singular focus on ‘masculinity’ not only propels a narrow research focus but also leads to health promotion campaigns that may have a limited effect. For example, the US Agency for Healthcare Research and Quality campaign ran billboards plastered with the slogan ‘this year thousands of men will die from stubbornness’. Likewise, a visitor to the men’s mental health webpage of ‘Beyond Blue’, the Australian national mental health campaign, is greeted with the sentence ‘Men are known for bottling things up’. The sub-text of such campaigns is an implicit criticism of the illness-bearer’s attitudes, behaviour, or lifestyles; sometimes laying the blame squarely at the feet of the afflicted men themselves. ^26,27

Instead of continuing this narrow focus, the 2 papers in this special issue adopt a public health approach, devoting much discussion to the social determinants of men’s mental health. This includes discussion of the relationship between social exposures (including unemployment and divorce) and mental health outcomes. Both papers acknowledge that traditional notions of masculinity may be detrimental to help-seeking and psychological coping. However, the authors note that it is only one factor in a complex web of causation, and that this factor has been needlessly emphasized to the detriment of social context.

Men and Mental Health Services: A Critical Analysis

Much research indicates that men under-utilize mental health services for various reasons. ^{31 –33} In a recent editorial for the Canadian Family Physician, prominent men’s mental health researchers at the University of British Columbia argue that this may be because ‘a lot of guys have the perception that current mental health services are set up mainly to serve women’. ³⁴ This idea has been taken further by British researchers in a commentary entitled, ‘Are mental health services inherently feminised?’. ³⁵ These and other authors argue that a clinical focus on talk, emotional vulnerability, and face-to-face self-disclosure may be alienating for many men.

Indeed, some research indicates that men may prefer a healing environment that involves ‘shoulder-to-shoulder’, action-oriented tasks outside of a formal clinic, rather than ‘face-to-face’, talk-focused therapy in a formal health clinic. ^36,37 Both papers in this in review series grapple with these critiques, engaging in critical discussion on the configuration and nature of mental health services vis-à-vis men’s mental health needs.

The paper by Bilsker et al. in particular examines reasons for low rates of mental health service utilization in men, discussing male-specific mental health programs. Both papers argue that there are different modalities of healing in the face of mental health issues, and that gender may play a role in determining individual preferences. Both papers argue against a deficit-based approach that focuses on ‘stubbornness’ or a tendency to ‘bottle-up’. These recommendations are consistent with other recent reports on men’s health; for example, a prominent British charity recommends that ‘practice needs to move from “blaming men for not being like women”‘. ³⁸

Instead, the authors argue for more choice within the mental health system, so that it becomes more male-friendly and responsive to men’s specific needs. This may involve creating (and consolidating) different modalities of healing that build on men’s strengths. This strengths-based approach is embodied in new interventions, such as ‘men’s sheds’, which are well-described by Bilsker et al. Initial evaluations show that men’s sheds may improve outcomes but there is a need for more controlled research on these innovative interventions.

Both papers examine distal as well as proximal factors affecting men’s mental health, and this is essential for developing appropriate downstream and upstream interventions. This is especially important given that governmental bodies are starting to take note of the alleged ‘silent crisis’ in men’s mental health. For example, the Quebec government just released a 5-year men’s health strategy including $31 million for prevention, health promotion, and improved service-access activities. ³⁹ This money must be spent wisely, with attention to the theory and science summarized and explored in these 2 papers.

To conclude, these are exciting times for men’s mental health advocates. These 2 papers are timely and will advance discussion and spur further action to improve men’s mental health in Canada and beyond.